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Ethical Dilemmas 6

Ethical Dilemmas 6

A days-old infant, after being asphyxiated during birth, sustained severe neurological injury; but the dying baby’s condition didn’t meet the criteria for brain death.

The baby was then transferred to a children’s hospital, where the family decided to withdraw life support. The family members also agreed to let surgeons there attempt to transplant the baby’s heart into an infant born with complex congenital heart disease. However, the potential donor heart had to stop working to accomplish the transplant.


The question here is:
To ensure the baby’s heart wouldn’t restart without intervention, how long should the retrieval team wait after cardiac functioning has ceased?


The Complicating Factors:

As the wait after cessation of cardiocirculatory function increases, odds of successful transplantation decrease; but then again, acting too soon can make retrieval seem like death by organ donation.


The surgeons waited 75 seconds and the infant who received that heart lived, as did two other babies who received hearts from donations retrieved shortly after cardiac death in transplants that were performed by the same team between May 2004 and May 2007. In August 2008, the results were published in the New England Journal of Medicine.


This has raised a clinical debate that is unsettled over whether 75 seconds without cardiac function after withdrawing life support is sufficient time to confidently declare death. Some physicians and bioethicists say that these cases are just the latest in the organ transplantation era to stretch the definition of death in ways that could potentially undermine people’s trust in physicians and in the organ donation process.


A Matter of Minutes:

Expanding the pool of potential pediatric heart donors beyond those who meet brain-death criteria can help meet a pressing need. Every year, about 100 infants receive life-saving heart transplants. According to an NEJM editorial, about 50 infants in need of heart transplants die while waiting on the United Network for Organ Sharing list.


About a third of infants in pediatric hospitals die after withdrawing life support. These infants represent a valuable pool of life-saving organs. The team of surgeons said that 12 potential infant donors died of cardiocirculatory causes at that hospital in particular in the three years of the study, which accounts for a possible 70% increase in organ donation. There are around 100 infants younger than 1 year that receive hear transplants each year.


Patients must be declared irreversibly dead according to the “dead-donor rule” before their vital organs can be retrieved for transplantation, on the condition that the patients or surrogate decision-makers give their permission.


Brain death is recognized as legal death. Ever since a Harvard Medical School committee formulated the criteria in 1968, securing organs from brain-dead patients has been deemed ethical.


Organ donation after cardiac death has become medically and legally acceptable over the last 15 years, though the timing question still doesn’t have an answer. Before declaring death and retrieving organs, the Pittsburgh protocol, which was published in 1993, called for a two-minute wait after cardiopulmonary arrest. In 1997, the Institute of Medicine said that before retrieving organs, the transplant teams should wait for five minutes after cardiac functioning ceases.


The Institute of Medicine said in 2000 that some data suggested a shorter interval of 60 seconds, though its report said “existing empirical data cannot confirm or disprove a specific interval at which the cessation of cardiopulmonary function becomes irreversible”. The Society of Critical Care Medicine recommends waiting at least two minutes but no more than five minutes.


The American Medical Association policy says that the practice is “ethically acceptable” as long as conflict-of-interest and palliative care protocols are followed, but it doesn’t address the time issue.


Another team of surgeons waited three minutes in their first infant heart donor case. However, the Children’s Hospital ethics committee determined that a 75 second wait would be sufficient and would reduce the risk of injury to the donor heart from blood loss. This was based on data the committee reviewed. Taking into consideration that 50 infants die each year while waiting for transplantation. This decision has received fierce criticism including a series of editorials that were published in the New England Journal of Medicine.


Drawing Lines to Ensure Ethical Donation:

As mentioned before, whether heart transplants performed within seconds of cardiac death are ethically permissible or not is still a subject of heated debate. James L. Bernat, MD, medicine and neurology professor at Dartmouth Medical School in New Hampshire laid out some principles to help guide the debate over donation after brain death and cardiac death:


In the case of brain-death and cardiac-death, these principles should be followed:

  • Respect the dead-donor rule
  • Determine death using accepted tests and procedures
  • Separate death-determination team from organ-procurement team
  • Obtain surrogate consent for organ donation
  • Provide end-of-life family support
  • Properly design and scrupulously follow protocol; document findings


In the case of cardiac-death when the brain is not dead, these principles should be followed:

  • Obtain surrogate consent for withdrawal of life-sustaining therapy
  • Provide palliative care during dying


If the patient is cardiac-dead but it’s not clear if he/she’s brain-dead, the decision to refuse life-sustaining therapy should be separated from the decision to donate.


A team of surgeons retrieved three hearts from infants for whom ongoing care was deemed futile by their families and physicians. After six months, the transplant recipients were all alive.

  • The first donor stayed alive for 11.5 minutes after life support was withdrawn. The doctors waited 3 minutes after cardiocirculatory function cessation to pronounce that the patient is dead.
  • The second donor stayed alive for 27.5 minutes after life support was withdrawn. The doctors waited 1.25 minutes after cardiocirculatory function cessation to pronounce that the patient is dead.
  • The third donor stayed alive for 16.0 minutes after life support was withdrawn. The doctors waited 1.25 minutes after cardiocurculatory function cessation to pronounce that the patient is dead.

Prepared By: Dr. Mehyar Al-khashroum
Edited By: Miss Yasmeen Jaby Al-Haramein

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