Monday, May 19, 2008

Donation Difficulties: More on San Luis Obispo

I have written before of the case of a transplant physician in San Luis Obispo, California, alleged to have acted inappropriately in the death of a patient eligible for donation after cardiac death. There is an update to the story here.

The initial allegations included concern that the doctor involved had affected the patient’s diagnosis of severe brain injury and/or the family’s decision to donate organs. Reportedly the physician was not involved in either of those decisions. The concern remains as to whether he hastened the patient’s death.

It’s important in understanding this to distinguish donation after brain death, our common expectation, from donation after cardiac death. You can read a good description of brain death here, but the basic information is that brain death is a diagnosis that the brain, from top to bottom (and in this case, “bottom” is important) has ceased to function. The brain has been so injured that not only is the damage not recoverable, but also the most basic, noncognitive functions of the brain have ceased. I say “bottom” is important because those most basic functions take place in the brain stem, that portion of the brain that connects brain functions to other parts of the body. A number of important functions connect there that don’t require thought, including especially breathing and some significant reflexes.

Note that I didn’t include heart function among those of the brain stem. The heart can function quite well on its own, as long as sufficient nutrition and oxygen are available. That’s why for many brain death is hard to see: the patient is on a ventilator, lungs being mechanically (and passively) pumped with air. Family members see the chest rise and fall. What they don’t necessarily realize is that the patient’s brain has nothing to do with that; it’s all the machine. At the same time, it’s enough to sustain the heart – for quite a long time, if not forever. Indeed, one of the definitive tests for brain death is an apnea (“not breathing”) test. The patient’s tube is disconnected from the machine, and physician and staff watch to see if that most basic reflex, the drive to breathe as carbon dioxide builds up in the blood, kicks in. They don’t wait forever, as it were; but they wait quite long enough to demonstrate that the patient’s brain cannot do that job. The apnea test isn’t the only test done, but it is quite significant.

So, the point of brain death is that the brain is so damaged that the patient would already be dead if it weren’t for the machinery pumping air into the body. As a result, brain death is one legal definition of death. The patient is considered legally dead from the time the diagnosis is confirmed and recorded by the physician.

Now, the decision has to be made independent of consideration of transplant. The standard of care is to have the decision made if possible by a neurologist or neurosurgeon; but certainly by a physician not involved with any transplant program.

But, what about patients who are so severely brain injured that best medical advice is that the patient cannot survive, but who are not brain dead? It’s possible for all but the brain stem to be injured so badly that the patient will die eventually, without affecting the functions of the brain stem. Such patients may be eligible for donation after cardiac death (also known as non-heart beating donation).

Once again, a decision needs to be made independent of any consideration of donation. In this case, the decision is the family's decision about whether and when to withdraw life support and allow natural death. If the patient is severely brained injured beyond hope of recovery, and the family decides to withdraw support, the patient may be eligible to donate.

Hospitals have procedures regarding donation after cardiac death. (They have to; having policies and procedures to participate in donation activities is a requirement for Medicare reimbursement.) If the patient is eligible to donate and the family consents, a team is assembled and a schedule prepared. When the family is ready, the patient is taken off the ventilator. The patient may be given medication for comfort, just as would happen if there would be no donation. The family and the team watch and wait with the patient until the patient stops breathing. There is a time limit (just how long varies from hospital to hospital), and if the patient doesn't stop breathing within the designated time, donation efforts end. The team continues to support patient and family while waiting for death to occur. If the patient does stop breathing within the designated time, the patient is taken to surgery. There the team stops for another five minute “hands off” period, just to be sure the patient doesn’t spontaneously breathe again. If after that time the patient has still not started again to breathe, the team proceeds with recovery of organs for transplant.

According to the article in amednews.com, the online edition of American Medical News from the AMA, the physician in question was not involved either in the family’s decision to withdraw support or in the family’s consent to donation after cardiac death. Instead, he was a member of the transplant team, present to follow through once the patient had died. However, he was apparently involved in caring for the patient after the ventilator had been withdrawn. During that time he gave the patient morphine. The allegations are that in doing so he inappropriately hastened the patient’s death.

Determining whether the morphine was appropriate, and whether it hastened the death, would seem straightforward. In fact it might not be. The allegation is based in part on the amount of morphine ordered. According to the article a number of physicians testified that in their opinions the doses were excessive; while a number of other witnesses testified that the patient did not seem to be in distress.

At the same time, and without taking a position in this case, such decisions are not necessarily simple. There would be other factors to consider, and especially, whether the patient was “narcotic na├»ve,” or whether he had a history of receiving large doses of narcotics. Patients are unique, and patients who have long experience with relatively large doses might continue to need unusually large doses simply to maintain comfort. Distress, too, can be determined by several different measures. A patient who is severely brain injured may not be able to move or to grimace. Distress would then be measured by an accelerating heart rate or respiratory rate. That’s something that a monitor would show; but if the professional didn’t explain it, the nonprofessionals present might not make the connection – especially when they are, very appropriately, focused on the patient and not on the monitor screen.

It will be interesting to see how this case plays out. The first successful kidney transplant took place in 1954. With all the educational efforts made over the past fifty years, the number of patients who might benefit from the generosity of transplant continues to far exceed the number of organs donated (much less the number of families who choose to donate). When professionals are not circumspect, they add to doubts about transplant that many in society already feel. It is easy for those in health care to see the generosity of donation and the benefits to organ recipients, and lose track of the concerns of families, and of the stresses they feel from simply from grief, without the further decision to donate. If the doubts in society, and the anxieties of grieving families are to be addressed appropriately and constructively, it is important for all who participate in donation programs to be sensitive, transparent, and careful.

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