August 14, 2008

Declaring Organ Donor Death Stirs Up Controversy

Many doctors are struggling to determine how and when someone can be declared dead in the case of organ donors.

In the past, doctors have had to determine that the donor's brain has completely stopped working, but a new report on three heart transplants involving babies is raising controversy.

The report shows that although the three babies were on life support and showed little brain activity, they failed to meet the general criteria for brain death.

Each of the infants' families had given consent for doctors to remove their ventilators as surgeons in Denver worked to remove their hearts.

All of the infants who received the hearts survived.

"It seemed like there was an unmet need in two situations," said Dr. Mark Boucek, who led the study at Children's Hospital in Denver. "Recipients were dying while awaiting donor organs. And we had children dying whose family wanted to donate, and we weren't able to do it."

The procedure - called donation after cardiac death - is being encouraged by the federal government, organ banks and others as a way to make more organs available and give more families the option to donate.

But the approach raises legal and ethical issues because it involves children and because, according to critics, it violates laws governing when organs may be removed.

As the procedure has been more widely used, the number of cardiac-death donations has risen. For instance, last year there were 793 cardiac-death donors, about 10 percent of all deceased donors, according to United Network for Organ Sharing. Most of those were adults donating kidneys or livers.

"It is a much more common scenario today than it would have been even five years ago," said Joel Newman, a spokesman for the network.

Editors of the New England Journal of Medicine, where the Denver cases are set to be published on Thursday, warn that it will be met with some controversy. They said it was published in hopes of promoting the discussion of cardiac-death donation.

In two of the Denver cases, doctors waited only 75 seconds; the Institute of Medicine has suggested five minutes, and other surgeons use two minutes.

State laws stipulate that donors must be declared dead before donation, based on either total loss of brain function or heart function that is irreversible. Some commentators contended that the Denver cases didn't meet the rule since it was possible to restart the transplanted hearts in the recipients.

"In my opinion, it's an open-and-shut case. They don't have irreversibility, and they don't have death," said Robert Veatch, a professor of medical ethics at Georgetown University.

But others argue the definition of death is flawed, and that more emphasis should be on informed consent and the chances of survival in cases of severe brain damage.

The authors said 75 seconds was chosen because there had been no known cases of hearts restarting after 60 seconds.

The hearts were given to three babies born with heart defects or heart disease. All three survived, and their outcomes were compared to 17 heart transplants done at the hospital during the same time but from pediatric donors declared brain dead.


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