The notion of organ donation after cardiac death (DCD) came into prominent public view in 1993, with the national awareness of the Pittsburgh Protocol.[1] More recently, the U.S. Department of Health and Human Services, through the Organ Transplantation Breakthrough Collaborative, strongly encouraged increased recognition and use of DCD in an attempt to increase the number of organs available for transplantation. Even more recently, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has stipulated that hospitals must have a DCD policy in place as of January 2007 in order to maintain accreditation. Consequentially, whereas some years ago, we might have sagely nodded our heads thinking, “this too will pass,” it is now quite apparent that the issue will not.
As a process, DCD allows the determination of cardiac death (in contrast to brain death) to contribute to the worthwhile goal of increasing the pool of available organs for donation. Historically, death was determined by simple observation: looking for breathing, feeling for a heartbeat. If neither was present, the person was declared dead (in essence, cardiac death). With the development of cadaver organ transplantation, the Dead Donor Rule was established early in the 1960s. This rule holds that it is unethical to cause death by procuring organs, and it is unethical for organ procurement to precede death (with the exception of selected donations such as a single kidney or a lobe of the liver). In 1968, the Harvard Brain Death Criteria, based on brain stem function, was defined.[2] Since then, every state has adopted into law some form of this definition.
Brain death was offered primarily because of quandaries involving intensive care units—the need to withdraw ventilator support in patients with irreversible coma coupled with issues of appropriate allocation of limited resources. Secondarily, as the science of organ transplantation advanced, these patients—after being declared brain dead—might become a source for organ donation and transplantation; with brain stem function criteria for death, transplantation could be encouraged and developed. In so doing, brain death became a recognized standard in the medical (and non-medical) world.
The next important historical step was the Uniform Determination of Death Act (1991), which stated, “An individual, who has sustained either irreversible cessation of circulatory and respiratory function, or irreversible cessation of all functions of the entire brain, including the brain stem, is dead.”[3]
DCD is an organ procurement procedure that relies on the declaration of death being made based on a lack of cardiopulmonary function (i.e., the heart and lungs stop functioning). These patients have suffered a severe neurological injury from which they most probably 1) will not regain any substantial and meaningful recovery and 2) will not proceed to brain death. Currently, many hospitals limit the potential donor pool to patients who have had catastrophic brain injuries and essentially no hope of significant recovery. Some hospital policies may allow DCD in patients who require continuous life-sustaining mechanical support for chronic illness and who will most likely not recover. When first evaluating DCD, a rather narrow category of inclusion is probably easier to consider and seems to be less problematic in application. In addition—and in order to safeguard the process—many hospitals require the participation of the Ethics Committee as part of the evaluation for the DCD process.
The DCD process must be transparent. That is to say, a combination of open communication, honor for the patient and family, and dignity for the process is required. The first step is taken by the patient (or the patient’s surrogate) with the primary care doctor who is assessing the patient’s medical condition and prognosis. The patient or surrogate—in conjunction with the family and physician—must decide about withdrawal of life-sustaining mechanical support. The patient’s personal preferences on this point should be awarded primary authority. The actual decision to consider organ donation must be an entirely separate process. Direct family contact by the Organ Procurement Organization (OPO) and discussion of organ donation must take place only after the decision to withdraw life-sustaining treatment has been made. In many cases, notification of the OPO (by hospital staff) is mandated in a situation where the death of a patient appears to be imminent and there is a possibility of organ donation. However, direct OPO contact with the family is assiduously avoided at the stage where decisions are made regarding withdrawal of life-sustaining treatment.
The next consideration relates to inclusion in the pool of potential organ-donating patients. This involves recognition of the fact that these patients are not brain dead, and that they are not expected to meet the Brain Death Criteria. The primary consideration for inclusion in the pool of potential donors is likelihood of meaningful recovery. Many, if not most, of these patients will have suffered a severe and devastating traumatic brain injury. Brain Death Criteria cannot be met, but there is essentially no hope of substantial recovery, and there may indeed be anticipated secondary consequences such as herniation, stroke, or massive infection.
However, in substantial contrast to this position, some hospital policies may allow patients with long-standing chronic conditions who require life-sustaining support to remain alive to become DCD candidates. This is a primary concern of many who advocate for patients with various types of “chronic conditions” who are viewed as unprotected or unwanted.[4] For example, many patients who are mentally retarded require ventilator support for breathing, and postoperatively, some type of intermittent or chronic mechanical support may be required. It is conceivable that some hospital policies would allow the withdrawal of life-sustaining therapies in a patient with mental retardation, without the rigorous consideration and control given to a non-retarded patient.
There are a number of specific issues regarding the medical facets of the DCD process. First, the primary care doctor (or her appointed representative) must declare the cardiac death. While the transplantation team is readily available, it would be both a conflict of interest as well as a medical impropriety for a member of the transplantation team to declare the patient’s death. Second, certain medications add to the viability and improved oxygenation of the organs to be recovered for transplantation. However, one must also recognize that these medications may hasten death. Consequently, most policies prohibit administration of these medications until after death has been pronounced. The final issue of medical awareness is the knowledge of what happens if the patient does not proceed to cardiac death. Most policies establish that if, after a period of one hour after the withdrawal of life-sustaining therapies, the patient is not declared dead on a cardiac basis, organ transplantation cannot proceed (the organs are damaged by hypoxia), and the patient is placed in an appropriate hospital unit and provided with comfort measures.
Perhaps the most troubling concern regarding DCD relates to the difference between dying and being dead. How do we know when death occurs? Even though this is such an important question, we might not be able to arrive at a specific answer. Initially, the Pittsburgh Protocol used a period of two minutes without a heartbeat in order to define cardiac death, but many felt that this was not long enough. Currently, most hospital policies follow the recommendations of the Institute of Medicine: waiting at least five minutes with no heartbeat and no meaningful cardiac electrical activity.[5] This longer period certainly is more reasonable, and allows a generous window for the possibility of spontaneous recurrence of the heartbeat. Nevertheless, it is interesting to recognize that the question of knowing exactly when someone dies remains unanswered. This issue may very well be epistemological; it might be the case that we simply cannot know precisely when death occurs.[6] As a consequence, we use somewhat nebulous terms such as the “moment of death.” Condic observes that there is loss of integrated bodily function and death occurs when “. . . the body ceases to act in a coordinated manner to support the continued healthy function of all bodily organs.”[7] This definition implies a process—that there may indeed be an ambiguous (somewhat indefinable) “instant” that death occurs.
According to 2006 data, a new patient is added to the organ transplant waiting list every thirteen minutes.[8] Organs harvested after death are truly “gifts of life” and are a very precious resource. Since God has given humans dominion, and we are “keepers of the garden while the Master is away,” what should be our response? Certainly, our Christian-medical duty is to help those who are suffering. In addition, we must recognize that—for the believer—death is not to be feared, and, in fact, “. . . to die is gain . . .” (Phil. 1:21). Nevertheless, our charge—as physicians and caretakers—is to provide competent compassionate care for both the patient and the family.
DCD is a difficult ethical problem with roots that are deep in the past (how do we know when a patient is dead), coupled with a blossom that is pleasing to the eye of the future (organ donation for research or transplantation). Some declare the DCD process to be a secular and utilitarian argument evolving from the tremendous need for organ donation. As a result, medical science relies on the concepts of brain death and cardiac death. Yet an important question remains: does the current medical-legal terminology accurately and adequately define death or is it simply a stipulated point in the dying process? It seems reasonable to assert that, as Christians living in a world of limited knowledge, we may not be able to ascertain exactly when death occurs. And yet, given the appropriate medical evidence (no heart beat or breathing) it is ethically permissible to allow the declaration of death at the bedside.
Donor after Cardiac Death is a complicated issue. Christians may not agree about the need of, or a desire for, the DCD procedure. Nevertheless, it is now part of the medical armormentarium because of the medical need for organ donation and because of JCAHO fiat for hospitals across the nation. DCD is an issue where Christians may take an important and active stand. Accurate knowledge about your hospital’s policy is a good first step. Individual participation through the hospital administration, medical staff, or ethics committee may be possible depending on hospital transparency and individual qualifications. Through such activity, we can honor God and our fellow man in both word and deed.
In my view, the DCD procedure is ethically permissible with strict guidelines for patient selection and with careful codification of the policy and procedure. Respect for life and the dignity of death must be simultaneously maintained. In so doing, as Christians, we must humble ourselves before God and our neighbor.
[1] Although this may seem somewhat recent, Christian Barnaard actually used this definition of death in his pioneering work in cardiac transplantation in South Africa. The Pittsburgh Protocol was described in M. Devita and J. Snyder, “Development of the University of Pittsburgh Medical Center policy for the care of terminally ill patients who may become organ donors after death following the removal of life support,” Kennedy Inst Ethics J 1993; 3:131-144. A key piece of the protocol was the observation time period of two minutes following the removal of life support before the declaration of cardiac death was made. Many observers felt that this period of time was inadequately short.
[2] See “Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, A Definition of Irreversible Coma”, 205 JAMA 337 (1968).
[3] Citation Uniform Determination of Death Act, 12 U.L.A. 340 (Supp. 1991).
[4] Nancy Valko, “Non-Heart-Beating Organ Donation: Are We Manipulating the Death of Some Persons to Get Organs for Others,” The Center for Bioethics and Culture, Summer 2004.
[5] Roger Herdman, John T. Potts, Non-Heart-Beating Organ Transplantation, The National Academy Press, 1997.
[6] This is taken from unpublished personal communication.
[7] Maureen L. Condic, “Life: Defining the Beginning by the End,” First Things, May 2003, pp. 50-54
[8] Upstate New York Transplant Services, 2006
