By Rob Stein
Washington Post Staff Writer
Sunday, March 18, 2007
The number of kidneys, livers and other body parts surgeons are harvesting through a controversial approach to organ donation has started to rise rapidly, a trend that is saving the lives of more waiting patients but, some say, risks sacrificing the interests of the donors.
Under the procedure, surgeons are removing organs within minutes after the heart stops beating and doctors declare a patient dead. Since the 1970s, most organs have been removed only after doctors declared a patient brain dead.
Federal health officials, transplant surgeons and organ banks are promoting the alternative as a way to meet the increasing demand for organs and to give more dying patients and their families the solace of helping others.
Some doctors and bioethicists, however, say the practice raises the disturbing specter of transplant surgeons preying on dying patients for their organs, possibly pressuring doctors and families to discontinue treatment, adversely affecting donors' care in their final days and even hastening their deaths.
Nevertheless, the number of these donations is on the rise. It more than doubled from 268 in 2003 to at least 605 in 2006, enabling surgeons to transplant more than 1,200 additional kidneys, livers, lungs, hearts and other organs.
"It's starting to go up exponentially," said James Burdick, who leads organ-donor efforts at the federal Department of Health and Human Services.
The trend is expected to accelerate this year. For the first time, the United Network for Organ Sharing, which oversees organ procurement, and the Joint Commission on Accreditation of Healthcare Organizations, which accredits hospitals, are requiring all hospitals to decide whether to allow the practice. In response, medical centers are scrambling to develop policies, sometimes sparking intense debate, especially at children's hospitals.
"It's an example of pushing the envelope to get more organs," said Stuart J. Youngner, a bioethicist at Case Western Reserve University. "Whenever we do that, we tend to step on various traditional social taboos."
The approach, known as "donation after cardiac death" (DCD), usually involves patients who have suffered brain damage, such as from a car accident or a stroke. After family members have made the difficult decision to discontinue a ventilator or other life-sustaining treatment, organ-bank representatives talk to them about donation.
Sometimes, the donor is suffering from an incurable disorder such as Lou Gehrig's disease and wants to donate his or her organs after deciding to forgo further care.
Once the decision has been made, a transplant team waits nearby so surgeons can begin removing organs soon after the heart stops. Because the heart can sometimes restart spontaneously, doctors wait a few minutes after pronouncing death before allowing the surgeons to begin. If the heart does not stop quickly, usually within an hour, the procedure is aborted and the patient is taken back to his or her room until death comes.
The practice was the norm before brain death became the standard for pronouncing death in the early 1970s and surgeons began keeping the donor's body functioning with life-support machinery until transplantation could begin. When surgeons resurrected what was then called "non-beating heart" donation in the 1990s, critics called it ghoulish and said it raised a host of ethical questions. Some called it tantamount to murder.
The National Academy of Sciences' Institute of Medicine examined the practice, however, and concluded that it is ethical as long as strict guidelines are followed, including making sure that the decision to withdraw care is independent of the decision to donate organs and that surgeons wait at least five minutes after the heart stops.
"People are dying on the waiting list," said Francis L. Delmonico, a transplant surgeon at Harvard Medical School, speaking on behalf of the United Network for Organ Sharing. More than 95,000 Americans are waiting for organs. "This is vital as an untapped source of organ donors."
Nancy Erhard's 25-year-old son, Bo, became a DCD donor at Massachusetts General Hospital in Boston in November 2005 after a burst artery caused devastating brain damage.
"There was no hope. He would never regain conscious thought," Erhard said. "This gave his life so much more meaning in the end because he was able to help so many others."
While some doctors and ethicists who initially questioned the practice have become more comfortable with the procedure, others remain troubled.
"The image this creates is people hovering over the body trying to get organs any way they can," said Michael A. Grodin, who directs Boston University's Bioethics and Human Rights Program. "There's a kind of macabre flavor to it."
Some say the practice can interfere with patients' dying peacefully, surrounded by loved ones, and can deny the family sufficient time to grieve. Many hospitals have responded by withdrawing life-support devices and other care in the intensive-care unit or allowing families to accompany loved ones to the operating room so they can be at the bedside when death occurs.
But many experts remain concerned and worry that the practice blurs the definition of death.
"The person is not dead yet," said Jerry A. Menikoff, an associate professor of law, ethics and medicine at the University of Kansas. "They are going to be dead, but we should be honest and say that we're starting to remove the organs a few minutes before they meet the legal definition of death."
In response to such concerns, most doctors wait five minutes after the heart stops before pronouncing patients dead. But doctors at some hospitals wait three minutes, others two. In Denver, surgeons at Children's Hospital wait 75 seconds before starting to remove hearts from infants, to maximize the chances that the organs will be useable.
"A lot of us are not particularly happy about cutting that line particularly close," said Gail A. Van Norman, an anesthesiologist and bioethicist at the University of Washington in Seattle.
Van Norman and others also worry that the practice could pressure family members and doctors to discontinue care, perhaps before it is undeniable that there is no hope. Those fears are particularly acute in pediatric intensive-care units, where the same nurses and doctors frequently care for both potential donors and potential recipients.
While many hospitals are adopting DCD policies, others have delayed because of objections. Some are opting out. One hospital chain went ahead but then instituted a moratorium because of concerns that the local organ bank was becoming too aggressive.
In addition to giving DCD donors morphine, valium and other drugs to make sure they do not suffer as life support is withdrawn, doctors often insert a large tube into an artery and inject drugs such as the blood thinner heparin to help preserve the organs. Some say those measures may hasten death.
"It's worrisome when you stop thinking of the person who is dying as a patient but rather as a set of organs, and start thinking more about what's best for the patient in the next room waiting for the organs," Van Norman said.
In California, police and state medical authorities are investigating whether doctors did anything to speed the death of a donor in San Luis Obispo last year.
David Crippen, a University of Pittsburgh critical-care specialist, asked, "Now that we've established that we're going to take organs from patients who have a prognosis of death but who do not meet the strict definition of death, might we become more interested in taking organs from patients who are not dead at all but who are incapacitated or disabled?"
One fear among health experts is that such concerns will discourage people from signing organ-donor cards.
Supporters, however, argue that hospitals have stringent safeguards are in place. Each case is reviewed by an independent panel, and the decision to withdraw care is separated from the decision to become a donor. They also argue that DCD patients meet the legal definition of death because there is no intention of reviving them, and that there is no evidence that anything done to the donors hastens their deaths.
"We are saying that if it is feasible and we can do it in a way that does not harm the patient, then we should do this," said Michael A. DeVita, a professor of internal and critical-care medicine at the University of Pittsburgh. "We believe it's the right thing to do for the patients who want to donate and for those who need organs."