Letter to the editor: Organ donations after cardiac death examined more closely

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A medical ethicist, an organ procurement expert, and an organ donation/transplantation advocate respond to Dr. Brodkey’s “Stories from the Intensive Care Unit” column on DCD.

As medical ethicists, organ procurement experts, and advocates for organ donation and transplantation, we welcome the opportunity to jointly respond to Dr. Brodkey’s June 13, 2024 article, “Why Doctors Stop Donating Organs After Cardiac Death.”

First of all, there can be no organ donation after a cardiac death attempt (DCD) as long as the patient/potential donor has not been declared dead. The Dead Donor Rule (DDR) requires that a patient must be declared dead before organs are removed for donation, and the DDR is fulfilled in both Organ donation after brain death (DBD) and DCD. In both cases, the process of organ procurement can only begin once death has been established according to neurological criteria (DBD) or cardiopulmonary criteria (DCD).

Categories of decision making

It is important not to confuse the requirement to obtain informed consent for medical procedures on living patients with the standards required to obtain or confirm authorization for organ donation. There are two distinct categories of decisions to be made in organ donation, and specifically DCD. Healthcare decisions, such as terminating treatment, require providers to obtain informed consent from the living patient or their legal representative. In contrast, the decision to authorize organ donation is made in accordance with organ donation laws (as defined by the relevant state’s Revised Uniform Anatomical Gift Act).

As Dr. Brodkey notes, approval for organ donation is usually obtained through a state driver’s license office through a donor registry. Since approval for organ donation is made easier after After the declaration of death, consent to organ donation is no longer required by law. From this point on, the DDR comes into force.

In terms of ethical concerns and potential conflicts of interest, as Dr. Brodkey notes, clinical practice guidelines should ensure that the patient/potential donor’s treating physician does not breach their duty to the patient. For example, in patients who progress as potential DCD donors, if death does not occur after withdrawal of life support, the patient remains in the care of the treating physician, who then provides palliative care. It is important to recognize that the organ procurement team has no interaction with the patient/potential donor unless and until the treating team determines death.

Although unlikely, we agree that patients who could be potential DCD donors can survive withdrawal of life support. For this reason, the guidelines provide an “intervention-free” period between declaration of death and organ procurement to ensure that the patient does not spontaneously revive.

We also agree that all partners in donation and transplantation (including providers and organ procurement organizations (OPOS)), regardless of their role, should treat the patient/potential donor family with sensitivity and that qualified and compassionate staff at both the hospital and the OPO should be clear about their ethical duties and obligations.