"New practices in organ donation inspire debate"

"New practices in organ donation inspire debate: Harvesting begins just minutes after heart stops beating", Rob Stein, Washington Post and San Francisco Chronicle.

[NB: Cet article a été publié le 19/03/2007 dans les deux journaux américains cités. Voir sur le même sujet un article du "New England Journal of Medicine" (NEJM) du 14/08/2008 : lire.]

"The number of kidneys, livers and other body parts surgeons are harvesting through a controversial approach to organ donation has started to rise rapidly, a trend that is saving the lives of more waiting patients but, some say, risks sacrificing the interests of the donors."

"Under the procedure, surgeons remove organs within minutes after the heart stops beating and doctors declare a patient dead. Since the 1970s, most organs have been removed only after doctors declared a patient brain dead.

Federal health officials, transplant surgeons and organ banks are promoting the alternative as a way to meet the increasing demand for organs and to give more dying patients and their families the solace of helping others.

Some doctors and bioethicists, however, say the practice raises the disturbing specter of transplant surgeons preying on dying patients for their organs, possibly pressuring doctors and families to end treatment, harming donors' care in their final days and even hastening their deaths.

Nevertheless, the number of these donations is increasing. It more than doubled from 268 in 2003 to at least 605 in 2006, enabling surgeons to transplant more than 1,200 additional kidneys, livers, lungs, hearts and other organs.

'It's starting to go up exponentially,' said James Burdick, who leads organ-donor efforts at the federal Department of Health and Human Services.

The trend is expected to accelerate this year. For the first time, the United Network for Organ Sharing, which oversees organ procurement, and the Joint Commission on Accreditation of Health Care Organizations, which accredits hospitals, are requiring all hospitals to decide whether to allow the practice. In response, medical centers are scrambling to develop policies, sometimes sparking intense debate, especially at children's hospitals.

'It's an example of pushing the envelope to get more organs,' said Stuart Youngner, a bioethicist at Case Western Reserve University. 'Whenever we do that, we tend to step on various traditional social taboos.'

The approach, known as 'donation after cardiac death,' usually involves patients who have suffered brain damage, such as from a car accident or a stroke. After family members have made the difficult decision to discontinue a ventilator or other life-sustaining treatment, organ-bank representatives talk to them about donation.

Sometimes, the donor is suffering from an incurable disorder such as Lou Gehrig's disease and wants to donate his or her organs after deciding to forgo further care.

Once the decision has been made, a transplant team waits nearby so surgeons can begin removing organs soon after the heart stops. Because the heart can sometimes restart spontaneously, doctors wait a few minutes after pronouncing death before allowing the surgeons to begin. If the heart does not stop quickly, usually within an hour, the procedure is aborted and the patient is taken back to his or her room until death comes.

The practice was the norm before brain death became the standard for pronouncing death in the early 1970s and surgeons began keeping the donor's body functioning with life-support machinery until transplantation could begin. When surgeons resurrected what was then called 'non-beating heart' donation in the 1990s, critics called it ghoulish and said it raised a host of ethical questions. Some called it tantamount to murder.

The National Academy of Sciences' Institute of Medicine examined the practice, however, and concluded that it is ethical as long as strict guidelines are followed, including making sure that the decision to withdraw care is independent of the decision to donate organs and that surgeons wait at least five minutes after the heart stops.

'People are dying on the waiting list,' said Francis Delmonico, a transplant surgeon at Harvard Medical School, speaking on behalf of the United Network for Organ Sharing. More than 95,000 Americans are waiting for organs. 'This is vital as an untapped source of organ donors.'

While some doctors and ethicists who initially questioned the practice have become more comfortable with the procedure, others remain troubled.

'The image this creates is people hovering over the body trying to get organs any way they can,' said Michael Grodin, who directs Boston University's Bioethics and Human Rights Program. 'There's a kind of macabre flavor to it.'

Many experts remain concerned and worry that the practice blurs the definition of death.

'The person is not dead yet,' said Jerry Menikoff, an associate professor of law, ethics and medicine at the University of Kansas. 'They are going to be dead, but we should be honest and say that we're starting to remove the organs a few minutes before they meet the legal definition of death.'

In response to such concerns, most doctors wait five minutes after the heart stops before pronouncing patients dead. But doctors at some hospitals wait three minutes, others two. In Denver, surgeons at Children's Hospital wait 75 seconds before starting to remove hearts from infants, to maximize the chances that the organs will be usable."

Source:
http://www.sfgate.com

Nancy Reyes is the pen name of a retired physician living in the rural Philippines. On March 20, 2007, she wrote in reaction to this article:
How dead is dead?
"In the 'good old days', your heart stopped, and you were declared dead.

Then came machines to keep the lungs breathing, so the heart went on and on and on…but no one wanted to turn off the machine, so doctors devised a new criteria: Brain death. In Brain Death, you turn off the machine, and there is nothing moving, and so the heart quickly stops.

Brain death allowed doctors to take organs out of people while their hearts were still beating.

But then came a huge increase in the demand for organs.

So doctors tried to figure out how to get more organs to save these patients (and like most docs, I’ve had patients who were alive and well due to transplants, so support organ donation).

The latest 'twist' to get more organs is to take organs from those whose heart has stopped. Big deal, you say. Ah, but that’s the problem... it can be.

LINK

Well, the heart stops and you’re dead, right? But you might not be brain dead. Or you might be handicapped, and decide to remove unwanted treatment instead of burdening your family.
'After family members have made the difficult decision to discontinue a ventilator or other life-sustaining treatment, organ-bank representatives talk to them about donation.'
Other life sustaining treatment? Like a feeding tube? a cardiac pacemaker? IV feeding?

And are the family aware that often sedatives are given to a person needing a ventillator? The reason is so they don’t 'fight' the ventilator. And some people need pain medicine for other injuries. So if the family is told it is hopeless, and see an unconscious patient on a machine, are they making a flawed decision? And if the person is removed from the breathing machine, does the medicine contribute to his not breathing enough to keep his heart going?

Sometimes, the donor is suffering from an incurable disorder such as Lou Gehrig’s disease and wants to donate his or her organs after deciding to forgo further care.

Yes, let all these paralzed people know they can 'help' others by stopping all that care that costs a lot of money and burdens their family.
In the USA, a lot of the elderly are supposed to be independent, and would be ashamed to ask for help. Many of the 'assisted suicides' are requrested for this shame, not because the person is in pain.
And a person with Lou Gehrig’s disease is alert. So if you stop the breathing machine, either you allow them to suffocate –a horrible death– or give them a sedative so they aren’t aware of the fact. But again the sedative will cut any ability to breath. (breathing is not 'all or nothing'….that’s why the article mentions that if a person doesn’t die as expected within an hour, they are taken back to their room…

Once the decision has been made, a transplant team waits nearby so surgeons can begin removing organs soon after the heart stops. Because the heart can sometimes restart spontaneously, doctors wait a few minutes after pronouncing death before allowing the surgeons to begin. If the heart does not stop quickly, usually within an hour, the procedure is aborted and the patient is taken back to his or her room until death comes.

So how long do the docs wait?

most doctors wait five minutes after the heart stops before pronouncing patients dead. But doctors at some hospitals wait three minutes, others two. In Denver, surgeons at Children’s Hospital wait 75 seconds before starting to remove hearts from infants, to maximize the chances that the organs will be usable.

The series Law and Order is on our Asian cable, and they had a case where a surgeon 'hurried up' such a death... nah, it’s fiction... right?

Ah, but check this (...) article by medical ethicists Arthur Caplan and Michael Devita, discussing a case where a transplant surgeon was accused of prescribing drugs to haten the death so his organs could be tansplanted more quickly.

Caplan and Devita point out that most people support organ donation, but that a climate where jokes about taking your organs are heard on the radio, and where Law and Order has TV shows about similar cases, the fact that the story of a real live case could be devestating to the public’s trust of the organ donor system.

To make it worse, as these ethicists point out, the California Legislature is considering a law saying that the organ donor permission should outrank a person’s living will.

Why is this important? Well, some people want everything done for them, but don’t object to their organs being donated if they are truly dead. (Some Ethnic groups are especially paranoid about doing everything possible... with good reason. But that’s another story).

Now, how do you treat a dying patient? By the Hippocratic oath, doctors treat the patient in front of them to the best of their ability. Most doctors will do ordinary treatment, but when even the Pope acknowledges that some extraordinary treatments are optional, then what this means is that everyone –family, doctor, ethics committes, knowledgable neighbors, and patient’s previous wishes– try to find the best treatment that the patient would wish. And the 'living will' or other guidelines are usually what we follow.

But the California law mandates that the caretaking doctor take the state law on organ donation into account when treating a patient.

Usually there is a strict line between the caretaking doctors and the decision on how much to treat a person. Once the family decides to let the inevitable death happen, then you call in the transplant person to discuss it with the family. Without this strict division of labour, there is danger of a conflict of interest by the one helping make the decision (which is why paying families for their loved one’s organs would be a similar conflict of interest).

The ethicists ask the same thing:

'People have clear opinions on their end-of-life care, including preferences for advanced life support and palliative medications, but also, organ donation. When making organ donation consent at a motor vehicles licensing office in San Jose, Los Gatos or Hollister, people are not asked whether the organ donation should nullify their living will. To assume otherwise makes no sense.(...)
It is essential that the line between caring for the dying and obtaining organs for those in need remain sharp and bright. One of the biggest barriers to obtaining consent for organ donation in California and around the nation is the fear that the consent will lead doctors to make end-of-life decisions based on what is best for organs rather than patients'."

Source:
http://www.bloggernews.net/15382