ethical aspects of nhbd

8/3/2019 Ethical Aspects of NHBD

1/19

Non heart beating organ

donation (NHBD):ethical aspects and safeguards

for NHBD performance


2/19

From brain death concept to NHBD

First transplantation attemps with organs

of conventionally died people

1963: introduction ofbrain death concept

at Harvard university:

problem of warm ischemia solved

Search for new organ sources :

Living donor transplants (Xenotransplants)

NHBD

usually graft failure due to long warm

organ ischemia period

increasing succes rates due to betterorgan qualitiy, immunological scienceand pharmacological support

transplantation medicine becameestablished method for final organfailure treatment

Increasing gap between organ

demand and supply


3/19

Classification of NHBD

Maastricht categories for NHB organ donors

I : dead on arrival uncontrolled NHBD

II : unsuccessful resuscitation uncontrolled NHBD

III: awaiting cardiac death controlled NHBD

IV: cardiac death in brain dead donor uncontrolled NHBD


4/19

Sequence of events in uncontrolled NHBD

procedures

unexpected pre-hospital / in-hospital cardiac arrest

unsuccessful CPR or DNR decision

asking for relatives permission for organ donation

organ retrieval

[postmortal in situ organ preservation]


5/19

Sequence of events in controlled NHBD

procedures

hopeless case-assessment of an ICU patient

therapy withdrawal decision with consent of relatives / time for family to saygoodbye

report to organ procurement organization with consent of relatives

therapy withdrawal in theatre under explantation stand by

patient dies spontaneously (< 1 h) patient dies not spontaneously (> 1h)

organ retrieval patient returns to ward for dying

[antemortal in situ organ preservation]

? min


6/19

The

ethics debate

about NHBD


7/19

Pro NHBD argument

Progress in neurocritical care and better

protection devices in cars due to

decreasing numbers of brain dead donors

while organ demand is increasing.

NHBD can moderate the shortage oforgans and in this way save lives.


8/19

Effects of NHBD on solid organ supply

Estimated increase in organ availability

20 % - 25 %

[Herdman R, Kennedy Inst Ethics J , 1988]

[Clayton HA, Transplantation, 2000][D`Alessandro AM, Surgery, 2000]


9/19

Donation sources for solid organ

transplantation in UK

Transplant 2004 - 2005

heartbeating kidney 1074 (64%)

non-hearbeating kidney 143 (8%)

Living donorkidney 475 (28%)

heartbeating liver/liver lobe 618 (96%)

non-heartbeating liver 19 (3%)

Living donorliver lobe 7 (1%)

UK Transplant Activity Report 2004 - 2005


10/19

Cadaveric solid organ donors in UK

2004-2005

0

100

200

300

400

500

600

700

heart-beating donors non-heartbeating donors

89 %

11 %


11/19

Ethical concerns about controlled NHBD

hopeless case-assessment of an ICU patient

therapy withdrawal decision with consent of relatives / time for family to saygoodbye

report to organ procurement organization with consent of relatives

therapy withdrawal in theatre under explantation stand by

patient dies spontaneously (< 1 h) patient dies not spontaneously (> 1h)

organ retrieval patient returns to ward for dying

[antemortal in situ organ preservation]

+

? min


12/19

Ethical concerns about uncontrolled NHBD

unexpected pre-hospital / in-hospital cardiac arrest

unsuccessful CPR or DNR decision

asking for relatives permission for organ donation

organ retrieval

[postmortal in situ organ preservation]


13/19

Ethical concerns: NHBD in conscious people

Intersection between the right to die and

organ donation

the organ donation will only increase the pressure on disabled people to

choose to die in belief that by giving their organs up, their lives can have

some meaning. The danger is especially acute for people who are newly

disabled, many of whom believe, falsley, that live can never be worth living.

[Wesley Smith, Culture of Death The Assault on Medical Ethics in America]


14/19

Ethical concerns:

Pressure for organs opens Pandoras box

dead donor ruel might be violated in future

Individuals who desire to donate their organs and who are either neurologically

devastated or imminently dying should be allowed to donate their organs,

without first being declared dead.

[RD Truog, Critical Care Medicine 2003]


15/19

Summary of ethical concerns

Conflicts of interest between potential donorsrights and potential recipient chances

Organ retrieval before patient irreversibly dead

Violation of relatives feelings by time pressuremistrust towards health care team and organ

donation in general

refusal of consent

Ethical borderlines might become more andmore blurred in future


16/19

The way of NHBD leads very closley along

ethical borderlines and therefore has to be

well defined.


17/19

Safeguards for NHBD performance

National / international approved and publicrevealed protocols which provide strict guidanceon every step of NHBD procedures to avoidpublic mistrust towards transplantation medicine

Strict avoidance of active euthanasia

Separat and independent teams for therapywithdrawal decision / death declaration andtransplantation to avoid conflicts of interestsbetween potential donor and recipient


18/19

Safeguards for NHBD performance

Case by case decisions about premortem organpreservation measures and family consent forthese measures

Respect for donor and family wishes

Special trained staff for taking care of the family

In conrolled NHBD procedures at least 5 minbetween determination of death and start oforgan removal (dead donor ruel)


19/19

Thank you for your

attention

ethical aspects of nhbd

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