A new definition of heart death has increased heart donations. Last year there were 30,000 solid organ transplants in the United States and there are 97,000 people on the waiting list. Seventy five percent were gifts from deceased donors with most of these from heart death donors rather than brain dead donors.

The usual organs donated are kidneys and livers, sometimes pancreases and lungs but rarely the heart. Rarely does a donation come from an unexpected fatal heart attack.

A brain dead patient is pronounced dead on the basis of neurological criteria even though they are on ventilators with good heart functions. The ventilators prevent the hearts from deteriorating.

Fifty years ago organs were only extracted after the heart stopped beating. Trauma or bleeding to the brain resulted in irreversible brain damage and further treatment deemed futile. Officially they are not dead.
All that is changing.

A private non profit group in Richmond Virginia called OPTN/UNOS (United Network for Organ Sharing) operate the Organ Procurement and Transportation Network. It is under contract by the Federal Government and is committed to get more donors.

The OPTN/UNOS network has developed rules finalized in March 2007 to get more heart donors. First a suitable candidate is selected. The next of kin is contacted to give consent to withdraw care and retrieve organs.

All life-sustaining measures are stopped in the ICU (intensive care unit) or in the OR (operating room). The new criteria for cardiac death are met and a doctor pronounces the patient dead. When the pulse is absent for 2-5 minutes there is no spontaneous return of circulation and death has occurred.

There can still be some heart activity seen on the EKG. Neither the doctor pronouncing the patient dead, the personnel involved in preparing end of life care, nor the transplant surgeon can participate in the removal of the organs. (This is to avoid a conflict of interest).

On Jan 9, the British passed a ruling that everyone who dies must be an organ donor unless he opts out. This will insure many more organ donors. In effect, this allows the government to make the decision for the Brits.

Could this catch on in the U.S?

Successful transplantation requires organs not deprived of oxygen. Livers must be remove within 1] 2 hour;: kidneys and pancreases have up to one hour for removal. Time is of the essence. Cold preservation solutions after removal preserve the organ.

If by chance the patient does not die quick enough after end of life care is initiated, the planned donation is cancelled and ICU care is resumed. This happens up to 20% of the time. Cardiac death donors raise more concern than brain dead donors. Since the potential donor is not dead when life-sustaining measures are stopped, complex issues arise.

There is little time between withdrawing care, pronouncing death, and revering the organs. The family must cope with this quick dying process. The family must find comfort in the ability to donate organs under these speeding special circumstances.

To maintain success of the donation, specific rules are in place.

The potential donor is wheeled into the operating room when he is still alive. He is given heparin with other agents to prevent clotting of the blood and maintain a functioning good heart. (A heart must be free of blood clots after removal and cold perfusion is started).

Heparin hastens death by causing bleeding. A large catheter is placed in the large arteries and veins to make sure a rapid injection of the heparin can preserve the heart from clots.

January 2007, the Joint commission developed accreditation standards for donation after cardiac death. Most hospitals never had an organ donor whose death was declared on the basis of cardiac pulse criteria (no pulse).

To meet the new standard the hospitals are required to have the policies in place, not just allow the practice. If the hospital wants to cop out or the personnel have concerns of the methods of ending life care they must document their strong efforts to reach agreement and must justify the reasons why they want to drop out of the program.

All 257 transplant hospitals and 58 transplant centers in America must comply with the new rules of the Joint Commission.

COMMENT: There is a great deal of concerns about the present new rules to increase heart donations. A donor is present, and the transplant surgeons are ready. They are in a hurry to obtain the organs.

Massive amounts of morphine are given to stop respirations. II the patient does not die quickly, the organs are not recoverable because they are not useful for transplantation.

If the end of life procedures is not followed death efforts may fail. Surgery and end of life procedures are cancelled and ICU procedures are resumed. This is not the case with donors of brain dead patients.

Do you have any concerns?