Chw s position on donation after cardiac death
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CHW’s Position on Donation After Cardiac Death. Carol Bayley VP Ethics and Justice Education Ethics Champion Program. Etiquette. Press * 6 to mute; Press # 6 to unmute Keep your phone on mute unless you are dialoging with the presenter Never place phone on hold

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Chw s position on donation after cardiac death

CHW’s Position on Donation After Cardiac Death

Carol Bayley

VP Ethics and Justice Education

Ethics Champion Program


Etiquette
Etiquette

  • Press * 6 to mute;

  • Press # 6 to unmute

  • Keep your phone on mute unless you are dialoging with the presenter

  • Never place phone on hold

  • If you do not want to be called on please check the red mood button on the lower left of screen


Galloping history of transplantation
Galloping History of Transplantation

  • 1955 first major organ transplantation (DCD)

  • 1962 immunosuppressive drugs

  • 1968 Harvard Brain Death Criteria

  • 1976 Quinlan allows withdrawal of life support

  • 1992 Pittsburg protocol; KIE Journal issue

  • 1997 60 Minutes

  • 1997, 2000 IOM reports


Dead donor rule 1997 iom report
Dead Donor Rule1997 IOM Report

  • In order to procure (“recover”) organs from a person, the person must be dead.

  • Seems obvious, but…


Language has changed
Language has changed

  • (Brain dead donor=Heart-beating donor)

  • Non heart-beating organ donor (NHBD)

  • Donation after Cardiac Death (DCD)

  • Asystolic organ donation


Language cont d
Language, cont’d

  • Organ

    • “harvest”

    • “procurement”

    • “recovery”

  • Organ recovery is the politically correct usage, but

  • “Patient allowed to die in a way that facilitates recovery.” What?


There is a difference between old dcd and new dcd
There is a difference between old DCD and new DCD

  • Old DCD: “uncontrolled” Patient found dead; organs recovered.

  • New DCD: “controlled” Patient in whom recovery is extremely unlikely has life-support removed under in a controlled environment; organs recovered.


Old vs new
Old vs New

  • Old DCD

    • Death happened on its own terms

    • Organs recovered but sometimes not in good condition

  • New DCD

    • Organs recovered in better condition

    • Death is negotiated


Case

  • 19 year old man hung himself; he was expected to “progress” to brain death followed by organ donation; did not die.

  • OPO suggested DCD

  • 10 days later, DCD performed

    • Patient taken to OR; life support removed

    • 20 minutes later, heart stopped beating; organs taken


Arguments in support of dcd
Arguments in support of DCD

  • Organ donation saves lives

    • Pool of recipients has grown more quickly than pool of donors

    • 90,000 on waiting list; 6,000 die each yr

  • DCD may honor pt/family wish

  • Family may find comfort in donation

  • Donation nurtures altruism*

  • DCD supported by transplant community


Arguments opposing dcd
Arguments opposing DCD

  • Conflict of interest

  • DCD manipulates definition of death

    • Pro literature first argued that Dead Donor Rule not violated; now same authors argue that violation of DDR is justified.

    • Is it two, five or ten minutes?

    • Permanent and irreversible: depends on intentions of those in OR


Arguments opposed cont d
Arguments opposed, cont’d

  • Do No Harm

    • DCD procedures prior to taking organs may not be in the patient’s best interest. (Ex)

    • Sometimes it doesn’t work

      • Patient is returned to floor to die

      • Families may be disappointed

      • Pressure to succeed; strain on resources


Arguments opposed cont d informed consent
Arguments Opposed, cont’d. Informed Consent

  • Families are not told that testing procedures may hasten death.

  • Families are not told that there is a ethical debate—OPOs do not believe there IS ethical debate.

  • Substituted judgment difficult: very few individuals understand what is involved in process. People with pink dot signed up for something different.


Camel s nose under the tent
Camel’s nose under the tent…

  • 15,000—35,000 persons in PVS. Almost 2/3 of medical directors and neurologists think PVS patients appropriate for organ donation (1993)

  • “Controlled suicidal donation”

  • High C-fracture, conscious patients


Delicate consensus on end of life care may be jeopardized
Delicate Consensus on End of Life Care may be jeopardized

  • Withdrawal of treatment is difficult

  • Some resist because they think we are trying to save money, or that the loved one’s life is worthless

  • DCD could backfire, resulting in fewer donations overall


What is our duty
What is our duty?

  • Hold to CHW’s policy of no DCD; transfer when family requests.

  • Increase donations from brain dead patients (e.g., St John’s); increase number of organs recovered from each donor by following protocols and calling OPO promptly.


Moral s of the story
Moral(s) of the Story

  • Dying patients are not a means to another’s end, even a good end.

  • Some things take time. Birth takes time; death takes time.

  • Patients are persons, not an assemblage of spare parts.


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