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Infant Heart Transplant Controversy Continues
Date:8/13/2008

3 new reports raise question of how long a heart must stop beating before death is certain,,,,

WEDNESDAY, Aug. 13 (HealthDay News) -- Three new reports challenge current guidelines on how long after cardiac death doctors must wait before taking a heart from an infant organ donor.

There's no question that organ donation saves lives, and there's also no question that there aren't enough donor organs to save everyone on the transplant list. However, deciding who is a suitable organ donor, particularly when the potential donor is an infant, is not so clear-cut.

Most people are familiar with the concept of organ donation after brain death, but organ donation is also permissible after cardiac death. Cardiac death occurs after life support is withdrawn, and the heart stops on its own. Because the heart can sometimes restart, the Institute of Medicine recommended in 1997 that 5 minutes should elapse between the time the heart stops and the organ retrieval begins. More recently, however, it's been suggested that cardiac death becomes irreversible after just one minute.

Now, in the Aug. 14 issue of the New England Journal of Medicine, surgeons from Denver Children's Hospital report on three cases in infant heart donors where surgeons reduced the time between when the heart stopped and when organ retrieval began. In one case, the time was shortened to three minutes, and in the other two to just 75 seconds.

The reason doctors might want to shorten this interval is to reduce the time that transplantable organs are deprived of oxygen, which likely increases the success of transplants. Doing so might also help increase the number of available organs for donations, which is important because as many as one in four babies awaiting a heart transplant dies while on the waiting list, according to the study.

"Donors who died from cardiocirculatory causes offer an opportunity to reduce waiting time and waiting-list mortality among children whose survival depends on a heart transplant," wrote the Denver doctors.

In two of the four accompanying perspective pieces in the same issue of the journal, two experts with normally divergent viewpoints on this issue, agreed on one thing: Under the current definition of cardiac death, cardiac function must be irreversible, and by definition, if cardiac function is irreversible, how can such a heart then be placed in another person where it starts beating again? Clearly, the loss of cardiac function was not irreversible, according to Dr. Robert Truog, director of clinical ethics from Harvard Medical School, and Robert Veatch, a professor of medical ethics from Georgetown University.

"I don't know how you can ever have a patient that meets the criteria for irreversible loss of function, and then reverse that function in someone else," said Veatch. Using other organs after cardiac death is possible, he said, but if surgeons are declaring someone dead because their heart has stopped, then under the current law, that heart shouldn't able to be used in someone else, no matter how long surgeons wait.

Truog also thinks the debate over how many seconds to wait before declaring cardiac death misses the point. "If death means irreversible loss of cardiac function and that heart beats in someone else's chest, it's not irreversible, is it?"

He said the debate over whether transplant surgeons are hastening death is similar to the debate over whether or not withdrawing mechanical ventilation was killing a patient or not from 30 years ago. Today, he said, many deaths occur in intensive care units when mechanical ventilation is withdrawn.

If a patient, or in the case of an infant or a child, the patient's surrogate, provides consent for organ donation prior to cardiac death, Truog said in his perspective, "With such consent, there is no harm or wrong done in retrieving vital organs before death, providing that anesthesia is administered. With proper safeguards, no patient will die from vital organ donation who would not otherwise die as a result of the withdrawal of life support."

Veatch takes a more conservative stance on organ procurement, and said he believes that most local organ procurement organizations wouldn't support the Denver procurements, no matter how successful the transplants may have been.

Veatch said, ideally, people would have a choice when they decide to become organ donors, and that choice would include organ donation after whole brain death, organ donation if you've suffered a permanent loss of consciousness, and cardiac death. Currently, organs are only harvested after whole brain death or cardiac death, according to Veatch, and he added that only New Jersey offers organ donors a choice with these options. But, he said he believes that many people, if offered the choice, would choose to have their organs donated if it was determined that they were in a persistive vegetative state.

Truog said the debate isn't likely to end soon, and sometimes, more than medical personnel get involved in these highly controversial decisions. In one case in California, prosecutors brought three felony charges against a transplant surgeon that they believed hastened the death of a disabled and brain-damaged organ donor. A judge has already dismissed two of the charges, and the doctor's lawyers have recently asked the judge to dismiss the remaining charge, asserting that the physician's actions were consistent with the usual standard of care.

More information

Read more about organ donation at the American Heart Association.



SOURCES: Robert Truog, M.D., professor, medical ethics and pediatric anesthesia, director, clinical ethics, Harvard Medical School, executive director, Institute for Professionalism and Ethical Practice, and senior associate, critical care medicine, Children's Hospital Boston; Robert Veatch, Ph.D., professor, medical ethics, Kennedy Institute of Ethics, Georgetown University, Washington, D.C.; Aug. 14, 2008, New England Journal of Medicine


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