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Death, donation and deliverance

by: LAWRENCE M. SHUER

Occasionally a medical procedure transcends its health care and scientific role to become a legal, cultural and historical phenomenon. So I don't think I'm being melodramatic when I say that heart transplantation, developed and then nurtured at Stanford, fits this larger-than-life category.

Although he did not receive credit for the world's first heart transplant - the headlines in 1967 went to Christian Barnard of South Africa - Stanford's Dr. Norman Shumway turned a highly experimental and controversial technical innovation into what today is standard care and is often cited as the centerpiece of a broad range of organ transplantation occurring every week at SHC. Dr. Shumway's world-changing role as a clinician and researcher has been often cited, but another arguably equal accomplishment was the persistence and boldness he and his team exhibited to promote the highly controversial procedure which helped clarify the concept of brain death - the criteria that for many years legitimized and legalized cadaver transplantation of organs. To illustrate, look back to 1973, when an attorney sought a murder defendant's acquittal by contending that it was Dr. Shumway, not his client, who had killed a gunshot victim by removing his heart for transplant. The defense didn't fly, and brain death was well on its way - despite millenniums of heart-centered poetry to the contrary - to becoming the criteria for human life. Yet in 2005, even as the concept of brain death is gaining credence globally, we find that technology and society's values require us to continue to reevaluate our criteria for life and death in a medical setting.

I have always believed that organ donation offers a family a chance to make something constructive, sometimes even wonderful, happen from a tragedy that brought a loved one to the brink but not finality of certain death. Nevertheless, at SHC we often face patients who do not officially meet the legal and hospital criteria for brain death, but who nevertheless suffer from injuries or illnesses that will inevitably end their life. In those situations, we face a dilemma, because we have not had hospital policies or procedures to facilitate organ donation.

This lack of a relevant donation policy has led the Ethics Committee and caregivers to observe that many families have been deprived of the satisfaction of seeing someone receive the "gift" of a new organ (heart, lungs, kidney, liver, etc.) from their loved ones. I can recall one family who wanted us to transfer a terminally comatose but not legally brain dead relative to another hospital where policies were in place to allow the end-of-life patient to donate organs.

Because of this sad and unnecessary disconnect between the reality of certain death and the technicalities and legal definitions that mark the end of some lives, the Medical Center has developed and proposed a new policy - the "Organ Donation After Cardiac Death Policy," otherwise known as the non-heart beating organ donors policy (NHBOD).

This policy, which will be presented to the Medical Board for consideration in March, applies when patients are a) kept alive solely by artificial life support, and b) the family and/or appropriate surrogate decision maker has explicitly designated the patient as an organ donor based on the patient's known wishes and/or a futile medical prognosis. In these situations an Ethics Committee consult will be required to assess the appropriateness of the request and the absence of a conflict of interest. If donation is deemed appropriate, the transplant network coordinator will be contacted to assess the suitability of the patient as a donor and to speak with the patient's surrogate and/or family regarding the donation.

More specifically, patients who would be considered candidates for this procedure must meet the following criteria:

1) The patient's terminal condition must be diagnosed and the patient must have a known cause of death without a known medical condition that would exclude organ donation. (The transplant network coordinator can assist in this determination).

2) The patient must have a non-recoverable illness or injury that has caused neurologic devastation, even if the patient does not fulfill the criteria for brain death and/or the patient has other systemic failure resulting in ventilator dependency.

3) The health care team should agree that death would likely occur within two hours after life support is withdrawn.

The following steps will then be taken to begin the process of organ donation for patients meeting both the above criteria, particularly the surrogate's explicit decision to donate:

A) The transplant network coordinator will have made the arrangements for organ and tissue procurement.

B) The donor will be taken to the operating room for the purpose of withdrawing support.

C) Cardiac death will be declared after five minutes of unresponsiveness, apnea and absent circulation (as measured by echo or intra-arterial catheter pressure).

D) A single physician not part of the organ procurement or transplantation process will be required to certify death.

E) Families of patients who become non-heart beating donors will receive psychosocial support and may request to be present at the time of death but will need to leave the room shortly after death to facilitate the organ and tissue procurement.

It is understood that the applicable transplant network is responsible for all costs related to the evaluation and recovery of organs for transplantation.

I believe this is an important policy and issue for the Medical Board to consider and for all of us to ponder and discuss, especially at this time when we face a severe national shortage of organs for transplantation. For example, the United Network for Organ Sharing reported that 87,571 persons nationally were on its waiting list on Feb. 25.

The more we can facilitate increasing organ availability, the more lives we can help. Sensitive policies will not only allow us to provide organ donations for patients who desperately need them, but they will also provide more compassionate opportunities and support for families.

If you have comments regarding our proposed organ donation policy or want to comment on this issue in general, I would welcome your e-mails at lshuer@ stanford.edu. You could also contact David Magnus, Ph.D., dmagnus@stanford.edu, or Jose Maldonado, M.D., jrm@stanford.edu, co-chairs of the Ethics Committee.

Let's continue Stanford's bold pioneering and innovative traditions of advancing medical progress to serve patients and families by connecting our policies to the cultural, social and scientific realities of the world we live in.

(lshuer@stanford.edu)