December 19, 2006

Donating Organs at the Edge of Death: The Urgent Need for Donor Organs Has Led to a Controversial Practice in Declaring Death

By Jamie Talan, Newsday, Melville, N.Y.

Dec. 19--Last July, Sea Cliff's beach pulsed with an open memorial celebration for 56-year-old Carolyn Ramirez, a popular waitress in the North Shore enclave. About 600 people arrived to cry, tell stories and console one another over her unexpected death.

In her final days, Ramirez was on life support at Glen Cove Hospital -- her brain badly damaged by loss of oxygen, her heart pumping with the help of machines. She was in a coma, brought on by an accidental toxic mix of a few glasses of alcohol and the ingestion of an unregulated herbal supplement that the family said she used to help her sleep.

When doctors asked the family whether Ramirez had ever considered organ donation, her son, Kyle Pratt, didn't know. But his aunt, Ramirez's sister, remembered a casual discussion in which she had said she would like to donate.

And so Ramirez became one of 17 Long Islanders who in the past two years have donated their organs to people in need under a hotly debated procedure called "donation after cardiac death."

"She was my best friend," said Pratt, 34, of Sunnyside. "I offered everything -- her skin, her eyes. They took whatever they could."

Widening the donor pool

The procedure Ramirez underwent has emerged in the past 10 years because donor organs are in such short supply. More than 94,000 Americans are on transplant lists, awaiting donations.

The process involves procuring organs from people on life support who, doctors say, have no hope of recovery. Their brains are still functioning, but machines are keeping their bodies alive. Until their brain or heart stops working, they do not meet the legal and medical criteria for death.

In the usual organ donation process, patients are declared brain-dead, but their hearts are still beating. The transplant team arrives and procures the organs.

In this new procedure, the patient, whose brain is still functioning but whose prognosis is grim, is taken to the operating room, and the life-sustaining machines are turned off. Then, only if the patient's heart stops, death is pronounced and the organs are harvested.

The rules for donation after cardiac death are stringent. Anesthesiologists on hand in the surgical suite are there to provide medicine to alleviate discomfort and pain but not to usher in death. There also is a time window. If a person has not died within an hour after the machines are removed, the procedure is aborted.

It is also not an easy discussion to have with families, doctors said. A family must decide whether their loved one's life is for all practical purposes over and whether donating organs would give them a measure of hope that a stranger may benefit.

The transplant team is kept separate from the patient and the family until after death is pronounced. The team waits in an adjacent room. The team must wait five minutes between the declaration of death and the removal of the organs. It must be done quickly because loss of oxygen can destroy the organs and tissues.

But sometimes, things don't go smoothly. Although Ramirez died within minutes after her ventilator was removed, weeks earlier another patient at Glen Cove Hospital clung to life. According to a doctor who asked not to be identified, the old man "woke up and everyone stood around wondering what to do." His heart was not ready to go, apparently. Nor was his brain.

After a grueling hour of the man looking around at his surroundings, doctors aborted the organ donation and sent him back to the intensive care unit, where he lived for another two weeks. By that time, his organs were too damaged to harvest.

Emotional and ethical issues

Families who opt for the new donation method often see it as a way to make something positive out of a terrible situation. By consenting to the donation after cardiac death, they ensure the organs will be as healthy as possible. Dr. Robert M. Arnold, a professor of medicine at the University of Pittsburgh, has been involved with a number of families who donated organs in this way. "It is a way of respecting people's wishes [to donate] while at the same time obtaining more organs for transplantation," he said.

Nevertheless, the procedure has raised ethical and medical questions. It has prompted two major meetings by the Institute of Medicine, a nonprofit advisory group that is part of the National Academies in Washington, D.C., and the organization has put out a book on the issue.

According to the Institute of Medicine's book on organ transplantation, there have been "concerns that death is hastened or that the patient's best chance at survival is compromised."

George Annas, a professor of health law, bioethics and human rights at Boston University School of Public Health, has argued that "this is a desperate attempt to get a few extra organs. The price you pay in the way you treat the patients, physicians, nurses and families is just not worth it."

He calls the process "gruesome."

"You are planning to use a person who is alive as an organ donor when they are dead," he explained. "And you are manipulating the time of death so that you can benefit someone else, certainly not the patient."

Dr. Michael Grodin, director of bioethics at the same institute, has argued against donation after cardiac death from the beginning. "It can blur the line between life and death and can ultimately backfire," he said.

"Families and patients might feel that the doctors care more for their organs than for them."

Grodin said that most people who are candidates are relatively young trauma victims whose organs are not damaged by disease. "Their prognosis is dismal, but they are not dead yet," he added.

But people whose jobs require finding transplantable organs to save lives defend the procedure and say it yields an important new source of badly needed organs.

"Families are not approached about organ donation by the patient's doctor until they have made the decision to stop care for their loved one," said Dr. Eric Grossman, medical director of the nonprofit New York Organ Donor Network. He said the process is designed so that transplant surgeons are in the next room, not close to the family or the doctors removing the life support "so that physicians are not influenced. People who have designed these policies have taken great pains to remove any substantial conflicts of interest."

'Nothing like a normal harvest'

Still, the process can be troubling for people like Justin Belin of Woodbury, a third-year medical student at Jefferson Medical College in Philadelphia who hopes to become a surgeon.

Belin was recently working with the transplant team when he was ushered by limo to a small hospital in Delaware. He'd done routine harvests -- in which the body is opened when the brain is dead, but the heart is still beating.

"This was nothing like a normal harvest," he said. "The patient was wheeled by, and I saw his face twitch." Belin draped the patient for surgery and scrubbed the man's abdomen with an antibacterial wash. Then, he and another transplant doctor were asked to wait in another room while a hospital surgeon and an anesthesiologist removed the machines keeping the patient alive.

"We just sat in the next room, waiting for this person to die -- or not die," he recalled. "Every 15 minutes, a nurse would come and give us his vital signs. The family sat at the patient's bedside, saying their final goodbyes. As it was getting closer to one hour, I didn't want him to die," Belin said. "It was OK to go home without an organ."

Exactly 59 minutes after the machines were turned off, a nurse came in and said that the patient had passed, he recalled. And that passage of time means that the body may be deprived of organ-saving oxygen. He said they worked quickly to pull out organs before they became too damaged to use.

"Perfect donor opportunity"

For some, like the family of Carolyn Ramirez, the new procedure does work out. Ramirez's son is glad that his mother's organs were donated. "She would have wanted that," Pratt said.

Joel Schlesinger feels the same way about his wife, Julia, who was the first non-heartbeating organ donor in New York back in 2002. The 41-year-old mother, a cardiac nurse, was undergoing a simple gallbladder operation when the procedure went awry. Her brain was starved of oxygen long enough to cause severe brain injury. Machines at the small hospital in Warwick, N.Y., breathed for her, but there was no chance for recovery.

That first night, Joel had gone home to tend to their two children when he looked in her wallet and found a donor card she had signed in the late 1970s.

Day by day, he watched his wife in a coma. He finally walked over to a nurse and said she wanted to be an organ donor. "It was the perfect donor opportunity," he said. "When they told me that she was [to be] the first [of this type of] donation, I was surprised."

Twenty minutes after the ventilator was removed, his wife's heart uttered its last whisper.

The moment of decision

Last year, Schlesinger, who lives in Vernon, N.J., received a note of thanks from the New York Firefighters Skin Bank. And recently he got a letter from someone who had received an organ from his wife and just wanted to say thanks.

For others, the decision is not so clear.

"The controversy is trying to predict the future," said Dr. Christian Sinclair, an associate medical director of Kansas City Hospice & Palliative Care. He sits down with families to figure out the likelihood of survival for their loved ones. "When," he asks, "do you stop considering life-saving therapy?"

Copyright 2006 Newsday Inc.


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