Donation After Cardiac Death

Quite a handful of people knows the meaning of the term “brain dead.” A person is said to be brain dead if his/her brain no longer functions. The term is used more often in various scenarios where it is incorrectly believed that when someone is brain dead, they are not legally dead.

A greater number of people also believe that a patient that is comatose is brain-dead. Such confusions and misconceptions make it easy to understand why there are still controversies about the relationship and determination of organ donation and death. At a more basic stage, there are tangible reasons for the rationality and logic of our present definition of death and other concepts related to it to be questioned, like the so-called DDR (Dead Donor Rule) which is very important in the current procurement policy of organ donation.

History

The era of organ transplantation in clinics started in the year 1954 when a kidney transplant was carried out from an identical twin to the other by Joseph Murray. Liver transplantation and heart transplantation (the both transplantation requires organs that can only be gotten from people that are dead already) became realistic in the year 1963 by Thomas Starzl and in the year 1967 by Christian Barnard respectively.

After both heart and liver transplant, the rate of survival was low until in 1980 when cyclosporine was introduced. Cyclosporine along with some effective immunosuppressive drugs helped to increase the rate of survival and made the field of organ transplant to expand rapidly. As a result of this, the demand for more organs increased especially from people that are already dead, creating a paradox (need for dead donors and living bodies). The Harvard Ad Committee and Henry Beecher in the year 1968 laid the groundwork that is needed to resolve the paradox issue, and they proposed that a person can only be diagnosed as a dead person if there is an irreversible cessation of the entire brain’s functionality. This has since then been known as brain death, and this has been integrated into every state’s law by them accepting UDDA (Uniform Determination of Death Act) after it was announced in the year 1981.

There’s just one type of death when someone is dead, the person is dead. But as described by law, you can determine death in two distinct ways. An individual that is brain dead but is warm, and has his/her lung ventilating and heart beating is as good as dead, legally, as someone whose body is cold heart has stopped beating.

The dead donor rule (DDR) is a generally accepted belief that it not right to save one’s life by killing another. This lead to the conclusion that before removing any vital organ from someone, they should already be dead. The Dead Donor Rule (DDR) is not a regulation neither is it a law. It is just an ethical belief that insists that before the removal of any important organ from an individual, the person should be dead first. The DDR in collaboration with the Uniform Determination of Death Act guarantees families, patients, health professional, and physicians that a brain dead person is, in fact, dead, making organ extraction for a transplant that will save another life ethically and logically accepted.

After cardiac death donors aren’t really dead

In the last 15 years, as organ shortage for a transplant became more severe, the emphasis on DCD (Donation after Cardiac Death) has rapidly increased. Patients suffering from serious brain injuries but are not brain dead can still be donors of an organ if the family of the patient decides to stop life support for the patient. When they have made the decision, and have obtained the organ donation consent. The patient will be taken into the operating room, life support will be removed, and after some minutes or hours when the heart has stopped beating without ventilation or any other kind of support, the doctor pays a close attention to the patient for some time and be very sure that the heart doesn’t beat anymore. If in the next 3 to 5 minutes there is no circulation, the patient will be pronounced dead by the doctor. It is at this point the team of transplantation comes into the operating room and extract organs, more often the liver and kidney from the patient that is now dead.

Brain dead donators aren’t really dead

For over thirty years now, this current system has been effective, and it tends to be competently working. But there are some considerable controversies regarding the validity of dead donor rule, to the extent that some people recommend the abandoning of the dead donor rule. First, brain dead extermination might not be reliable. A lot of patients that meet all of the brain death criteria don’t have “irreversible cessation of the entire brain functions,” because some of the homeostatic functions are still in the stem of the brain, like electrolyte and water balance and temperature control.

To contradict this observation, many argued and said it is not every brain function that needs to inactive for a person to be pronounced dead, the ones needed are just the ones critical to keeping the body functions’ integration. When these critical functions of the brain are lost, this will result in hours or even days of cardiac arrest, even with the presence of intensive life support. Yet, despite the fact this is usually true, some patients’ bodies that met the brain death criteria can survive for several years with all the function of their bodies intact excluding the reflexes of the brain stem and consciousness.

Withdrawing life support leads to death

Ever since the decision made by the Supreme Court in New Jersey over the case of Karen Ann Quinlan in the year 1976, a norm that is accepted universally is that withdrawing life support doesn’t cause the death of a patient, instead, life-support withdrawal only allows the person to die, it’s the disease the patient has that causes the death of the patient. Yet, this doesn’t seem to be correct, because the doctor is the person responsible for the proximate cause of the death of the patient. Troug and Miller gave an illustration of this scenario with a clinical situation that is identical, the two patients both depend on a ventilator. One of the patient’s ventilator was removed by someone who wanted the patient dead, and the other patient’s ventilator by a doctor in accordance with the request of the patient to take away life support technology. It is obviously contradictory to say that death was the fault of the person that removed the ventilator in the first case (therefore being convicted of murder). But in the second scenario, the doctor that removed the ventilator did not cause the death, but the death was caused by the disease the patient is suffering from.

There is clearly a huge difference between the two cases, but the agent that caused the death in both scenarios is the person that disconnected the ventilator (life support).

Although life support withdrawal (not the disease of the patients) lead to death, it isn’t a morally or legitimately responsible act. The argument that death is caused by life support withdrawal is a non-sequitur and unethical because the main problem here is not what caused the death, but the principle that is overridden as regards to the respect of the anatomy of the patient. The self-determination right can be expressed directly by someone who is competent or via an advanced directive, or by the patient’s appointee or a surrogate agent that is legally appointed. This is a well-established process in law and ethics, and it is not undermined or modified by acknowledging that life support withdrawal is what causes death. Therefore the doctor that removes life support caused the death of the patient but is not morally or legitimately responsible for the action.

Recovering vital organs from nearly dead patients is accepted ethically

If patients that are brain dead are close to death but not entirely dead, it is ethically grounded to recover vital organs from them. Since the year 1968, brain death diagnosis has been comprehended to make valid both vital organs recovery and life support withdrawal, and there is no change when brain dead patients are certified to be in an irreversible coma state, but alive still, they still meet UDDA conditions. Given a consent that is needed for organ donation and for life support withdrawal, if it’s satisfactory to cause the death of a patient with brain death by life support withdrawal, then it must also be logically agreeable to cause the death of the patient by recovering the vital organs before from the patient before withdrawing the life support of the patient.

In the scenario of donation after cardiac death (DCD), the same action comes to play if when the patient is very close to death, and an artificial ventilation is used to support the patient. If the self-determination right is exercised by the patient or their proxy surrogate decision agent by first giving the consent for every life support to be withdrawn and then giving consent again for vital organs to be recovered. An event chain set to play that leads to the patient’s death. The patient is not done any wrong or harm by the event chain, so these should not be perceived as an act criminality.

The reality that patients that are brain dead are not actually dead before they recover vital organs from them, and that donation after cardiac death (DCD) donors are going to die very soon but aren’t dead yet. This means that present organ donation practices from both DCD donors and brain dead patients aren’t constant with dead donor rule (DDR). But such practices are legitimately and ethically grounded.

Conclusion

The act of ignoring the dead donor rule has implications that are radically hypothetical. The doctor that removes the life support of the patient causes the death of the patient (not the disease involved), brain death doesn’t comprise the death of a patient, and organs are recovered from donation after cardiac death (DCD) donors that are already dying, but not already dead. However, practically ignoring the dead donation rule (DDR) has some implications attached to it. The only change in the donation of organs brains dead patients that donate organs would be when death declaration is not present before the recovery of vital organs. Whereas in donation after cardiac death (DCD) donation, there won’t be any death declaration before the recovery of organs. This helps to reduce long delays in the wait for cardiac arrest and the long wait for death declaration, contributing to a healthier transplant of the organ.

We don’t know if dropping the dead donor rule (DDR) will result in a general decrease or increase in the donation of organs. There isn’t any data to prove this. But that’s not the primary issue. The primary purpose of ignoring the DDR is to pursue and honor truth. This is the same reason why doctors are required to be truthful and honest when they are dealing with patients.