Debate Renews over Timing of Death

Abstract

American Journal of TransplantationVolume 8, Issue 12 p. 2482-2482 Free Access Debate Renews over Timing of Death First published: 11 November 2008 https://doi.org/10.1111/j.1600-6143.2008.02496_2.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Abstract This month The AJT Report looks at how CMS regulations on transplantation outcome measures could affect which patients are selected to receive transplants, as well as new research that is re-igniting the debate over timing of death. An article in the New England Journal of Medicine (NEJM) has renewed debate about when cardiac death occurs.1 Is it five minutes after heartbeat ceases, as recommended by the Institute of Medicine (IOM),2 or as little as two minutes, as recommended by the Society of Critical Care Medicine?3 The NEJM article reported that Denver surgeons had pushed the limits even further,waiting only 75 seconds after cardiocirculatory death to remove hearts in two of three cases reported. In a commentary in the same NEJM issue, one article noted that “if a heart is restarted, the person from whom it was taken cannot have been dead according to cardiac criteria.”4 Another said that “although everyone agrees that many patients could be resuscitated after an interval of two to five minutes, advocates of this approach to donation say that these patients can be regarded as dead because a decision has been made not to attempt resuscitation.”5 Michael DeVita, MD, a critical care physician at the University of Pittsburgh, says that “the controversy regarding when death can be declared is centuries, perhaps millennia old, and will not go away. I doubt that it will resolve soon.” He suggests the following test: Sit in a room and run a stopwatch for five minutes without talking to anyone. “Now imagine that you are watching your loved one and waiting for the information that s/he is dead,” he says. “Even two minutes seems very, very long. In reality, in the ICU, death is determined in under a minute in most circumstances. The criteria used for donation after cardiac death [DCD] are exceedingly strict by routine medical floor or ICU standards.” He believes “the current national standard of between two and five minutes is reasonable.” Bioethicist John J. Paris, SJ, of Boston College, told The AJT Report that, “it is not clear that the Denver Children's Hospital Committee had the medical expertise or legal acumen to make such a judgment. If we are to have society's acceptance of a radical shift in the understanding of cardiac death in infants, it will require more than the determination of a single hospital ethics committee.” Transplant ethicist Arthur Caplan, PhD, of the University of Pennsylvania in Philadelphia tells The AJT Report that “the problem is we have a national standard for brain death but not for cardiac death, so there is no consensus on how long you need to wait to declare cardiac death in an infant or adult.” Dr. Caplan suggests that a national consensus committee and conference are needed to examine these issues and create guidelines. Perhaps the bottom line was best expressed by his comment that having individual centers lay out DCD protocols threatens to undermine public confidence and enhance the fear that someone might be declared dead solely to get their organs. He adds that this is “a very common fear that leads some to not sign donor cards.” References 1 Boucek MM, Mashburn C, Dunn SM, et al. Pediatric heart transplantation after Declaration of Cardiocirculatory Death. N Engl J Med.; 2008; 359(7): 709- 714. CrossrefCASPubMedWeb of Science®Google Scholar 2 Institute of Medicine, National Academy of Sciences. Non-heart-beating organ transplantation: medical and ethical issues in procurement. Washington , DC : National Academy Press; 1997. Google Scholar 3 Bernat JL, D'Alessandro AM, Port FK, et al. Report of a national conference on donation after cardiac death. Am J Transplant.; 2006; 6: 281- 291. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 4 Veatch, RM. Donating hearts after cardiac death-reversing the irreversible. N Engl J Med.; 2008; 359(7): 672- 673. CrossrefCASPubMedWeb of Science®Google Scholar 5 Truog RD, Miller FG. The dead donor rule and organ transplantation. N Engl J Med.; 2008; 359(7): 674- 675. CrossrefCASPubMedWeb of Science®Google Scholar Volume8, Issue12December 2008Pages 2482-2482 AST and ASTS members - please log in via your Society website for full journal access.AST Members >> ASTS Members >> ReferencesRelatedInformation