ETHICAL ISSUES IN ORGAN DONATION Kate Payne, JD, RN Director, Ethics & Palliative Care Saint Thomas Hospital, Nashville, Tennessee Ascension Health

OBJECTIVES  Describe the ethical obligations of the stakeholders in organ donation including patients, families, society and health care professionals.  Identify ethics best practices related to organ donation.

Society’s Role  Increased public awareness regarding organ donation  Greater efforts to dispel public concerns  Organ donation can help with tragedy  Remember "organs wasted are lives lost”

WHAT IS ORGAN DONATION?  Process: tissues or organs are removed from a live, or recently dead, person to be used in another.  Donor gives the organs  Recipient gets the organs  People of all ages can become donors  Organs can also come from animals (xenotransplantation)

COMMON CONCERNS ABOUT DONATION  Disfigurement  Funeral Arrangements  Financial Responsibility  Religious Beliefs  “I cannot be a donor because of my medical history.”  “If I want to be a donor, they won’t try and save me!”

TYPES OF DONORS  Dead donors Almost all organs can be donated by someone dead but the organs have to reach the recipient within a few hours after the donor's death. Brain death Donation after cardiac death (DCD) Tissue donation  Live donors Related and unrelated

NATIONAL TRENDS  Deceased donor numbers decrease by 1.0% (7,944 from 8,022), but deceased donor transplants increased by 1.6%  Decline in deceased donors due to drop in ECD donors  DCD donor numbers continue to increase and now comprise 12% of deceased donors overall  Slight decline in living donors from , but relatively stable for last few years

U.S. DECEASED AND LIVING DONORS

U.S. DECEASED DONORS BY TYPE %

U.S. DECEASED DONOR TRANSPLANTS

CONSENT  Cadaver donation Relatives provide consent State law may allow other surrogate consent  Generally voluntary Opt In: Donor consents in advance Opt Out: Anyone who has not refused is considered a donor  In live donation the donor consents Parental for children

SOLID ORGAN TRANSPLANTS  Adults and children with end stage organ failure Heart Heart-Lung Lung Single and double Liver Kidney Kidney-Pancreas Pancreas Intestine Skin

U.S. WAITING LIST REGISTRATIONS

ORGAN DONOR CRITERIA  Age is generally less than 80, but is based on patient’s current medical history  Dead by neurologic criteria “Brain Dead”  Dead by cardio-pulmonary criteria  Medical history is examined at the time of death  Free of HIV All serologies are examined at time of death HIV to HIV is possible

TISSUE DONOR CRITERIA  Donation occurs after cardiac death  Criteria: Age < 70 Recovered within 24 hours after death if body is cooled in the first 12 hours No active, transmissible disease No autoimmune disorder

TISSUES BEING TRANSPLANTED  Heart valves  Pericardium  Skin  Bone -Whole or processed grafts  Veins  Fascia  Ligaments/Tendons  Eyes: Cornea, Sclera Whole Eyes for Research

EYE DONOR CRITERIA  Donation occurs after cardiac death  Criteria: No upper age limit 1 year to 68 years Cornea transplant Less than 1 year or greater than 68 years Research History of cancer is acceptable Other research for patients with history of glaucoma, diabetes, etc.

UNIFORM DETERMINATION OF DEATH ACT  An individual who has sustained either 1)irreversible cessation of circulatory and respiratory function, or (NHBD or DCD) 2)irreversible cessation of all functions of the entire brain, including the brain stem, is dead. (Brain dead donor)  A determination of death must be made in accordance with accepted medical standards.

PONTIFICAL ACADEMY OF SCIENCES  1985 two years after the UDDA: “A person is dead when he has suffered irreversible loss of all capacity for integrating and coordinating physical and mental functions of the body.

DETERMINING DEATH  “Dead Donor Rule” 1)Procuring organs should never kill patients; and 2)The procurement of organs may only begin after the donor has died.  Biological, psychological, metaphysical death

BRAIN DEATH  Typical scenario: a critical head injury causes swelling of the brain within the inflexible skull so that the supply of oxygenated blood to the brain is cut off causing the brain to die. Patients are often on life support already so cardiopulmonary function continues. Determination of brain function is made (perfusion, apnea testing) and if the brain is found to have lost all functions, the patient is declared dead. Optimal for organ procurement, because the procurement surgery may begin even while organs are still perfused with oxygenated blood. All solid organs

IS BRAIN DEAD, DEAD?  Body functions continue  Artificial supports

NHBD/DCD  Circulatory-respiratory death criteria.  Typical scenario: a patient’s family decides to discontinue artificial ventilation. If they agree to donate, the patient is declared dead shortly after they stop breathing and circulation is lost. The Institute of Medicine recommends a five-minute wait.  Patient is typically prepped for surgery before the ventilator is removed and is pronounced dead either in or near the operating room. Kidneys, liver, lungs (usually)

ISSUES  Prep in advance Increased suffering Increased risk in a non brain dead patient Hastening death Heparin for organ perfusion and double effect  Time (for irreversible death) 2 minutes? 5 minutes?

CONSENT  Free and informed  Parents consent kids for their siblings Having a baby for bone marrow  De-coupling the conversation from care givers  Donor advocacy for live donors

PRESSURE  Medicare Conditions of Participation  Washington Post article

OTHER DONATION CONTROVERSIES  Who should be transplanted? U.S. Citizens only? Smokers? Alcoholics? The very young or old? The rich or the poor? Those in prison? Organ tourism in the developing world Only those who have agreed to be donors themselves?

OTHER DONATION CONTROVERSIES  How should organ donation be increased? Financial Incentives More Public Education? Presumed Consent? New DCD rules