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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 Pandora´s 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)

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