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CHW’s Position on Donation After Cardiac Death

CHW’s Position on Donation After Cardiac Death. Carol Bayley VP Ethics and Justice Education Ethics Champion Program. Etiquette. Press * 6 to mute; Press # 6 to unmute Keep your phone on mute unless you are dialoging with the presenter Never place phone on hold

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CHW’s Position on Donation After Cardiac Death

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  1. CHW’s Position on Donation After Cardiac Death Carol Bayley VP Ethics and Justice Education Ethics Champion Program

  2. Etiquette • Press * 6 to mute; • Press # 6 to unmute • Keep your phone on mute unless you are dialoging with the presenter • Never place phone on hold • If you do not want to be called on please check the red mood button on the lower left of screen

  3. Galloping History of Transplantation • 1955 first major organ transplantation (DCD) • 1962 immunosuppressive drugs • 1968 Harvard Brain Death Criteria • 1976 Quinlan allows withdrawal of life support • 1992 Pittsburg protocol; KIE Journal issue • 1997 60 Minutes • 1997, 2000 IOM reports

  4. Dead Donor Rule1997 IOM Report • In order to procure (“recover”) organs from a person, the person must be dead. • Seems obvious, but…

  5. Language has changed • (Brain dead donor=Heart-beating donor) • Non heart-beating organ donor (NHBD) • Donation after Cardiac Death (DCD) • Asystolic organ donation

  6. Language, cont’d • Organ • “harvest” • “procurement” • “recovery” • Organ recovery is the politically correct usage, but • “Patient allowed to die in a way that facilitates recovery.” What?

  7. There is a difference between old DCD and new DCD • Old DCD: “uncontrolled” Patient found dead; organs recovered. • New DCD: “controlled” Patient in whom recovery is extremely unlikely has life-support removed under in a controlled environment; organs recovered.

  8. Old vs New • Old DCD • Death happened on its own terms • Organs recovered but sometimes not in good condition • New DCD • Organs recovered in better condition • Death is negotiated

  9. Case • 19 year old man hung himself; he was expected to “progress” to brain death followed by organ donation; did not die. • OPO suggested DCD • 10 days later, DCD performed • Patient taken to OR; life support removed • 20 minutes later, heart stopped beating; organs taken

  10. Arguments in support of DCD • Organ donation saves lives • Pool of recipients has grown more quickly than pool of donors • 90,000 on waiting list; 6,000 die each yr • DCD may honor pt/family wish • Family may find comfort in donation • Donation nurtures altruism* • DCD supported by transplant community

  11. Arguments opposing DCD • Conflict of interest • DCD manipulates definition of death • Pro literature first argued that Dead Donor Rule not violated; now same authors argue that violation of DDR is justified. • Is it two, five or ten minutes? • Permanent and irreversible: depends on intentions of those in OR

  12. Arguments opposed, cont’d • Do No Harm • DCD procedures prior to taking organs may not be in the patient’s best interest. (Ex) • Sometimes it doesn’t work • Patient is returned to floor to die • Families may be disappointed • Pressure to succeed; strain on resources

  13. Arguments Opposed, cont’d. Informed Consent • Families are not told that testing procedures may hasten death. • Families are not told that there is a ethical debate—OPOs do not believe there IS ethical debate. • Substituted judgment difficult: very few individuals understand what is involved in process. People with pink dot signed up for something different.

  14. Camel’s nose under the tent… • 15,000—35,000 persons in PVS. Almost 2/3 of medical directors and neurologists think PVS patients appropriate for organ donation (1993) • “Controlled suicidal donation” • High C-fracture, conscious patients

  15. Delicate Consensus on End of Life Care may be jeopardized • Withdrawal of treatment is difficult • Some resist because they think we are trying to save money, or that the loved one’s life is worthless • DCD could backfire, resulting in fewer donations overall

  16. What is our duty? • Hold to CHW’s policy of no DCD; transfer when family requests. • Increase donations from brain dead patients (e.g., St John’s); increase number of organs recovered from each donor by following protocols and calling OPO promptly.

  17. Moral(s) of the Story • Dying patients are not a means to another’s end, even a good end. • Some things take time. Birth takes time; death takes time. • Patients are persons, not an assemblage of spare parts.

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