California RNs Debate Organ Donation After Cardiac Death

By Cynthia Saver, RN, MS

March 9, 2009

Organ Procurement Organizations in California

Four OPOs serve California:

California Transplant Donor Network: Serves the following counties: Alameda, Alpine, Butte, Contra Costa, Del Norte, Fresno, Glenn, Humboldt, Inyo, Kings, Lake, Lassen, Madera, Marin, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Napa, Plumas, San Benito, San Francisco, San Joaquin, San Luis Obispo, San Mateo, Santa Clara, Santa Cruz, Shasta, Siskiyou, Solano, Sonoma, Stanislaus, Tehama, Trinity, Tulare, and Tuolumne

Golden State Donor Services: Serves these counties: Amador, Calaveras, Colusa, El Dorado, Nevada, Placer, Sacramento, Sierra, Sutter, Yolo, and Yuba

LifeSharing -- A Donate Life Organization: Serves Imperial and San Diego counties

OneLegacy: Serves Kern, Los Angeles, Orange, Riverside, San Bernardino, Santa Barbara, and Ventura counties

For many years ethicists have debated, "When does life begin?" A lesser-known ethical question now being debated is "When does death begin?"

This question stems from the practice of organ donation after cardiac death (DCD, also referred to as non-heart-beating donation). It's a procedure that significantly boosts the number of organs -- experts estimate as much as 48% -- available for the more than 100,000 people who desperately need them. For some clinicians, DCD is a boon; for others, it raises ethical questions that haven't been sufficiently answered.

Declaring Death

The Uniform Declaration of Death Act of 1980 gives two options for declaring death: 1) irreversible cessation of circulatory and respiratory function, referred to as cardiopulmonary death; or 2) irreversible cessation of all function of the brain, referred to as brain death. DCD puts the focus on the first option, cardiopulmonary death.

In a comatose patient with irreversible brain damage, after a specified time after asystole and cessation of circulation following withdrawal of life support, death is declared and organ procurement begins immediately.

Once the decision to withdraw life support has been made, the organ procurement organization (OPO) coordinator and a family coordinator, from either the OPO or the hospital, talk with the family. Julie Morgan, RN, CCRN, CPTC, procurement transplant coordinator for OneLegacy, a nonprofit OPO that serves Southern California, emphasizes, "Families make the decision for donation after cardiac death independently of withdrawing life support."

Of the 401 donations OneLegacy was involved in last year, about 40 were DCD. "The national benchmark [for DCD] is 10% of donations," Morgan says.

Speed is essential to ensure the donor's organs are in the best possible condition for the recipient, so life support is usually removed near or in the OR.

Regulations for organ donation vary slightly from state to state. As of 2007, hospitals must have a policy that addresses DCD. The physician, who must be independent of the transplant team, declares death. Death parameters are defined by the hospital, not the OPO.

Beginning in 2008, The Joint Commission stipulated that if the hospital and medical staff don't want to provide DCD and the OPO doesn't agree with the decision, the hospital must document its efforts to reach an agreement with the OPO, and the policy must address the justification for not providing DCD.

The Organ Procurement and Transplantation Network has developed 'model elements' for DCD protocols. They can be downloaded at www.optn.org.

The Controversy

Objections have arisen around several areas, including premortem care and time of death.

"Providing treatment in the interest of preserving organs is about the commitment the patient has to donate," says Lisa Day, RN, PhD, associate clinical professor at the UCSF School of Nursing.

When DCD is planned, patients are given a large dose of heparin before withdrawal of life support to keep the blood from clotting in the organs. This has drawn criticism from those who say the large dose theoretically can cause death by worsening or causing intracerebral hemorrhage, thus violating the clinician's obligation to 'do no harm'. However, there is no clinical evidence that heparin, as opposed to the underlying pathology, causes patients to die.

Day says the ethical principle of double effect has been used by both sides to defend their position. Double effect states that in some cases, an action that has an unintended, harmful effect may be defensible in certain situations such as when the good effect outweighs the bad effect and when the bad effect is foreseen but unintended. "I don't believe medications are covered by the principle of double effect because they don't benefit the patient," Day says.

On the other hand, Barbara Daly, RN, PhD, FAAN, says, "The argument for giving meds is that it's our duty to promote good." Daly is associate professor of bioethics at Case Western Reserve University and clinical ethics director at University Hospitals of Cleveland. "For this patient and family, their view of what's good is to be able to salvage some rescue in tragic situations."

Morgan adds that she explains the use of heparin to families and notes that protamine sulfate can be given to reverse heparin's effects if the patient does not die.

Time of Death

"The hospital needs to have a procedure on how to declare death," Day says. In some hospitals, that includes confirmatory tests such as intra-arterial monitoring or Doppler study.

The Society of Critical-Care Medicine recommends two minutes from asystole, but not more than five; the Institute of Medicine recommends five minutes.

Another difficulty is autoresuscitation, or the spontaneous return of circulation, also known as the Lazarus syndrome. Joan McGregor, PhD, professor of philosophy and Lincoln professor of bioethics at Arizona State University in Tempe, cites studies in which resuscitation occurred 10 to 15 minutes after the heart stopped and brain death did not occur.

"My concern is that there isn't sufficient information and dialogue and understanding about this procedure," says McGregor, who also believes there aren't enough experts outside of the transplant community included in the discussion. Like other critics, she cites the financial incentives for OPOs to obtain organs as one reason the transplant community should not drive guideline development for DCD.

The Benefits

Whatever the potential difficulties, potential transplant patients are benefitting from DCD. Also, Morgan says, "It comforts so many families for them to know that something good is going to come out of what is often tragic or senseless."

Cynthia Saver, RN, MS, is president of CLS Development, Inc., in Columbia, Md. To comment, e-mail editorCA@nurseweek.com.

This article posted July 4, 2009.