Personal Views: Die and let live
Authors: Alison Pittard
Journal: BMJ (2003)

Today I did something I swore I would never do. In fact it was something I felt so strongly about that I had previously considered changing my job plan to avoid the issue. However, this afternoon I did it. I helped three people to live. What's so strange about that? After all, I am a doctor. Well, these three patients each received a life saving transplant from a non-heart beating donor.

Most of my working week is spent on an intensive care unit in a large teaching hospital. I have been directly involved with many patients who have become brain stem dead and ultimately organ donors. The number of organ donors fell from 876 in 1992 to 773 in 2002, while the number of patients on the waiting list for a transplant has steadily risen. In response to this the national transplantation support service, UK Transplant, has looked at new initiatives to reduce the number of people who die while waiting for an organ. One initiative is the retrieval of organs from non-heart beating rather than from heart beating, or brain stem dead, donors.


My overwhelming feeling is one of pride at having honoured this young man's wishes


About 18 months ago the possibility of piloting a non-heart beating programme was discussed in the trust I work for. I was extremely uncomfortable. Such a programme would mean a significant alteration in clinical practice. Traditionally, organ donors have been those patients who have become brain stem dead, despite our best efforts. No clinical decision is needed. However, in the case of non-heart beating patients the likelihood of their becoming an organ donor is directly influenced by a clinical decision regarding withdrawal of treatment.

I had difficulty with three issues. A decision to withdraw futile treatment should not be influenced by the possibility of the patient becoming a donor. I was unsure how easy it would be to separate the two issues clinically. Secondly, to ensure that organs are in optimal condition the patient must be in the operating theatre within 10 minutes of death. The thought of relatives clinging to patients, not wanting them to leave and with insufficient time to come to terms with their loss, I found particularly distressing. Finally, if the patient doesn't die within a certain time the organs are not suitable, and again this could be upsetting for the family.

I was well aware of the arguments in favour of transplantation from non-heart beating donors. The decision to withdraw treatment should be transparent and should be reached by a multidisciplinary team. The most appropriate people to discuss organ donation with the family are the team that knows the patient. Asystolic death is more acceptable to the public than brain stem death. With a comprehensive explanation the family knows what to expect and is free to withdraw its consent at any time. But I am afraid the arguments against were much more powerful in my mind.

To say I have been on a long journey of discovery is a bit of a cliche, but that is what it feels like. The concern I felt about non-heart beating donation led me to question every aspect of my routine practice involving dying patients. I have had to work through my own fears, do a lot of reading, and talk with colleagues, friends, and my own family. Sometimes I felt as though I was going round in circles. However, what I have realised is that I am a competent clinician. Any decision to withdraw treatment that I am involved in is dealt with professionally and in a multidisciplinary manner. I am comfortable that the decision that is made is robust. And finally I would be extremely angry if my wishes were not respected at any time—and therefore a patient's or family's wishes should always be met wherever possible.

So at 8 30 this Monday morning I was faced with a young patient who had a non-survivable brain injury. He was unlikely to become brain dead, and as he carried an organ donor card the family wanted to give him the opportunity to become an organ donor. I can't say that the day was easy. Many tears were shed, mostly from myself and the staff on the unit. Withdrawing support in this situation was absolutely the right thing to do. He would have died anyway, and the family didn't want to go through the agony of waiting by the bedside for the inevitable. They had enough time to say their goodbyes both before and after he was certified dead and after organ retrieval. There was an air of calm and no sense of urgency. His family was extremely grateful, and despite all our tears every member of staff involved in the case was convinced that the decision was entirely appropriate.

As I drove home this Monday evening I was saddened thinking about the young man's tragic death. My tears reminded me that I am still human. I am pleased to have been involved in a process that has helped others to live, but my overwhelming feeling is one of pride at having honoured this young man's wishes.