The number of people waiting for organ transplants in the United States increases every year. More than 120,000 are currently on waiting lists, yet only about 27,000 transplants were performed in 2013 from around 13,000 donors.
While organ donation organizations and transplant centers around the country—including the University of Chicago Medicine—work to increase public awareness of the urgent need for more organ donors, some members of the medical community have proposed increased use of donation after cardiac death (DCD) as another strategy to grow the pool of available organs. But the practice is fraught with controversy and ethical considerations.
In a recent article in the journal Academic Emergency Medicine, UChicago emergency medicine physician and bioethicist Aasim Padela and his colleagues on the Society of Academic Emergency Medicine’s ethics committee, Jeremy Simon of Columbia Unviersity and Raquel Schears of Mayo Clinic, explain how these issues pose challenges to more widespread adoption of DCD
Cardiac death occurs when a person’s heart stops beating, either in the hospital or in an emergency situation outside the hospital when a patient doesn’t respond to resuscitation. Only around 5 percent of organs donated in the United States come from donors after cardiac death; however, it’s estimated that more than 20,000 patients who die from cardiac arrest outside the hospital each year may be eligible to donate organs, potentially doubling the pool of candidates.
Most organ donation occurs after a patient has been declared brain dead, or when the brain has lost the blood supply of oxygen and medical tests show a complete loss of function. Although the declaration of brain death can be controversial, Padela says there is greater acceptance of donation after brain death where the heart is still beating, rather than declaring someone dead after their heart stops in the field and then having EMS perform CPR or other measures to preserve organs for donation.“There is an understanding by the lay community that when a person is declared brain dead, this person is dead. We even use that term, ‘death,’” he said. “There are controversies around that, but when you see someone who is in the hospital and has no cerebral function, that, I think is easier to accept as a situation where physicians may procure organs with consent.”
The difference, especially in an emergency department scenario, Padela said, is the impression that doctors could take actions to potentially reverse cardiac death but decide not to. For example, emergency responders or physicians can continue performing CPR, or place a patient on heart bypass. Declaring cardiac death means they have to make a decision to stop trying to resuscitate the patient.
Padela says in a case where the patient is a potential organ donor, this can lead some patient families to question the priorities of doctors and first responders. Did they try hard enough to save their loved one’s life, or were they more interested in procuring the organs?
“Let’s say the EMS providers haven’t been able to get a pulse back, and they declare death. But if they think there might be an organ donation possibility, they have to start CPR in the field,” Padela said. “If you’re from the family, you’re thinking, ‘What’s going on here? They just declared death but now they’re starting CPR again.’”
To overcome this confusion and perception of conflict of interest, in New York City, two EMS teams arrive for out-of-hospital cardiac arrests. The first team tries to resuscitate the patient, regardless of organ donation possibilities. If those attempts fail and the deceased is a candidate for donation, the second team takes over and coordinates organ retrieval with a team at the hospital.
A second route to overcoming objections to donation after cardiac death, Padela says, is increased education in the patient community and among medical providers about the special circumstances of DCD and the urgent need for more organ donation in general.
“There’s such a stark disparity in the number of organs needed versus how many transplants actually happen. We need to have town hall-type meetings with the community and our colleagues to talk about how we might do this,” he said. “We need to start having conversations about what we feel will be the ethical challenges and how we’ll negotiate them, so all patients and clinicians alike are aware and thinking robustly about all of the issues.”
Simon J.R., Schears R.M., Padela A.I. & Goldstein J.N. (2014). Donation After Cardiac Death and the Emergency Department: Ethical Issues, Academic Emergency Medicine, 21 (1) 79-86. DOI: 10.1111/acem.12284