Recent pediatric heart transplants performed in Colorado have created disturbing questions about determinations as to when a patient is dead. For decades, determine that a donor’s brain has completely stopped working before harvesting organs for transplant. In the case of at least three infants, each was on life support and showed little brain function, but did not meet the criteria for brain dead.
With their families’ consent, the newborns were taken off ventilators and surgeons in Denver removed their hearts minutes after they stopped beating. The hearts were successfully transplanted, and the babies who received the transplanted hearts survived.
In the first case, doctors waited for three minutes after the heart stopped before death was declared. Then the waiting time was reduced to 75 seconds on the recommendation of the ethics committee to reduce the chances of damage to the heart. State laws stipulate that donors must be declared dead before donation, based on either total loss of brain function or heart function that is irreversible. Some medical ethicists contend that the Denver cases fail to meet this criteria since it was possible to restart the transplanted hearts in the recipients.
The Denver transplants were done over three years; one in 2004 and two last year. The three donor infants had all suffered brain damage from lack of oxygen when they were born. On average, they were about four days old when life support was ended. The hearts were given to three babies born with heart defects or heart disease.
The procedure is gaining acceptance and it has been termed donation after cardiac death. The federal government and organ banks are encouraging the practice as a way to make more organs available and give more families the option to donate. But the approach raises legal and ethical issues because it involves children and because, according to some legal commentators, it violates laws governing when organs may be removed for transplants.
Not surprisingly, as the method has gained acceptance, the number of cardiac-death donations has steadily increased. Last year, there were 793 cardiac-death donors, about 10 percent of all deceased donors, according to United Network for Organ Sharing. Most of those were adults donating kidneys or livers.
The heart is rarely removed after cardiac death because of damage resulting from lack of oxygen. In brain-death donations, the donor is kept on a ventilator to keep oxygen-rich blood flowing to the organs until they are removed.
The Denver cases are detailed in today’s issue of The New England Journal of Medicine. The editors noted that the controversial article was published to promote discussion of cardiac-death donation, especially for infant heart transplants.
There were nine other potential cardiac-death donors at the hospital during the same period, but there wasn’t a suitable recipient in the area for their hearts, the report said.