New protocol increases both donations, worries

The decision of the parents of a Colbert car crash victim to donate their daughter’s organs was aimed at wringing hope from tragedy.

Gabriella Autry’s tiny heart, liver and kidneys likely saved the lives of three children in a region where 38 kids under age 18 were waiting for organs this week. Nationwide, more than 96,000 people of all ages are awaiting transplants, according to the Organ Procurement and Transplantation Network.

“She was young, she was healthy,” explained Belle Autry, the toddler’s mother. “We’re both donors; we thought she should be, too.”

For Belle Autry and her husband, Steve, the choice was mercifully straightforward. Gabriella was declared brain-dead, meeting a long-recognized – if complicated – standard for organ donation.

Increasingly, however, that’s not the case.

Hospitals in Spokane and across the country have been forced to consider a controversial method of donation that aims to increase the number of available organs, but also raises questions among some ethicists and practitioners worried about blurring the line between care for the dying and hope for those who wait.

Starting this year, transplant centers nationwide are required to adopt protocols for a procedure known as “donation after cardiac death,” or DCD, a technique in which doctors remove livers, kidneys and other organs within minutes after a person’s heart stops beating, instead of after brain death is declared.

Officials at Sacred Heart Medical Center and LifeCenter Northwest, the region’s organ transplant network, said they long ago resolved questions about the practice, which has been conducted in Spokane since about 2001, including three times last year.

“We’ve been on board since Day One,” said Dan Ritchie, a chaplain at the Inland Northwest’s leading transplant center. “Sacred Heart just knows it’s the right thing to do.”

But that view is not universally accepted. Some ethicists and practitioners in Washington and across the country are concerned that the procedure has the potential to devalue donors, perhaps leading caregivers to alter medical treatment or even hasten death.

“Individuals deserve respect and care and valuing even when they’re dying,” said Dr. Gail A. Van Norman, an anesthesiologist and bioethicist at the University of Washington in Seattle. “We cannot be seeing them as a commodity we can use for someone else until their last breath is taken and their last heartbeat ends.”

The number of DCD cases nationwide has increased exponentially in recent years, rising from 118 in 2000 to 645 in 2006 and allowing collection of more than 1,000 additional organs, according to the United Network for Organ Sharing, or UNOS. In the region that includes Washington state, 27 transplants were from DCD donors last year, nearly 20 percent of the 139 total donors, according to LifeCenter Northwest.

To Dr. Jim Shaw, the medical ethicist at Sacred Heart Medical Center, the reasons are clear.

“The number of brain-dead donors is decreasing and the need for donors is increasing,” he said.

Better safety equipment, more efficient emergency care and advances in medical technology mean that fewer people suffer injuries that culminate in a diagnosis of brain death, which is determined by a precise series of neurological and other examinations, Shaw noted.

For nearly 40 years, that’s been the standard for the withdrawal of life support and the principal requisite for the donation of organs, according to the New England Journal of Medicine.

But in the past several years, transplant advocates have urged consideration of DCD, not only to meet growing demands for organs, but also to allow patients and their families to honor the wishes of the dying.

It has been frustrating to some families whose loved ones have suffered irreversible brain damage, but who did not meet the definition of brain death, to be told they couldn’t donate organs, Shaw said. Before brain death was the standard, he added, death was determined when a person’s heart stopped.

“It’s revisiting an area where organ donation is very feasible. It’s developing an appropriate way to honor their wishes,” he said.

At Sacred Heart, as elsewhere, practitioners adhere to ethical guidelines and practical procedures that retain the value of the dying patient, he said. First, the difficult decision to withdraw life support is made independently of any discussion about organ donation. Teams of medical personnel are kept separate, and the care of the dying person remains paramount.

“Some people think the organ procurement people are off trying to retrieve organs from people who don’t want it,” he said.

Nothing could be further from the truth, said Monica Johnson-Tomanka, vice president of donation services for LifeCenter Northwest and a board member for UNOS.

“By the time we’re in the picture, the family has made the decision to withdraw life support,” she said. “With DCD, it’s what laypeople understand better than brain death. The general public thinks you donate your organs after your heart stops.”

Under Sacred Heart’s protocol, life support is withdrawn and the heart is allowed to stop. If the heart doesn’t stop within 60 minutes after life support is withdrawn, the patient is returned to a room for comfort care, Shaw noted.

Once the heart stops beating, surgeons wait two minutes before they begin harvesting organs. Some hospitals wait five minutes. Time is crucial because organs must be retrieved within two hours or less to remain viable. A liver, for instance, must be transplanted within an hour.

But Van Norman, the UW bioethicist, said she and others worry about that narrow window – and about the specter of a transplant team hovering nearby.

“Is two minutes enough?” she said. “We’re defining this window more and more narrowly, not because we think it’s the best thing for the donor, but we’re doing it because we’ve already frame-shifted away from the donor.”

In addition, she said, there’s the possibility caregivers will become less concerned about treatment that eases pain for the dying patient and more concerned about treatment that optimizes the sought-after organs.

At Sacred Heart, when DCD cases do occur, life support is withdrawn while the patient is still in the intensive care unit, typically with family members at their side. After the heart has stopped, the patient is transferred to the operating room, where a transplant team retrieves the organs.

After 15 years of counseling families in crisis about organ donation, Ritchie, the hospital chaplain, said most are relieved to have the option, DCD or no.

“When you approach a family for organs or for tissue, it is remarkable,” he said. “It takes it from an area of just total grief to an area of just total hope. It is the most powerful thing.”