Organ Transplantation after Cardiac Death

Abstract

The American Organ Crisis Despite the recent surge in healthcare technologies and medical practice innovation, increasing rates of organ donation to meet the need for solid organ transplants remains one of the largest unsolved problems in the American health industry. The United Network for Organ Sharing (UNOS) lists the current number of candidates on the transplant wait list at 120,000,22 with that number steadily increasing each day. Unfortunately, the number of American donors is nowhere near the number of potential recipients, as a low 40% of Americans consent to organ donation after death.21 As a result, only 28,000 transplants are performed annually,23 and an average of 21 people die each day due to not receiving a vital organ.4 America's potential supply of viable organs shrinks even further when considering the overall weaker physical health of Americans; those who want to donate are more likely to have unhealthy organs due to the prevalence of obesity and other health issues.7 As researchers struggle to grow organs and tissues in vitro to increase America's viable organ supply, hospitals must look towards other means of procuring donations. One potential resource is a small percentage of Americans who no longer need their organs: those who have sufered from cardiac death. First, a distinction must be drawn between the medical defnitions of "brain death" and "cardiac death." Candidates for both include patients with severe neurological injury (from stroke, trauma, anoxia, hemorrhaging), degenerative neuromuscular diseases, or end-stage cardiopulmonary diseases.2 Although both outcomes stem from severe brain injury, cardiac death does not meet the clinical standards for brain death. The concept of brain death evolved between 1902 and 1950. After brain death was defned, the organs used during transplantation could be more freshly harvested from brain dead organ donors. This led to overall more successful organ transplantations were overall more successful.10 Organ transplantation and brain death are now inextricably linked, and a diagnosis of brain death is used in the status quo to determine the appropriateness of organ transplantation for dead hospital patients. There are a variety of tests a physician can administer in order to diagnose brain death: brain stem refex assessments, apnea tests, and coma appraisals that determine if a patient has truly passed.14 Examples of tests include searching for an absence of gag refex, corneal refex and cough refex. Other tests look for high body temperature or lack of spontaneous respiratory efort. The time of brain death is marked as a patient's legal time of death, and then donation after brain death (DBD) can occur. In contrast, cardiac death, or non-heart-beating death, occurs when a patient cannot be legally declared dead due to lingering neurological activity, yet the patient has no chance of recovery. In this case, a physician must determine that the patient would die without life support, and the patient's family must subsequently choose to end life support.24 Only then is donation after cardiac death (DCD) discussed with the patient's family. A referral is made to an Organ Procurement Organization (OPO), which then determines the patient's eligibility to be an organ donor. If a patient is suitably eligible to donate and the patient's family gives consent, the patient is removed from life support and the donation process can begin.25 Although DCD could theoretically be as viable as DBD in determining a patient's eligibility for donation after serious brain injury, many hospitals do not accept DCD organs as readily as DBD organs. This piece will now delve into the reasons why the American medical community has been wary of accepting DCD.