We read with interest Dr Cottle and Dr Dean’s correspondence on ethical issues and donor numbers [1]. We would like to congratulate them upon the frankness of their account and the invitation for further debate. It is not made clear in the text of their letter whether they considered non-heart beating donation, as this is something that may potentially circumnavigate the ethical dilemma of continuing treatment, that is not in the patient’s best interest.
The Review of the United Kingdom Transplant Support Service Authority (UKTSSA) published in 1999 [2], recommended to the Department of Health a wider use of non-heart beating donors. The four Maastricht categories of non-heart beating donors are:
1. Dead on arrival at hospital
2. Unsuccessful resuscitation
3. Awaiting cardiac arrest
4. Cardiac arrest in a patient confirmed dead by brain stem death testing.
The young male in the author’s case would have belonged to category 3. Patients in category 3 will usually have global and unrecoverable
damage to the brain, without the specific features of death confirmed by brain stem examination. Withdrawal of support in these patients
will inevitably lead to their cardio-respiratory death, and hence make them eligible for non-heart beating donation.
The rapid and widespread increase in non-heart beating donation, since the Organ Donor Task Force report is to be applauded, but over the same period, the number of heart beating donors has continued to fall. There is anecdotal evidence that some of the increases in non-heart beating donors have come at the expense of heart beating donors. Non-heart beating donor organs are fewer in yield per donor, and are thus less than ideal, with higher rates of organs being discarded and worsened short term outcomes for the recipients. Some patients are possibly being declared as non-heart beating donors very early, with a view to reducing the donor's stay in the intensive care unit. Intensive care unit management for a few more hours would doubtless make some of these donors appropriate for heart beating donation. This would avoid the increase in the recipient's morbidity, the recipient's stay in the intensive care unit and the recipient mortality's associated with non-heart beating donation.
With respect to the use of cerebral angiography to diagnose death, various assessments of the relative benefits and complexities of supportive neuroradiological and neurophysiological tests may be found [3]. Four-vessel angiography is reliable, but its availability is limited and it is invasive. It requires high expertise to perform but is relatively easy to interpret. There are risks to the patient, which have been recorded as less than 1%. The presence of residual cerebral blood flow does not preclude a diagnosis of brain death, and this technique may produce false negative results. Neurophysiological tests, such as evoked potentials, are reliable, readily available, portable, easy to interpret and carry no risk to the patient.
No external funding and no conflicts of interest declared
A. Iqbal
J. Isaac
S. Bramhall
Queen Elizabeth Hospital
Birmingham, UK.
E-mail: docasimiqbal@msn.com
References
1. Cottle D, Dean P. Ethical issues and donor numbers. Anaesthesia 2010; 65: 84.
2. Department of Health. Review of the United Kingdom Transplant Support Service Authority (UKTSSA) 1998/99. London: Department of Health, 2000.
3. The Academy of Medical Royal Colleges. A Code of Practice for the Diagnosis and Determination of Death. London: Academy of Medical Royal Colleges, 2008.