Non-heart-beating organ donation

[One of the authors responds:]

We agree that potential ethical problems accompany this type of organ donation and they must be addressed before embarking on non-heart-beating organ donation. Cameron Guest and Hugh Devitt feel it is inappropriate for physicians to approach a family regarding organ donation while the patient is still "alive." Clearly, with brain-dead patients and with severely brain-injured patients with no hope of survival, giving the bad news to relatives should not include an immediate request for organ donation: a family needs time to digest the death of a loved one. Indeed, giving the bad news and requesting organ donation at the same time does give the appearance of a conflict of interest. Studies indicate that success in obtaining consent is improved by separating the 2 events.[1, 2]

Deciding to withdraw care in the event of a hopeless situation is different from withdrawing it when brain death is declared, because the criteria are not as well defined. However, in patients with severe brain injury, there is still one more criterion to meet - cardiac arrest - before death can be declared and organs retrieved. We believe that properly informed families can understand this situation and make a decision.

With a policy for non-heart-beating organ donation in place intensivists might change the way they treat severely brain-damaged patients or change the time that they declare brain damage irremediable, to facilitate organ donation. This is a real problem that would require an oversight committee of arm's-length observers. This committee must assess every case, give timely direction to the physicians involved and review the process once completed.

The criteria for declaration of death in the operating room must not change from the normal hospital practice. The people who normally declare death - intensivists, neurosurgeons and neurologists - should do so in this circumstance. The transplant team has no role in the declaration of death.

Clearly there are potential ethical pitfalls associated with non-heart-beating organ donation. However, the existence of pitfalls should not prevent us from proceeding with caution. Proper and ongoing review of the process should be sufficient to check any slip down an ethical slope.

An increasing number of Canadians are dying without a lifesaving organ transplant. To ignore a source of organs because of a potential ethical problem creates a real ethical problem.