Are we overlooking a hidden source of organs?

Nursing, Jan 2000 by Popernack, Myra L

An alternative method of organ recovery that doesn't require brain death could help alleviate the critical shortage of organs for transplantation.

"Non-heart-beating (NHB organ donor" it was only the second time this unique term applied to one of our pediatric intensive care patients. This time, the donor would be my patient, 16-year-old Ryan, who'd been critically injured in a car crash.

I was familiar with "heart-beating" donors who met brain-death criteria, but I knew little about organ donation involving patients who'd suffered irreversible brain damage and had no hope for recovery or survival without life-sustaining mechanical support.

Caring for Ryan and his family taught me a great deal about the technical and ethical issues involved in NHB organ donation and its promise as an important source for donor organs. By sharing my experience, I hope to raise your awareness of this lesser-known type of organ procurement. Let's start by comparing NHB and heart-beating organ donation.

Brain death vs. cardiac arrest

A heart-beating donor must have sustained a neurologic injury and meet the criteria for brain death established by the Uniform Determination of Death Act: Simply described, brain death is the irreversible and total cessation of cortical and brain stem function. The heartbeating donor is already pronounced dead and requires mechanical support to maintain oxygenation, ventilation, and perfusion to vital organs prior to organ procurement.

In contrast the NHB organ donor is pronounced dead not on the basis of brain function but because his circulatory and respiratory functions have ceased. Either the person has a brain injury from which he won't recover and he can't survive without mechanical support, or the person is in an uncontrolled situation, such as a trauma, and cardiopulmonary resuscitation won't be successful.

The NHB donor's organs aren't oxygenated or perfused for at least 5 minutes after the person is declared dead. Asystole must occur within I hour after withdrawal of hemodynamic and mechanical support to proceed with organ recovery. If the heart continues beating on its own, the organ recovery attempt is aborted.

In a controlled situation, patients can be prepared prior to organ recovery to limit ischemia. Femoral cannulas can be placed before life support is withdrawn; after the patient is pronounced dead, a preservative solution is rapidly infused to limit ischemia. Controlled NHB donation limits anoxic injury to the organs and improves their viability. Rapid procurement under controlled conditions can result in recovery of the kidneys, liver, and pancreas from one donor.

Uncontrolled NHB organ donation can occur when a person dies suddenly, but the potential for variables affecting renal and extrarenal organ viability increases.

Tackling ethical questions

The need for organs far exceeds the supply, and alternative sources are being explored to offset the shortage. As I'm sure you'll recognize, NHB organ donation has its own unique set of legal and ethical issues. These emotionally charged issues are compounded with the inclusion of pediatric donors.

Organizations such as the United Network for Organ Sharing, which among other duties matches organs to recipients, and the Institute of Medicine (IOM) are tackling these concerns. Some of the NHB organ donation guidelines recommended by the IOM thus far follow:

* Hospitals should establish protocols and make them readily available to the public.

* Conflict of interest safeguards must be in place.

* Death should be determined by cessation of cardiopulmonary function as measured by electrocardiographic and arterial pressure monitoring for at least 5 minutes.

The IOM also identified several principles to be considered when developing NHB organ donation protocols, including absolute prohibition of active euthanasia, commitment to informed consent, and respect for donor and family values.

Meeting Ryan

The day I met Ryan and his family, I didn't realize an education concerning NHB organ donation would be ahead.

Lying quietly as if in a deep sleep, Ryan was a handsome, robust-looking young man with red hair and a freckled face accented by long, curly lashes. He was intubated and mechanically ventilated.

A restrained passenger in a motor vehicle accident 2 days before, Ryan took the brunt of a collision on his right side. He'd suffered a shearing brain injury with major bleeding in the pons region. His Glasgow Coma Scale score was 3. An abdominal incision extended from his sternum to the pubis from an emergency laparotomy performed to repair a ruptured bladder. He'd also suffered a liver laceration and a fractured right femur.

The attending pediatric neurosurgeon had painted a bleak picture of Ryan's chances but stopped short of a definitive prognosis, opting to wait for the results of the magnetic resonance imaging (MRI) scan. I could see that Ryan's family eagerly grasped that one thread of hope.

The more time I spent with Ryan and his large, multigenerational family, the more I came to know him, not only as a patient, but also as a person through pictures posted on a large display at his head. I saw him as a laughing toddler, a handsome prom date in a tux, and a son, big brother, cousin, and grandson at various family events. His radiant smile and sparkling eyes in the photos gave life to the still and silent form in the bed before me.