Sunday, October 20, 2013

How dead must a deceased donor be?

How dead do you have to be to be a deceased organ donor, and how dead can you be? Deceased donation of organs for transplantation stretches definitions, because you can't be so very dead that your organs are dead too.

Two recent papers in the New England Journal of Medicine raise this uncomfortable question...

The Dead-Donor Rule and the Future of Organ Donation

Robert D. Truog, M.D., Franklin G. Miller, Ph.D., and Scott D. Halpern, M.D., Ph.D.
N Engl J Med 2013; 369:1287-1289October 3, 2013DOI: 10.1056/NEJMp1307220
The ethics of organ transplantation have been premised on “the dead-donor rule” (DDR), which states that vital organs should be taken only from persons who are dead. Yet it is not obvious why certain living patients, such as those who are near death but on life support, should not be allowed to donate their organs, if doing so would benefit others and be consistent with their own interests.

Life or Death for the Dead-Donor Rule?

James L. Bernat, M.D.
N Engl J Med 2013; 369:1289-1291October 3, 2013DOI: 10.1056/NEJMp1308078

The increasing disproportion between the supply of donor organs and the demand for transplants as well as the tragic deaths of patients awaiting organs have encouraged the development of creative solutions to increase the donor supply. In the domain of donation from deceased donors, the protocols for organ donation after the circulatory determination of death (DCDD) have been one such response. Most U.S. organ-procurement organizations have seen organs from DCDD protocols account for a growing percentage of all organs donated from deceased donors (see graphOrgan Donation in the United States by Donor Status, 2002–2011.). In England, DCDD organs currently constitute a greater percentage than organs donated after the determination of death by brain criteria (“donation after the brain determination of death,” or DBDD).
Another innovative strategy is the kidney-donation protocol recently proposed by Paul Morrissey of Brown University.1 This protocol permits a lawful surrogate decision maker for a patient with a severe, irreversible brain injury (but who is not “brain dead”) to authorize withdrawal of life-sustaining treatment and premortem donation of both kidneys. Whereas DCDD protocols entail removal of organs after the cessation of life-sustaining therapy and the subsequent declaration of death, the Morrissey protocol provides for procuring organs while the patient remains alive. Life-sustaining treatment is withdrawn after the donation has been accomplished. The patient dies of the respiratory complications of the original brain injury, which is fatal in the absence of life-sustaining treatment.

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