Introduction

Due to a shortage of organ donors, NHBOD is gaining popularity. In 2008/9 it accounted for 32% of cadaveric donations 1. Before criteria for brainstem death were introduced in 1976, NHBOD was the only source of cadaveric organs. Since then heart beating donation has become the principal source of organs 2. NHBOD poses significant ethical questions and is thus controversial. It also raises important logistical challenges. This case provided me with direct experience of many of the issues surrounding NHBOD.

Clinical problem

A 48 year old man was brought into hospital during the night after collapsing at home. He was intubated and ventilated in A&E before going for a brain CT. The patient was then transferred to the Intensive Care Unit. Imaging revealed an extensive subarachnoid haemorrhage which was deemed to be unsurvivable after consultation between the neurosugeons and intensivists.

Management

Brainstem death tests were carried out in daylight hours which revealed preservation of some brainstem function (spontaneous breathing). The patient was considered a potential candidate for NHBOD. The transplant coordinator was called and NHBOD was discussed with the family. Whilst the patient was not a registered organ donor, his relatives agreed to organ donation. Unfortunately the transplant coordinator was delayed and some hours past. During this time the relatives changed their mind as they did not want the patients death prolonged by waiting any longer for donation. Treatment was withdrawn and the patient died within 1 hour. As a result of this donation failure, the hospital was given funding for its own transplant coordinator.

Discussion

Suitability for NHBOD

The modified Maastrict classification 3 recognises 5 categories of potential NHBODs

  • Brought in dead
  • Unsuccessful resuscitation
  • Death expected after withdrawal of treatment
  • Cardiac arrest after brain-stem death
  • Cardiac arrest in a hospital inpatient
1, 2 and 5 are termed uncontrolled while 3 and 4 are controlled. It is category 3 (and 4 if the retrieval team is on site) patients that apply to NHBOD. All organs except the heart can be used from category 3 patients. Usually patients will have suffered irrecoverable brain injuries (trauma, haemorrhage and hypoxic brain injury) but may have other diagnoses. All patients should be considered if:

  • A decision has been made to withdraw treatment
  • They are expected to die within 2h
  • They have organs suitable for transplantation
The only absolute contra-indications are HIV or CJD. The final decision on suitability is made by the retrieval/transplant surgeons.

Withdrawal of treatment

This should be based on guidance from the ICS 4 and GMC 5. The decision to withdraw treatment must be completely separate from the one to donate organs so as not to be seen as a utilitarian approach (treatment withdrawn to facilitate organ donation). For this reason the retrieval team can have no involvement with the withdrawal decision and they should only be contacted after it has been decided further treatment is inappropriate (if futile then treatment constitutes harm). The family should first be made aware that treatment is not in the patients best interests. They can then be approached about donation after the transplant coordinator has been contacted, the organ donor register checked and consent obtained from the coroner. The coordinator and senior clinician will ideally approach the family together.

Ongoing treatment

The key consideration here is what is deemed to be in the patients best interests and does not cause harm or distress to them or their family. If they have expressed a wish to donate organs then blood testing and maintenance of life sustaining treatment is acceptable (including escalation of treatment). Similarly delaying withdrawal or moving the patient to facilitate transplantation is considered to be in the patients best interests if their wish to donate is known. Systemic heparinisation, femoral cannulation and CPR are not acceptable as they have a significant risk of harm. The Department of Health issues clear guidance on this subject 6.

Death

The definition of death from the Academy of Medical Royal Colleges 7 is ‘the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe’. A clinician should monitor the patient for a minimum of 5 minutes to establish that irreversible cardiorespiratory arrest has occurred. This can be confirmed by absence of a central pulse, absence of heart sounds, asystole on an ECG display and absence of pulsatile flow using direct intra-arterial pressure monitoring. Following this 5 minute period death can be confirmed by:
  • No pupillary response to light
  • No corneal reflexes
  • No motor response to supra-orbital pressure
Following death the patient must be transferred to the operating theatre as quickly as possible to minimise warm ischaemic time. The family cannot be prevented from seeing the patient if they wish to do so first. Consent can be withdrawn up to the point that surgery commences.

Ethical issues
Many ethical questions arise around NHBOD. These include the withdrawal of treatment (some argue this may be utilitarian), appropriateness of ongoing treatment to facilitate donation, the method of diagnosis of death and the time left between cessation of cardiorespiratory function and confirmation of death. The purpose of this case history was to focus on the practicalities and legality of the process rather than explore the ethical arguments surrounding it. There are a number of good ethical reviews on this topic which I have referenced. 8 9 10

Lessons Learnt

NHBOD is clearly complicated and controversial but also very important. Thankfully there are clear guidelines on the topic which resolve many of these issues. Even though the donation process did not go ahead in this patient it was important for me in raising many of the issues I have gone on to learn about and outline here. I now have a clear framework for the process and have wrestled through the ethics for myself - I personally agree with the process if done according to the guidance above. The lesson learnt by the hospital was of their need for an on site transplant coordinator.


References

NHS Blood and Transplant. Transplant Activity in the UK 2008-2009. Available at http://www.organdonation.nhs.uk/ukt/statistics.jsp

Intensive Care Society (2005). Guidelines for Adult Organ and Tissue Donation. Prepared on behalf of the Intensive Care Society by the Society’s Working Group on Organ and Tissue Donation.

Categories of non-heart-beating donors Kootstra G, Daemen JH, Oomen AP. Transplant Proc. 1995 Oct;27(5):2893-4.

Intensive Care Society (2003) Guidelines for limitation of treatment for adults requiring intensive care. Available at http://www.ics.ac.uk/intensive_care_professional/standards_and_guidelines/limitation_of_treatment_2003

General Medical Council. Withholding and Withdrawing Life-prolonging Treatments: Good Practice in Decision-making. 2002. http://www.gmc-uk.org

Department of Health (2009) ‘Legal issues relevant to non-heartbeating organ donation’ Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_109864.pdf

Academy of Medical Royal Colleges (2008). A code of practice for the diagnosis and confirmation of death.

Pro/con ethics debate: is nonheart-beating organ donation ethically acceptable? Whetstine et al. Critical Care 2002, 6:192-195

Pro/con ethics debate: When is dead really dead? Whetstine et al. Critical Care 2005, 9:538-542