Wednesday, December 23, 2009

When Does Death Start?

H/T to @ctsinclair and @doclake  for the link to this December 16th NY Times article.  If you haven’t read it, it is worth the time, especially if you have any interest in this topic.

When does death start? from NYT http://bit.ly/8xGXjL

The article, "When does death start?",  was written by Darshak Sanghavi, the chief of pediatric cardiology at the University of Massachusetts Medical School, is Slate’s health care columnist and the author of “A Map of the Child: A Pediatrician’s Tour of the Body.”

The article uses the story of Amanda to discuss “brain death” and “death after cardiac arrest”  in conjunction with organ procurement.   No organs can be procured until a person has been declared dead (the so-called dead-donor rule). 

The question of “when does death start?” comes from the 5 minute of no heart activity after cardiac arrest.

In procuring organs from patients like Amanda, doctors have created a new class of potential organ donors who are not dead but dying. By arbitrarily drawing a line between death and life — five minutes after the heart stops — they have raised difficult ethical questions. Are they merely acknowledging death or hastening it in their zeal to save others’ lives?

The article takes the reader through the history of transplantation and the need to define “when death starts.”

Henry Beecher, a Harvard anesthesiologist and medical ethicist, convened a 13-member committee to write a definition of “irreversible coma,” or brain death, for The Journal of the American Medical Association.

President Jimmy Carter asked a blue-ribbon commission to examine the issue. The commission culminated in the Uniform Determination of Death Act in 1981, which defined death as “irreversible cessation of all functions of the entire brain, including the brainstem.”

The 1981 Uniform Determination of Death Act also defines death as the “irreversible cessation of circulatory and respiratory functions,” which left an opening for another source of donors.

In 1987, the nation’s pediatrics authorities tried to standardize the diagnosis, listing 14 different criteria to confirm brain death, like the absence of reflexes, and requiring, under certain conditions, additional X-rays and tests for brain-wave activity.

In 1997, the federal government asked the Institute of Medicine, an independent advisory body, to gather experts to determine how a dying donor might be treated. The experts ended up endorsing the procedure for donation after cardiac death, in which death occurs through a process of withdrawing life support and allowing the heart to develop “irreversible cessation.”

In 2004, pediatric cardiologist Mark Boucek at Denver Children’s Hospital, financed by a federal grant,  wrote a far more aggressive D.C.D. protocol that would save the heart, which was adopted after going through the hospital’s review process. His version …..most controversially, rejected the five-minute rule imposed by the Institute of Medicine and initially picked three minutes instead.

David Campbell, the pediatric cardiac surgeon at Denver who procured the first heart using the (Boucek) protocol, realized that even three minutes was too long. ….. In reviewing the medical literature, Boucek found the longest recorded time that a heart had ever stopped and then spontaneously restarted without medical intervention was 65 seconds.

 

The article goes on to discuss the current needs for organ donation.  It is estimated that at least 18 people on the transplantation list die each day before the needed organ becomes available.  This need makes the need for an answer to the question of “when does death start?’ extremely important.  The answer could increase the availability of viable organs.

The Institute of Medicine created a new class of potential organ donors: living patients with little hope of recovery who could be declared dead soon after life-support removal. Within a decade, the number of such donors increased tenfold; they now account for 8 percent of organ transplants nationwide, up to 20 percent in certain areas. Still, many hospitals were slow to adopt the practice.

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