uring this past year, your Committee on Ethics has spent a great deal of effort responding to anesthesiologists who have asked for advice on their role in organ recovery from patients who die by the usual criteria of cessation of cardiac and respiratory activity, also referred to as donation after cardiac death (DCD). Most of these patients will have been in the intensive care unit (ICU) and fully dependent on ventilatory and circulatory support. They or their spokesperson will have declined the further use of ICU modalities and requested that they be withdrawn. Most, but not all, of these patients also will be neurologically devastated but do not meet criteria for whole brain death. In these patients, the ethical principle of “double effect” allows the use of appropriate doses of analgesics and sedatives “intended” to relieve or prevent suffering during treatment withdrawal. It would be illegal, however, to give any drug or dose “intended” only to cause death.

The interest in this group of people as potential organ donors has grown steadily over the last decade, mostly because the demand for usable organs far outstrips the needs of potential recipients. Pressure also has come from donor patients’ families who struggle to find some meaning in the death of their family member.

Predicting whether a patient will die rapidly after the withdrawal of ventilatory and circulatory support can be difficult. The selection of patients suitable for withdrawal of ICU modalities and donation of organs is being studied. Also the viability of organs from these donors has already been extensively studied. It is clear that some organs will perform better than others when donated after the cessation of circulation.

Intensivists have been withdrawing ICU modalities from patients who can no longer benefit from such treatments for decades. Nonbeneficial care is defined as care that no longer holds the promise of restoring a patient to a life that they themselves have defined as worthwhile. The further burdens of nonbeneficial care are declined because they are thought to postpone or make an inevitable dying process more burdensome. Humane and respectful withdrawal of circulatory or ventilatory treatments now always involves consideration of how to prevent possible suffering during this process. The patient’s own physician is best suited to withdraw unwanted treatments and should be welcomed into the operating room (O.R.) to do this for the patient who desires to donate organs.

Anesthesiologists are the natural leaders of the O.R., and as such, must be prepared to help with patients who come to the O.R. to donate organs. The best way to prepare to help is to develop written guidelines for DCD before the first case occurs in your hospital. The main principles for institutional DCD guidelines are:

1) that the donor’s care and decisions are paramount;

2) the decision for withdrawal of ICU treatments must be made before and separate from any decision to donate organs;

3) in order to avoid the appearance of conflict of priorities, the physician caring for a donor should not be involved in any of the organ recipient procedures, and that physician should be the declarant of time of death;

4) criteria for death by circulatory arrest need to be defined (most institutions accept a two- to five-minute interval of a flat arterial line tracing, since that may be more accurate than electrical silence of the myocardium); and

5) the policy needs to outline how long a patient should be in the O.R. after withdrawal of treatments if circulatory death does not occur as predicted. Many institutions say that one hour of observation is appropriate, and plans for where the patient is to be cared for after the hour is up are made in advance. Relatives must be informed of this possibility. Caregivers must not be under any pressure to hasten death when it does not occur as a result of the withdrawal of nonbeneficial treatments.

There was a national consensus conference on DCD in April 2005 in Philadelphia, Pennsylvania. The proceedings from that conference will be available soon from the United Network for Organ Sharing (UNOS) at <www.unos.org>.

Ethically and legally, DCD is not equivalent to donation that occurs after time of death has been documented by whole brain death criteria. We know that for brain dead patients, there can be no consciousness, and therefore no suffering. Our care for those patients usually follows UNOS guidelines for maintaining perfusion of organs until donation occurs. This type of care would be inappropriate for a donor completing the dying process with the cessation of circulation.

Anesthesiologists can show their compassion as physicians by providing leadership on the issue of DCD. Anesthesiologists do care about respecting their patients, their decisions and their comfort, including when they are dying.


For Further Information:

• Van Norman GA. Another matter of life and death: What every anesthesiologist should know about the ethical, legal, and policy implications of the non-heart-beating cadaver organ donor. Anesthesiology. 2003; 98(3):763-773.

• Donation after Cardiac Death: A Reference Guide. This CD is available from the U.S. Department of Health and Human Services, Health Resources and Services Administration. Call your local UNOS/organ procurement organization for a copy. See <www.organdonor.gov/opo.htm> for a list of organ procurement organizations.

Susan K. Palmer, M.D., is a staff anesthesiologist with Oregon Anesthesiology Group, Salem Hospital, Salem, Oregon.