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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
slide9
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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