Outcome of out‐of‐hospital cardiac arrest

The authors of the editorial on nonheart-beating organ donation [1] are to be congratulated for a thorough and fair review of the many conflicting priorities which exist around this difficult subject. As an intensivist in the same critical care network as the authors I am expressing my own opinions, and as a group in Derby we have failed to reach a clear consensus. I fully support the author’s stance in opposing NHBD at the present time and I fail to see anything other than an irreconcilable conflict of interests between the duties of a doctor acting in the best interest of a patient while in the ICU and the subsequent scheduling of them for organ donation once ‘futility’ (whatever that means) is declared. I recognise I am in the minority in regretting the direction taken nationally with liaison between the intensive care and transplant teams to increase donation rates from heart beating (brainstem dead) donors. One of the requirements is that the treating doctors and transplant teams should remain independent because of conflicts of interest. These struggles become, arguably, more apparent when nonobjective criteria for withdrawal of treatment or futility exist, as opposed to brainstem death, and if I was a transplant co-ordinator my natural instinct would be to pressure the critical care team to withdraw therapy when things look bleak. But if the ICU team are not maximising a patient’s (often slim) chances of surviving, who is? Once the transplant team has a presence or representation within the unit that distinction is gone, and the organ recipient exerts pressure over a potential donor’s care. I can only echo the authors’ concerns regarding the practicalities of declaring death and the timescale required to do so in an NHBD programme. I will walk off for at least 30 min and reconnect the monitors when I return so my conscience doesn’t bother me about sending a ‘dead’ patient to the mortuary who perhaps wasn’t. Time is an essential part of this diagnostic process, reflecting death as a process itself, and I wouldn’t sleep too well knowing that patients were going for NHBD after 5 min. Finally, I would remind the entire profession of recent events surrounding a medical ‘scandal’ which occurred according to the standards of the time and judged subsequently by largely artificial and unrepresentative criteria. I refer to the retention of organs following post mortem examination, the outrage which followed and the subsequent decline in post mortems such that no hospital post mortems are currently offered in Derby and the public have lost out as a result. The dynamic between the medical profession and society has changed forever and we are no longer thanked for being the driving forces behind changes; it is far more likely that a Big Brother contestant will direct society than the current organ shortage or the NHBD issue. Medical paternalism has become a naughty word, despite the reality that the majority of patients and next of kin still need a degree of it and autonomy is so frequently undermined by patients who don’t comprehend it. So, with this in mind, who is actually seeking NHBD? The medical profession recognises the transplant shortages and the tragedies within – so why are the public not crying out to donate their organs when their heart stops? We would do well to remember that the (medical) heroes of today pushing the process forward can easily become the body snatchers of tomorrow, and be judged by tomorrow’s even more perverse standards. I will act in society’s best interests when society matures slightly and decides what it wants! Until that point the rules seem simple – you look after the patient in front of you in their ‘best interests’; a vague term certainly, but usually pretty obvious. I cannot reconcile this role with lining patients with an overall slim chance of survival for NBHD. I can only hope that this topic receives the public debate which it deserves, and that any drive to pursue the NBHD programme does not come from within medicine. Witnessing society’s thirst for all things scandalous, medical and subsequently legal, I suspect this will not be the case and so until that time, I don’t want to be that pioneer or villain.