Organ donation

The ‘dead donor rule’ sets guidelines or organ harvesting

A friend of mine, a doctor, gave me a brief document. “You are doing transplant surgery,” she said. “You must read this.”

The document is a “statement of concern” issued by the American College of Physicians (ACP). It describes a procedure called “normothermic regional perfusion (PRN) with controlled donation after circulatory determination of death (cDCD)”.

NRP-cDCD is done with the goal of obtaining healthier organs for donation when those organs are more susceptible to ischemic damage after circulation has stopped.

Keeping perfused organs in situ allows more time to assess organ function before it is transplanted.

Made in other countries, now offered for use in the United States

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The way the NRP-cDCD works is that after a patient is considered to have “circulatory death” (defined as death confirmed by irreversible cessation of circulatory and respiratory functions), the chest is opened and the large vessels are connected to a bypass machine or ECMO Circuit (extracorporeal membrane oxygenation).

Blood circulation is thus restored to preserve the organs for donation, but only after occlusion of the carotid and vertebral arteries to prevent reperfusion of the brain.

The heart can then resume its beating, calling into question the determination of irreversibility that was required for the diagnosis of circulatory death.

Because the brain is denied a blood supply, the term “regional perfusion” is used and brain death quickly follows.

The CPA press release specifies that this procedure is called “organ harvesting after cardiopulmonary arrest and induction of brain death” and calls into question the ethics of this approach.

The “dead donor rule” says that donors cannot be killed to obtain their organs and that organ harvesting cannot cause death.

PNR resuscitates the patient, with the exception of the brain.

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The ACP asks “Is declaring a patient dead according to irreversible circulatory criteria, then rendering the patient brain dead before restoring circulation honest, transparent and respectful of the patient’s autonomy and dignity?”

What if the donor or the donor’s family has given consent? Can laymen who are not physicians or medical experts be made aware of all the details of what this protocol entails?

The ACP asserts that “informed consent in itself cannot confer ethical legitimacy on the PNR-cDCD”.

In addition, the standards of medical ethics do not allow consent to take precedence over all other ethical considerations.

There are existing alternatives. Organs can be removed and then reperfused using machines outside the body.

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In what strikes me as an understatement, the CPA says “that there is an important and ethically significant difference between perfusion of an organ and perfusion of an individual”.

My driver’s license testifies to my willingness to be an organ donor if the situation arises. But I hope they don’t make NRP-cDCD for me.

“So what’s your response to that?” My doctor friend asked.

“We don’t do any of that with corneal donors,” I replied.

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