Legal and ethical issues related to nonheart beating organ donation

AORN Journal, May, 2003 by Elizabeth McKenney, Bridgette Parker

The process of organ donation and transplantation has advanced since the first successful kidney transplantation was performed by Joseph Murray, MD, in 1954. (1) Since that time, major breakthroughs in immunosuppressant medications and advances in surgical techniques have increased the number of successful transplantations and the quality of life for recipients of donated organs. Organs that can be donated and transplanted successfully include the kidneys, lungs, pancreas, liver, heart, and intestines. Tissues such as corneas, skin, bone, bone marrow, cartilage, tendons, veins, and fascia also can be transplanted successfully. Despite advancements related to immunosuppressant medications and surgical technique, many people who need organs or tissues never have the opportunity to benefit from transplantation because a donor organ never becomes available. Organ demand far outweighs supply, and as the number of people on the waiting list increases, alternatives to increase organ donation are being explored.

ORGAN DONATION CRITERIA

For some time, the criteria for organ donation was that the donor must be brain dead. In 1968, Harvard Medical School, Boston, defined the criteria for brain death as the

   irreversible cessation of circulatory
   and respiratory functions,
   or irreversible cessation
   of all functions of the entire
   brain, including the brainstem. (2)

Until recently, brain death has been the preferred criteria for determining organ donor status. With the shortage of donor organs and an ever-increasing number of people waiting to undergo transplantation, use of cardiac dead donors has become a means of increasing the supply of organs to be transplanted. This method is called nonheart beating (NHB) organ donation or donation after cardiac death. Organ transplantation was performed before the establishment of the brain death criteria, and NHB organ donation was the method used to procure the first organs that were transplanted.

NONHEART BEATING ORGAN DONATION

Nonheart beating organ donation has been advocated as a means of increasing the supply of donated organs. The Institute of Medicine (IOM) has guidelines for NHB organ donation that include

* written, locally approved NHB donor protocols;

* public openness of NHB donor protocols;

* case-by-case decisions about the premortem administration of medications;

* family members' consent for premortem cannulation;

* conflict-of-interest safeguards;

* determination of death by cessation of cardiopulmonary function for at least five minutes by electrocardiographic and arterial pressure monitoring in controlled NHB donations; and

* family member options (eg, attendance at life support withdrawal) and financial protection. (3)

Nonheart beating organ donation is altruistic in nature because one person donates organs that can save the lives of five or more people, or as many as 50 people if bone and skin are donated. Nonheart beating organ donation respects the dead donor rule introduced in 1988, which is the ethical and legal rule that states donors cannot be killed to obtain their organs. (4) This is delineated in NHB organ donation by the pronouncement of death by cardiopulmonary criteria before organs are procured.

Nonheart beating organ donation is an option only after family members of a patient with unrecoverable brain damage who does not meet the neurological criteria for brain death request withdrawal of ventilatory support. After family members request withdrawal of ventilatory support, they are approached by a representative of an organ procurement organization (OPO) about the option of donation. With this form of organ donation, family members who would be unable to donate their loved ones' organs under the brain death criteria now are able to do so.

Family members have the authority to accept or deny organ donation as an option, regardless of whether the patient signed an organ donor card. Even if a donor card has been signed expressing the patient's desire to donate under the Uniform Anatomical Girl Act, most hospitals currently rely on surrogate consent from family members. This consent can present a dilemma to family members, who must decide whether to honor the patient's signed organ donor card. This process can become more complicated if family members contemplating organ donation do not have a firm understanding of the patient's wishes or have hesitations based on their own values. Consequently, a once competent person's wishes, which are known either orally or in writing, can be overruled by the next of kin. If family members do not know the patient's wishes, their actions may be based on emotions rather than the patient's desires. Organ procurement organization policy changes are underway to respect the consent of the patient if a donor card has been signed, permitting the procurement of donated organs with no additional consent from family members. Since August 2002, some states on the East Coast have deemed the indication of consent on a driver's license to be legally binding and family members' consent unnecessary.