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The Nasty Side of Organ Transplanting.

Chapter 6

Aggressive Hospital Harvest Teams

Most people retain a warm view of doctors and nurses cooperating with each other to save lives, but reality is different. Hospitals are stressful places where workers frequently end their shifts exhausted and disturbed. Doctors have higher suicide and drug addiction rates than others. They've been deprived of normal comforts for ten years to complete their medical education. They are driven and ambitious to succeed in a demanding profession.

Transplant technology dangles the possibility of fame and wealth like Christiaan Barnard, Denton Cooley and Norman Shumway ― and that mystical lure of eternal life.

Governments and pharmaceutical corporations pressure hospitals and donation agencies to increase organ supply to “save more lives”. The drugs companies crave more patients dependent on permanent medication while governments seek reduced dialysis costs. Surgeons and immunologists are the third force desperate to maintain their market share.

When a brain-injured patient arrives by ambulance it isn’t just a million dollars worth of surgical activity at stake. It’s the reputations and life dreams of men and women who seek victory for the sake of themselves and their patients. From this boiler room of adrenaline and hyperactivity the declaration of “brain death” resembles the starter gun at the Olympic one hundred-metre race.

The aggression temperature rises in this boiler room when two medical ideologies collide. Hindering the transplant faction’s goals are those tending the brain-injured patients. They try every desperate attempt to maintain life, occasionally beyond the dignity of the patient and financial capacity of the hospital. They are motivated by similar conflicting drives as the transplant crowd: pride, ambition and compassion. Their allegiance is to maintaining life at all costs rather than releasing the patient for spare parts. These neurologists, neuro-surgeons, cardiologists and nurses wish to see apparently terminally injured patients walk out of the hospital. Transplant teams see them as impediments to an early diagnosis of “brain death” and subsequent rush to the harvest table.

Transplant coordinators are under similar pressures. They need consent or, at least acquiescence from relatives to deliver what they call, “heart-beating cadavers” to the surgeons. They have the creepy task of looking through patient files to identify brain-injured patients or peeking through one-way mirrors at grieving families in the waiting room. They discuss among themselves who can best obtain consent. They're like those street charity collectors who quickly decide among themselves who will ask: “Excuse me, can I ask you a quick question?”

It is crucial to obtain consent. The coordinator, (or intensive care staff member), faces similar pressure to football players who need to score a goal every game or are relegated to the minor league. They operate under similar motivations of pride, compassion, ambition and a basic desire to stay employed. Coordinators especially will pester and interrogate reluctant relatives until there is outright anger or acquiescence. Other hospital staff may discreetly intervene with coffee or throw the odd harsh glance at the coordinator.

Doctors are increasingly pressured to declare “brain death” earlier than before because waiting lists grow while supply stagnates.

Governments want increased kidney and cornea donation for financial as much as for compassionate reasons. Eighteen months on dialysis costs equal to a kidney transplant that should last seven years. Kidney transplants also improve the quality of life unless surgery or immunological complications turn nasty.

Transplanted corneas are cost effective when they improve the sight of a blind citizen who might otherwise require continuous and expensive care. Corneas don't depend on blood circulation so rarely require dangerous immuno-suppressant drugs though there are exceptions where blood vessels infiltrate the transplanted cornea and all hell breaks loose.

And if an aged patient dies due to surgical complications it’s a financial boost to the health budget though not a successful social outcome.

Transplant coordinators are under pressure to pursue government objectives, which are to reduce public medical costs by increasing transplant activity.

Doctor Richard Nilges, Emeritus Attending Staff in Neurosurgery of the Swedish Covenant Hospital in Chicago, USA recounts being pressured to declare patients dead for organ removal who later walked out of the hospital.

“Committed as I was to the seriously injured or very sick patient under my care, whether he or she was brain dead or not, I had to literally fight off the transplant teams. One case I recall was when the transplant team was called to our community hospital without my knowledge and before I was ready to declare brain death on an unconscious patient who had a severe head injury in a motorbike accident. He had reflex extension of his arms and legs on painful stimulation. He was, therefore, not unresponsive even though his movements were no longer under the control of his will. His pupils reacted sluggishly to light. He had none of the criteria of brain death (except unresponsiveness). I rather too abruptly dismissed the transplant coordinator and his “team”. I continued to treat this young man’s brain swelling. He walked out of the hospital and returned to college”^[44]

Same Day Harvesting and Aggressive Transplant Teams

Doctors previously had a minimum of forty-eight hours to treat the patient prior to “brain death” testing. This gave relatives time to discuss the issue of consent with religious advisers and extended family. Time was allowed for repeated electroencephalograms and, most importantly, time for the patient’s condition to improve.

In the era of Day Surgery where patients don’t even spend one night in hospital we also have Same Day Harvesting. Half of all Australian donor patients are declared “brain dead” within 33 hours of entering hospital. 69% are harvested within 12 hours of “brain death” diagnosis and 98% within 24 hours. Queensland is the quickest to harvest incoming donors. Patients may be harvested within 24 hours of suffering brain injury or a stroke.^[45]

Doctors worldwide are reporting increased pressure to declare “brain death” before adequate periods of observation, treatment and self-recovery. Transplant surgeons demand other doctors administer drugs and prepare organs for harvesting despite these procedures accelerating brain damage. This changed priority from treatment to harvest preparation shows the paranoia that recuperative treatment may be reduced for prospective donors is not an urban myth.

Dr Richard Nilges recounts more of his experiences.

“With patients closer to brain death, the struggle was even more agonizing. The transplant team would be present in full panoply. The coordinator would object to my policy of two flat EEGs separated by 24 hours. I repeat his demand as I recorded it in a newspaper article: “Dr Nilges, you don’t need another electroencephalogram tomorrow. Today’s is flat. Declare death today”. Of course, I did not declare death that day.”^[46]

Dr Nilges reports pressure to preserve the organs for transplant at the expense of the patient,

“I grew weary of being at loggerheads with the demands of the transplanters when their demands were contrary to the interests of my patients. To preserve a suitable kidney for transplantation, transplant technicians would demand that I order what I would judge to be an intravenous fluid overload. I would refuse patiently and sometimes impatiently, explaining that too much fluid would cause more swelling of the already injured brain and might cause my patient’s brain to die sooner. My commitment was to my patient, not to a faceless “society,” to the next unknown (to me) patient on a waiting list.^[47]

The pressure to declare “brain death” prematurely isn’t limited to United States and Australia. Dr Yoshio Watanabe, a cardiologist at the Chiba Tokushu-kai Hospital in Funabashi, Japan reports that,

“…a 40-year old crime victim with a head injury was brought to the emergency room of Osaka University Hospital in August 1990, the team of physicians apparently looked at him as a potential kidney donor from the outset. Thus, as early as three days before the first diagnostic tests for brain death were made, they had started a set of new regimes (a combination of anti-diuretic hormone that reduces the urine volume, drugs that elevate blood pressure, and a drip infusion of a large amount of fluid) developed by this group, which is considered very effective in keeping transplantable organs fresh and viable. It would, however aggravate brain oedema, increase intracranial pressure, and accelerate the process of brain death. Without telling this fact to the victim’s wife and by using words of threat, they persuaded her (in a manner far from an informed consent) to donate his kidneys.^[48]

The above example was in 1990 but things haven’t changed. Dr Watanabe reports on one of only four brain dead donors in Japan in a six-month period of 1999,

“…a middle-aged female with a subarachnoid (and perhaps cerebral) haemorrhage. When she was brought to Kochi Red Cross Hospital, the physicians failed to give certain important life-saving measures, including administration of drugs to lower her extremely high blood pressure. Instead, they immediately told her family that she was in the state of “impending brain death” and did not explain the possibility of surgical removal of intracranial hematoma. A clinical diagnosis of brain death was made 60 hours after admission, disregarding the fact that repeated Phenobarbital administration could have made an accurate evaluation of brain function difficult. Preparations for organ transplantation were expedited…”^[49]

Dr Watanabe reports that a subsequent review of the incident showed that repeated apnoea tests were performed before the electroencephalogram became flat. This is illegal in Japan. Apnoea testing deprives the brain of oxygen and speeds up “brain death”. When done repeatedly, one might suggest, it’s being done to create “brain death” rather than test for this condition.^[50]

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