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‘A shifting line in the sand’; Donation after brain death generally accepted, but donation after cardiac death remains controversial — the Ottawa Citizen; written by Patrick Dare
Understanding death is one of the keys to increasing organ donation in Canada.
Due to the importance of healthy organs for transplantation, people who die can only become organ donors under very controlled circumstances in a hospital.
There are two ways to die and become an organ donor. The first way, fully accepted in the medical community as the standard for deceased donation but not well understood by the public, is donation after brain death. You have a sudden illness or accident, often a severe trauma to the head, and are rushed to the hospital. The emergency and intensive care staff give you any treatment that might save you, most importantly putting you on a ventilator so you continue to breathe. But if the injury to your head is severe, the brain may be irretrievably damaged and may die.
The organs continue to function with the intake of oxygen and the circulation of blood, but if the brain dies, there is no hope for revival. This is the point where there’s a chance to save people’s lives by donating organs. But this is also the point at which families can say no, in part because they may not understand what’s happened to their loved one. The person’s body is not cold. His chest moves with the beating of the heart. It can be hard to accept that the person is gone and that his healthy organs will be wasted if not recovered.
Dr. Leslie Ivan, former head of neurosurgery at the Children’s Hospital of Eastern Ontario and emeritus professor at the University of Ottawa, says people should understand that when brain death occurs, there is no chance of revival. In a just-published book he wrote with his wife Maureen Melrose, called The Way We Die, Dr. Ivan says: “The brain is the guidance system of our whole response to life and to the environment, our physical, intellectual and spiritual existence. When the brain dies, experience must cease.”
In fact, if a patient’s brain dies and he is kept on a breathing machine for a substantial period of time, 24 hours or more, Dr. Ivan reports that autopsies show further damage to the brain is dramatic. The damage ranges from haemorrhages to disintegration and liquefaction of the contents of the skull. The brain can fall apart when attempts are made to remove it for post-mortem examination. … It’s the use of ventilators — and the fact that patients were being kept hooked up to the machines on hospital wards for days after their brains had died — that led to the formal recognition of brain death by Harvard Medical School in 1968. The recognition of brain death helped end senseless, drawn-out family vigils over lifeless bodies where there was no brain function.
The second way to die and become an organ donor is through donation after cardiac death. This method is more controversial in the medical community, though it’s winning support from some families who are strong advocates for organ donation. This method of organ donation is used in Europe and the United States. With donation after cardiac death, the patient has not suffered brain death. However, the patient has suffered severe brain injury and is breathing through a ventilator in intensive care. After a period of time, when doctors and the family conclude that there is no hope for recovery, a decision will be made about turning off the ventilator. Under the traditional rules of organ donation, there’d be no chance for organ donation because the patient isn’t brain dead. But the patient is about to die and families sometimes press medical staff to allow organ donation after death. This was the case for Sarah Beth Therien, the 32-year-old woman in Ottawa who told her parents she wanted to be an organ donor before she unexpectedly died. She began a new era of organ donation in 2006, donating her organs after cardiac death. Her parents, Emile and Beth Therien, went public with the news and have become advocates for organ donation.
With donation after cardiac death, after the decision has been made to turn off the ventilator, organ-recovery doctors are assembled at the hospital. The ventilator is switched off. Once the heart stops beating, one physician in the room declares the patient dead. Then there is a wait, in case there is an auto-resuscitation — spontaneous return of breathing or pulse. After five minutes of no signs or life, a second physician confirms that death has taken place. Then they move to the operating room to recover the organs. …
Donation after cardiac death is considered by Trillium and advocates of organ donation to be a method of boosting the number of donated organs in Canada, perhaps by 20 per cent. Emile Therien, Sarah Beth’s father, says the donation of his daughter’s organs saved the lives of several people and gave her life extra meaning.
Since the Therien case, there have been about 20 such cases in Ontario, several of them at the Ottawa Hospital. But the practice has not been taken up in other provinces, in part because of uneasiness about the balance between lifesaving hospital care and the urgency of the need for organs.
FACT: Organ and tissue recovery takes place only after all efforts to save your life have been exhausted and death has been legally declared. The medical team treating you is completely separate from the transplant team. The organ procurement organization (OPO) is not notified until all lifesaving efforts have failed. The OPO does not notify the transplant team until the family has consented to donation.
It is then important to discuss your wishes with your family.