More organs are being donated after the heart stops, not brain death. Policies are changing too
WASHINGTON– The vast majority of organ donations once came from people who were brain dead. Today, they increasingly come from people who died when their hearts stopped beating, a major change that may boost transplants but also sow confusion among the public, researchers reported Thursday.
So-called circulatory death donation, or DCD, has increased dramatically in a short time: it accounted for 49% of all deceased donors in the United States last year, up from 2% in 2000.
Technology has helped overcome barriers to using these organs — ways to prevent them from deteriorating as the heart rate slows — spurring this type of donation just as the country seeks ways to overcome a severe shortage. More than 100,000 people are on the transplant waiting list and thousands die waiting. Just over 49,000 transplants were performed last year.
But NYU Langone Health specialists have found that donation after circulatory death is much more common in some areas of the country than others. This suggests that better education of the public and local hospitals about this option could further increase access to life-saving transplants.
The findings, published in the medical journal JAMA, come as rare but frightening reports of potential donors showing signs of life have shaken confidence in the transplant system.
Additional safeguards are being developed by both federal officials and nonprofit organ procurement organizations, or OPOs, that the government certifies to coordinate donations. The new findings could make it easier to develop these policies.
Donation after circulatory death is complex and “we need to make sure we do it right,” said Dr. Babak Orandi, a transplant surgeon at NYU and co-author of the study. “If we stop doing it or severely limit it, there will be some pretty significant repercussions for patients.”
While living donors can provide certain organs, most transplants are done using donations from the deceased. Brain death is declared when tests show that a person no longer has any brain function. If it is a potential organ donor, the body is kept on a ventilator to support the organs until they are retrieved.
Donation after circulatory death may be an option if a person has an unsurvivable injury but not all brain function has ceased and the family chooses to terminate life support. Death occurs after the heart gradually stops beating. Once that happens, there’s a mandatory wait — five minutes, according to American Society of Transplant Surgeons guidelines — to be sure the system won’t restart. Then the person’s doctor declares the person dead.
By law, donation and transplantation groups cannot participate in the decision to terminate life support, and they are not present in the room when life support is withdrawn. Organ harvesting cannot begin until death is declared. If death does not occur quickly enough, within about two hours, the organs are not usable and harvesting is not attempted.
To track donor progress, the NYU team analyzed data from the National Organ Procurement and Transplantation Network and 55 OPOs that retrieve organs in assigned regions across the country.
Last year, circulatory deaths accounted for more than half of donors at 24 organ donation agencies. But this varied widely, with some making up as little as 11% of donors.
Hospital resources play a role, according to the Association for Organ Procurement Organizations. Decisions to remove life support are common, but smaller or rural hospitals may not be as familiar with the additional steps involved in donation.
Another factor is whether hospitals have adopted this new technology. Organ quality can suffer when the heart stops, briefly depriving them of oxygen. Once death is declared, a tool called normothermic regional perfusion allows surgeons to temporarily restore that blood flow to organs in the chest or abdomen – avoiding the brain – while they carry out the delicate work of removing them.
This helped enable the use of organs from older, sicker donors after cardiac arrest. But even temporarily restoring blood flow after death raises ethical questions.
The Health Resources and Services Administration is preparing new national policies to improve safeguards for this type of donation. One proposal would allow anyone involved with a potential donor who questions whether their condition is suitable for removal from life support to call for a pause in those preparations.
Other proposals would require OPOs to document that hospitals caring for the potential donor perform appropriate neurological examinations and to inform families of potential DCD donors about the required steps.
The Association of Organ Procurement Organizations has similar guidelines, and some OPOs have already created checklists to help hospitals.
The group also recommends removing life support in the intensive care unit, not an operating room, to avoid public confusion about when death occurs and when organ groups intervene, said association President Jeff Trageser.
Donation after circulatory death “requires a lot of buy-in from the community, including local hospitals, to make it happen,” said NYU’s Orandi. “A few cases among many others have led to a loss of confidence. »
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