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Non heart beating organ donation (NHBD): ethical aspects and safeguards for NHBD performance

From brain death concept to NHBD


First transplantation attemps with organs of conventionally died people 1963: introduction of brain death concept at Harvard university: problem of warm ischemia solved usually graft failure due to long warm organ ischemia period increasing succes rates due to better organ qualitiy, immunological science and pharmacological support transplantation medicine became established method for final organ failure treatment Increasing gap between organ demand and supply

Search for new organ sources : Living donor transplants (Xenotransplants) NHBD

Classification of NHBD
Maastricht categories for NHB organ donors I : dead on arrival uncontrolled NHBD

II : unsuccessful resuscitation uncontrolled NHBD III: awaiting cardiac death controlled NHBD

IV: cardiac death in brain dead donor uncontrolled NHBD

Sequence of events in uncontrolled NHBD procedures


unexpected pre-hospital / in-hospital cardiac arrest

unsuccessful CPR or DNR decision


[postmortal in situ organ preservation]

asking for relatives permission for organ donation

organ retrieval

Sequence of events in controlled NHBD procedures


hopeless case-assessment of an ICU patient

therapy withdrawal decision with consent of relatives / time for family to say goodbye

report to organ procurement organization with consent of relatives


[antemortal in situ organ preservation]

therapy withdrawal in theatre under explantation stand by

patient dies spontaneously (< 1 h)


? min

patient dies not spontaneously (> 1h)

organ retrieval

patient returns to ward for dying

The ethics debate about NHBD

Pro NHBD argument


Progress in neurocritical care and better protection devices in cars due to decreasing numbers of brain dead donors while organ demand is increasing. NHBD can moderate the shortage of organs and in this way save lives.

Effects of NHBD on solid organ supply


Estimated increase in organ availability 20 % - 25 %

[Herdman R, Kennedy Inst Ethics J , 1988] [Clayton HA, Transplantation, 2000] [D`Alessandro AM, Surgery, 2000]

Donation sources for solid organ transplantation in UK


Transplant heartbeating kidney non-hearbeating kidney Living donor kidney heartbeating liver/liver lobe non-heartbeating liver Living donor liver lobe 2004 - 2005 1074 (64%) 143 (8%) 475 (28%) 618 (96%) 19 (3%) 7 (1%)

UK Transplant Activity Report 2004 - 2005

Cadaveric solid organ donors in UK 2004-2005


700 600 500 400 300 200 100 0 heart-beating donors 11 % non-heart- beating donors 89 %

Ethical concerns about controlled NHBD


hopeless case-assessment of an ICU patient

therapy withdrawal decision with consent of relatives / time for family to say goodbye

+
report to organ procurement organization with consent of relatives
[antemortal in situ organ preservation]

therapy withdrawal in theatre under explantation stand by

patient dies spontaneously (< 1 h)


? min

patient dies not spontaneously (> 1h)

organ retrieval

patient returns to ward for dying

Ethical concerns about uncontrolled NHBD


unexpected pre-hospital / in-hospital cardiac arrest

unsuccessful CPR or DNR decision


[postmortal in situ organ preservation]

asking for relatives permission for organ donation

organ retrieval

Ethical concerns: NHBD in conscious people Intersection between the right to die and organ donation
the organ donation will only increase the pressure on disabled people to choose to die in belief that by giving their organs up, their lives can have some meaning. The danger is especially acute for people who are newly disabled, many of whom believe, falsley, that live can never be worth living. [Wesley Smith, Culture of Death The Assault on Medical Ethics in America]

Ethical concerns: Pressure for organs opens Pandoras box dead donor ruel might be violated in future

Individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead. [RD Truog, Critical Care Medicine 2003]

Summary of ethical concerns


Conflicts of interest between potential donors rights and potential recipient chances Organ retrieval before patient irreversibly dead Violation of relatives feelings by time pressure mistrust towards health care team and organ donation in general refusal of consent Ethical borderlines might become more and more blurred in future

The way of NHBD leads very closley along ethical borderlines and therefore has to be well defined.

Safeguards for NHBD performance


National / international approved and public revealed protocols which provide strict guidance on every step of NHBD procedures to avoid public mistrust towards transplantation medicine Strict avoidance of active euthanasia Separat and independent teams for therapy withdrawal decision / death declaration and transplantation to avoid conflicts of interests between potential donor and recipient

Safeguards for NHBD performance


Case by case decisions about premortem organ preservation measures and family consent for these measures Respect for donor and family wishes Special trained staff for taking care of the family In conrolled NHBD procedures at least 5 min between determination of death and start of organ removal (dead donor ruel)

Thank you for your attention

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