Non-Heartbeating Organ Donation (NHOD)

NHOD involves recovering organs from individuals who have been declared dead using cardiac criteria rather than brain-death criteria.

At first glance this may appear to be unproblematic because it uses a more standard form of determination of death than usual. However, there are a number of issues that have been raised with regard to this practice. The major ones are...

• Protection of the potential donor from harm:
  • Pain and Distress & Comfort Care (patient and family), high-tech death
  • Potential for Coercion - Should the family be approached? When?
  • “Irreversibility” of Death, effect of cooling, Are our criteria sufficient?(In other words, how will this impact on the donor’s pre-death treatment, the dying process, and declaration of death?)
  • Potential for withdrawing/withholding for donation, not patient autonomy/beneficence
  • Should we include presumed consent in the event of no clear prior statements by the patient?
  • Should any patient refusing life sustaining care have this option?
• Conflicts of Interests for health care professionals:
  • Determining death “as quickly as possible”
  • Should one provide treatments to maximize organ viability prior to the death of the donor?
  • Resuscitation for donation, heparin, line and catheter placement, cooling
  • Should the newly declared non-heartbeating cadaver be put on a ventilator?
• Justice, Society, and Policy:
  • Can we manage the risks sufficiently? What is sufficient?
  • Will this reduce public trust?
  • What is the role of finances in this situation?

My Working Assumptions:

• The decision to withdraw/withhold life-sustaining treatment should be treated separately from the decision to donate.
  • Ideally this decision should be made prior to any discussion about donation.
  • There should be no indication that the decision to donate plays a role in the decision to withdraw or withhold life-sustaining care (other potential conflicts of interests should also be considered).
  • The patient’s wishes or the support for the surrogate’s decision to withdraw/withhold should be clear.
• The physician who pronounces the patient dead should not be associated with the transplant program.
  • The health care professionals involved should avoid conflicts of interests or possible coercion, real or perceived.
• The care and comfort of the dying patient should be the primary concern.
  • The dying patient should be kept comfortable and should not be given any medications or procedures which might harm him or her.
• Compassion for the dying patient’s family should also be taken into account (for example, as with ordinary withdrawing /withholding, allowing them some control over the time).
  • The family should be informed about the effect NHBOD will have on when and where the patient dies and whether or not the family can be with the patient until death.
  • The family’s questions should be answered respectfully and with compassion.
• The donor’s diagnosis and prognosis which led to the withdraw/withhold decision should be virtually certain as well as the claim that the patient will die quickly once the treatment is withdrawn & withheld.
• Although candidates for NHBOD do not meet strict brain death criteria, most protocols require that the dying patient have sustained a severe, nonrecoverable neurologic injury.

CKP