Donation after cardiac death: perceptions versus reality.

The paper by Rady et al 1 criticizes donation after cardiac death (DCD) on 3 levels: (1) it defies the spirit if not the letter of the dead donor rule; (2) asserts some manipulations of the DCD patient may inappropriately hasten death in patients technically still alive by brain death criteria, and (3) claims DCD is a threat to public trust in the organ donation system. These criticisms should stimulate further debate on these issues. The authors suggest that DCD evolved to access more viable organs from the potential pool. However, some have stated the primary reason was a utilitarian argument to allow families of severely brain injured (but not technically brain dead) patients to circumvent the dead donor rule to donate. If the dead donor rule interfered with the altruistic desire to donate organs from a patient who would die anyway, the dead donor rule was perceived as impedimentia. So there was incentive to circumvent it by creative interpretation. This is a shaky argument. It does not matter if there is an intent to resuscitate or not. Neither the patient nor his or her family can consent to any procedure that will result in death, nor can the family consent to the patient’s being dead in a predetermined number of hours or minutes. Consenting to either of these options is tantamount to consenting to euthanasia. The most fundamental criticism of DCD involves ambiguity in the rules created to determine whether a potential donor’s organs are alive enough to donate but the whole patient is dead enough to avoid vivisection. What ethicists call “irreversible cessation of the integrated functioning of the organism as a whole” (not the whole organism). The rules seem clear. In 1968, the Harvard Criteria objectified the progression of disease, thereby making it possible for clinicians to predict inevitable death, but the Uniform Determination of Death Act (UDDA) of 1980 made brain death an objective criterion for death. The UDDA specifically required that death be irreversible. This act states that an individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem, is dead and that a death certificate may then be filled out. However, the UDDA does not elucidate how these 2 differing standards reflect the same phenomenon, opening the interpretation that there are actually 2 kinds of death: brain and cardiac. This ambiguity made the issue of determining death amenable to a creative interpretation. Pronouncement of death could make brain function irrelevant if the heart stops. A problem with this interpretation is the inability to establish precisely when death transitions from a reversible process to an irreversible event. Brain death is an actual diagnosis of death and is clearly defined in terms of irreversibility. Cardiac standstill is a prognosis of death. When the heart stops, the brain will die in time, but its progress is unknown and unmeasured. Because the point of irreversibility is not known at the time death is declared, the exact time of death cannot be determined. Technically, the From the Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.