Non-Brain Death Organ Donation Part Two

By Nancy Valko, RN, ALNC

February 20, 2015

(This is an updated version of an article originally published in the February newsletter of the Pro-Life Healthcare Alliance .

Although non-brain death organ donation started over 20 years ago, it is mostly unknown to the  general public who sign organ donor cards assuming that they will be carefully diagnosed as  “brain dead” before their organs are harvested. (See “Non-Brain Death Organ Donation, Part  One,” )

Originally called non-heart beating organ donation (NHBD), and later DCD (donation after cardiac death), it is now called donation after circulatory death (also DCD) because donor hearts can sometimes be restarted for transplantation. I call it non-brain death organ donation because “brain death” criteria are not used.

In March, 2011, the Organ Procurement and Transplantation Network (OPTN) published proposed policy rules on non-brain death organ donation and opened its website for public comments. Despite many critical comments and an article in the Washington Post titled “Changes in controversial organ donation method stir fears” [1], the OPTN has now finalized some very dismaying standards.[2]

In one of the most disturbing sections, “Consent for DCD”, the OPTN states that “Conditions involving a potential DCD donor being medically treated/supported in a conscious mental state will require that the OPO (organ procurement organization) confirms that the healthcare team has assessed the patient’s competency and capacity to make withdrawal/support and other medical decisions.” [Emphasis added.] There is no mention of evaluation for depression or other difficulties that may influence the person’s decision, which omission obviously could lead to a new form of assisted suicide.

The OPTN policies also state that “Any planned withdrawal of life sustaining medical treatment/support will be carried out in accordance with hospital policy.” Even the guidelines suggested in the two Institutes of Medicine reports on non-brain death organ donation, like waiting a minimum 5 minutes (after cessation of the donor’s breathing and heartbeat) before harvesting, have been generally jettisoned in favor of locally decided rules. As the OPTN admits, its policies “…set the minimum requirements for DCD recovery but do not address local practices, cultural and resource issues…” Thus, like brain death criteria, the rules surrounding non-brain death donation can potentially vary even from hospital to hospital without the patient or family even being aware. And as one of the inventors of the NHBD protocol, Dr. Michael DeVita, has admitted, “the possibility of [brain function] recovery exists for at least 15 minutes.”[3]

Another major problem is that, even though doctors screen such patients for a rapid inability to continue breathing without a ventilator, at least an estimated 20 per cent of non-brain death donors do not stop breathing and heartbeat fast enough after withdrawal of a ventilator to have usable organs. These patients are then just returned to their rooms to die without further treatment.[4]

How can doctors be so wrong in some cases? Could such patients potentially improve? A 2003 article in the New England Journal of Medicine illustrated a disturbing lack of objective medical standards for withdrawal of ventilators even outside an organ donation decision. This article admitted that no study was done to “validate physician predictions of patients’ future functional status and cognitive function” and the researchers did not ask doctors to ”justify their predictions of the likelihood of death or future function.”[5]

These are just a few of the criticisms of non-brain death organ donation that have been raised by ethicists, doctors and other concerned people.

Informed Consent

 How many people know the Uniform Anatomical Gift Act was revised in 2006 to include “first person” authorization when a person signs an organ donor card or other legal donation document that “not only continues the policy of making lifetime donations irrevocable but also is restated to take away from families the power, right, or authority to consent to, amend, or revoke donations made by donors during their lifetimes.”[6]?

With the discussion about problems with non-brain death organ donation absent in mainstream media, what can you do to protect yourself from a potentially unwanted organ donation?

First of all, know the facts. It is necessary to do your own research since fact sheets often provide only minimal information when you sign an organ donor card while you are renewing your driver’s license or checking off a box in your advance directive. Therefore, you may not be giving the truly informed consent such a momentous decision requires.

Keep informed about new strategies being proposed such as “presumed consent” which is the assumption that everyone is willing to donate his/her organs unless there is evidence that they would not want to donate. Illinois narrowly avoided a “presumed consent” statute a few years ago.

However, there are alternative ways to donate that people who are uncomfortable with brain death and/or non-brain death donation might consider. For example, people can become a living organ donor for a kidney. Such kidneys also have many advantages over both brain dead and non-brain dead kidneys such as usually lasting twice as long. (See: “The Benefits of Living Donation”) While there are risks to such a surgery for the donor, living organ donation avoids the ethical concerns about determining death.

Other alternatives are the donation of blood or bone marrow donor while living or, after death, the donation of tissues like bone or corneas that can be taken even hours after death is certain.

In addition, there is hopeful medical research involving adult stem cells to repair organs and building artificial organs that may someday replace the organ donation we have now.

Having a daughter-in-law who currently needs a living donor kidney transplant, I am aware of how much such a “gift of life” can mean, but I believe it should not be at the expense of ethics or informed consent.

About the author: Nancy Valko, RN, ALNC, has been a registered nurse for 45 years and is a spokesperson for the National Association of Prolife Nurses . A long-time speaker and writer on medical ethics and other health issues, she has a blog “A Nurse’s Perspective on Life, Healthcare and Ethics” and an archive of her articles from 1988-2014 titled “Nancy Valko, RN ALNC”.  She is also now a legal nurse consultant.

FOOTNOTES

[1] “Changes in controversial organ donation method stir fears” by Rob Stein. Washington Post, September 19, 2011. Online at:  http://www.washingtonpost.com/national/health-science/changes-in-controversial-organ-donation-methodstir-fears/2011/09/15/gIQAlY9agK_story.html

[2] Organ Procurement and Transplantation Network Policies. U.S. Department of Health & Human Services. Current as of 2/1/2015. Online at http://optn.transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf

[3]”The Death Watch: Certifying Death Using Cardiac Criteria,” Michael A. DeVita, MD, University of Pittsburgh Medical Center, Pittsburgh, Pa., Prog. Transplant 2001; 11(1):58-66, © 2001 North American Transplant Coordinators Organization

[4] “Organ Procurement after Cardiocirculatory Death: A Critical Analysis”, Mohamed Y. Rady, MD, PhD, Joseph L. Verheijde, PhD, MBA, and Joan McGregor, PhD. Journal of Intensive Care Medicine. September/October 2008, available online at http://jic.sagepub.com/cgi/reprint/23/5/303.pdf

[5] Withdrawal of Mechanical Ventilation in Anticipation of Death in the Intensive Care Unit” by Deborah Cook, M.D., et al. New England Journal of Medicine, Volume 349:1123-1132, September 18, 2003, Number 12. Abstract available online at: http://content.nejm.org/cgi/content/short/349/12/1123

[6] REVISED UNIFORM ANATOMICAL GIFT ACT (2006), page 30. Online at: http://www.uniformlaws.org/shared/docs/anatomical_gift/uaga_final_aug09.pdf