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The Nasty Side of Organ Transplanting.

Chapter 10

Donation after Cardiac Death

(Non heart-beating vital organ donation)

One could be forgiven for thinking that Donation after cardiac death is a return to the good old days when organs were removed after the donor died. This was prior to the invention of the “brain death” concept when removing organs from a heart beating donor might have carried a murder charge.

The controversy begins even before life-support is removed and when the patient is still being treated therapeutically in the hope of recovery.^[60] 

Transplant technicians thin the patient’s blood with heparin to reduce blood clotting during harvesting. This may cause bleeding inside the skull of the patient being treated therapeutically by other doctors. Phentolamine is administered to widen blood vessels to protect the organs during harvesting, but may also cause a “precipitous drop in blood pressure and cardiac arrest",^[61] which, not coincidentally, is what the harvesting team desires. Perfusion fluids are further added to the blood stream to cleanse the organs of blood and other substances.

Warm kidneys inside a warm body lacking circulation may become unusable after an hour, sometimes sooner, depending on how quickly the body and organs are chilled after cardiac arrest. The ethical issue here is that these medical interventions hasten death rather than help the still living patient.

Transplant technicians are reluctant to share secrets about cooling the body before death but here is a brief description.

A saline/gelatine hydrosilate primer containing heparin is pumped into the femoral artery and out of the femoral vein via a refrigeration unit and oxygenator that chills the body to 15Cº. ^[62] This extends kidney viability inside the body to hours rather than minutes, which is especially helpful if death has been sudden, relatives can't be found for permission or the transplant team isn't ready with the recipients. Some of this treatment may be performed on living patients.

Ventilation is withdrawn while the prospective donor is still classed as a living person. Surgeons anxiously wait for cardiac arrest, which usually happens within two hours.

Up to 10% refuse to die and annoyingly for the surgery team these chilly patients are wheeled back into intensive care sicker than ever and full of non-therapeutic organ donation drugs. This leaves little doubt that organ donors receive inferior treatment to non-donors. For the other ninety percent that do suffer cardiac arrest death is declared from two to ten minutes after the heart stops and a strange process begins in earnest.

Kidneys from older and less healthy donors may become unusable if left for over fifteen minutes in a body without circulation. This may not leave enough time for excision so circulation may be restarted using cardiopulmonary resuscitation (CPR). It may be done by hand or by using The Thumper^TM that compresses the chest 50-100 times a minute creating a rudimentary circulation that feeds the organs with oxygenated blood.

The blood is oxygenated using an extracorporeal membrane, which means the “deceased” patient’s blood is streamed through a machine called the “artificial lung”. Blood passes from a tube stuck into a large neck vein to the lung machine which adds oxygen then pumps it back into the body through the carotid artery.

The corpse has ceased breathing and is without a heartbeat yet maintains a twilight zone existence. Was two or five-minutes without breath or heartbeat enough to kill the patient’s brain? Another quiet dilemma is whether the corpse’s heart will begin beating naturally because that is what cardiopulmonary resuscitation is designed to accomplish. And what will the transplant team do if this happens?

Kidneys are further chilled and cleansed after circulation cessation by inserting a double balloon catheter in the aorta that isolates the renal circulation system. Hyperosmolar citrate cooled to 4Cº is pumped through the femoral artery in the groin and washes the kidneys of blood to prevent clotting and replaces renal substance to inhibit cellular swelling. The effluent drains from a second catheter placed in the femoral vein.

There aren't standard protocols and some transplant establishments will declare a cardiac arrest patient dead after two minutes to enable them to get useful livers. This contrasts with other hospitals where at this point they are still trying to revive the patient. The key is whether they want the patient “dead” for harvesting or alive. Protocols are based on how much hospitals want to increase organ transplanting rather than objective medical science.

Specialists are reluctant to share professional secrets like whether donors are conscious when life support is removed; whether donor hearts restart beating during cardiopulmonary resuscitation; how long before life support removal are organ preservation drugs administered? Another question arises when a patient doesn't die after life support removal and is then wheeled back into intensive care. How long before this patient is returned for another go and how many times will this be repeated?

What isn't in question is that being this type of organ donor ensures inferior recuperative treatment. And donors aren't even “brain dead” when surgeons begin a process that kills them.^[63]