Friday, August 15, 2008

Infant Heart Transplants Raise Questions on Criteria for Death

From Bloomberg.com:

By Nicole Ostrow

Aug. 14 (Bloomberg) -- Doctors have reignited a debate over when an organ donor should be declared dead after a study reported on the first three known successful cardiac transplants from infants who were pronounced dead after their hearts stopped.

The research, published by the New England Journal of Medicine, reported on transplants from babies whose hearts had stopped after life support was removed. Infant donor hearts usually are removed only after the child is considered brain dead, which has limited the number of hearts available for infant transplant.

About one-fourth of babies needing heart transplants die before organs become available. The finding that a heart that irreversibly ceases to beat in one infant can be restarted and give new life to another raises ethical and medical questions about donor death, doctors said in three commentaries in the journal. The U.S. now has 44 infants awaiting heart transplants.

The findings ``open the door'' to heart transplantation following cardiac death, wrote Robert Veatch, a professor of medical ethics at Georgetown University in Washington, in a commentary in the journal accompanying the study. They also raise the question: ``When can death be pronounced on the basis of loss of heart function?'' he wrote.

A declaration of cardiac death requires that the cessation of function of the heart and circulatory system be irreversible. To ensure a viable heart from a cardiac death donor, procurers of organs try to minimize the time from when a heart stops to when death is pronounced. Death usually isn't pronounced for at least two to five minutes after the heart stops, the journal article said.

Current data suggests that cardiac arrest becomes irreversible in 60 seconds or less, according to a 2000 report by the Institute of Medicine.

Speed is Critical

In the transplant study, the time between cardiac death and pronouncement of death for one infant was 3 minutes. For two other donors, it was 1.25 minutes. Physicians not involved in the care of the heart recipients, with the consent of the babies parents, decided to end mechanical life support that had been keeping the infants alive, the article said.

The three transplants were done at the Denver Children's Hospital from 2004 to 2007. All three recipients are still alive, according to the study.

``The fact that the children did reasonably well suggests that this could be a viable technique if people wish to use it,'' said Jeffrey Drazen, editor in chief of the New England Journal of Medicine, in an Aug. 12 telephone interview. The study ``raises significant issues concerning the use of organs in the setting of both the pediatric and even the adult intensive care,'' he said.

The commentary authors called for review of current transplant rules.

Defining Death

``It may ultimately be deemed acceptable to amend either the dead donor rule or the brain-based definition of death,'' Veatch said in his commentary. ``But whether or not any such legal changes come to pass, any successfully transplanted heart cannot have come from a person who was declared dead on the basis of irreversible stoppage of the heart.''

Robert Truog, professor of medical ethics at Harvard University and author of one of the commentaries, said it was wrong to conclude from the study that doctors are ``doing something unethical.''

``We sort of set ourselves up for people to believe that the dead donor rule is a fundamental and inviolable principle that we need to follow in the ethics of organ transplantation,'' Truog said. ``The worrisome thing that people might take away from the study is that doctors are doing something unethical in order to increase the number of organs for transplantation. That would be the wrong conclusion.''

Irreversible Heart Death

Mark Boucek, the study's lead author and director of cardiovascular services at Joe DiMaggio Children's Hospital in Hollywood, Florida, said cardiac death of the donors was irreversible because parents had decided they didn't want the children to be resuscitated.

The hearts were restarted in other babies because there was nothing wrong with the organ in the donors, Boucek said.

``It's simplistic to say that a heart that can't work in one individual can't work in another individual. It depends on the environment that the heart is working in,'' Boucek said in an Aug. 12 telephone interview.

More than 6,000 children have received transplanted hearts from donors who were declared brain dead over 25 years, according to the study. Children who need a heart face higher risk of dying while awaiting a transplant than kids waiting for other organs, the researchers said.

Three-Year Study

Over the three-year study, 12 potential donors who died from cardiocirculatory causes were identified. If their hearts had been used, the number of transplants at Denver Children's Hospital would have increased 70 percent during that time, the study said. During those years, one pediatric heart donor was declared brain dead. No other newborns' hearts could be harvested under traditional criteria at the hospital, according to the study.

``It's terribly frustrating to lose a child while awaiting transplant,'' said Boucek. ``I'm hopeful that the study will make it possible for children or at least infants to have more donor organs and for more children to have the opportunity at life.''

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