The New York Times had a recent story on organ donation that generated a lot of discussion on social media:
But in recent years, as the system has pushed to increase transplants, a growing number of patients have endured premature or bungled attempts to retrieve their organs. …a New York Times examination revealed a pattern of rushed decision-making that has prioritized the need for more organs over the safety of potential donors.
In New Mexico, a woman was subjected to days of preparation for donation, even after her family said that she seemed to be regaining consciousness, which she eventually did. In Florida, a man cried and bit on his breathing tube but was still withdrawn from life support. In West Virginia, doctors were appalled when coordinators asked a paralyzed man coming off sedatives in an operating room for consent to remove his organs.
Stories like these have emerged as the transplant system has increasingly turned to a type of organ removal called donation after circulatory death. It accounted for a third of all donations last year: about 20,000 organs, triple the number from five years earlier.
This is an important (and disturbing) story, but I do wish the Times had taken more care with the framing. Although the piece suggests that the problem is donation after circulatory death (DCD), the article actually documents the importance of protocols that separate the donation decision from removal of life support decisions, and that separation is important in both brain death and circulatory death.
As Al Roth says, at his Market Design Blog:
The NYT has a disturbing story this morning about organ donation after circulatory death. These are cases in which a decision has been made to remove the patient from a ventilator, in anticipation that they are irreversibly dying. If death (via cessation of heartbeat and breathing) occurs almost immediately after removal, the patient may still be a viable organ donor, and otherwise not. Organ procurement organizations (OPOs) are not supposed to be involved until after death has been declared, but apparently in some small hospitals they get involved earlier, and have sometimes pressured physicians to proceed prematurely.
A recent episode of the Taboo Trades podcast focuses on donation after circulatory death and we discuss the possibility of mistakes in some detail:
Thao Galvan: Well, I think that you tap into like the, like one of the deep fears and dreads of people when they think about organ donation is are you going to take my organs while I’m alive? Right. So that's, that's really what you're suggesting.
And I, and I think that's part of the public trust question. Like, and I think it's a salient point. However, it's always been true whether you're talking about IDD or not.
And, and I think that this is a failure on our part in transplant medicine. But the truth is I come to, I get in a car wreck, I come to the hospital, the intensivist takes care of Me. The surgeons take care of me. Everyone takes care of me. The neurosurgeons take care of me.
And there comes a point where I'm probably not recovering, right? And so in that case, then they might call the op of the organ procurement organization, but the organ procurement organization is not going to come in until the medicine doctors who are caring for me, trying to save my life, are assured that there's nothing further that medicine can do for me. Only then does a totally separate team come in and start deciding, well, is this a very viable candidate for organ donation?
And then once they make that assessment separate of your medical team, your medical team's just like, oh, okay, well, I mean, there's nothing else we can do. Well, then, then we, we come to the family and say we were very sorry for what you're going through.
Is organ donation something that you think your loved one would have participated in? Is that something that you would like to participate in?
And so then after that, say, the family says, yes, but it's going to have to be DCD because we don't fulfill the definition of brain death. Well, then we go to the or, we allocate all the organs, the teams fly in, and then we wait, right?
We wait, we pull the tube, and then we wait the five minutes.
Well, does a patient suddenly breathe on their own? Are they going to last this X amount of time?
I will say there's a lot of insecurity, even amongst intensivists and the medical community. Like, do we make a mistake? Are we notoriously bad at determining when someone will die?
And I will say that, like a large scale, like months to years, we're probably pretty bad at it.
But as far as days, I mean, there's a stark difference between someone who has cancer that may survive two, ten more years, as opposed to someone who just got a huge car accident, got into a huge car accident, huge neurological insult, and will probably never recover. And you can probably tell within a number of days in that situation.
Clearly (assuming the facts as reported by the Times are correct) these procedures and protocols were not followed in the cases reported in the article. Anyway, listen to the whole episode here or in the embedded player below (or apple, Spotify, etc.)