Pediatric DCD in the news

Today The Washington Post has an article -- Infant Transplant Procedure Ignites Debate -- that builds on yesterday's AP article about three cases in which infant hearts were harvested under a "donation after cardiac death" ("DCD") protocol, which all transplant centers are required by UNOS and HHS. The details of each center's protocol may vary.

On the crucial issue of how long to wait before death is declared following the removal of life support and the onset of pulselessness, the Children's Hospital of Denver team waited 75 seconds in two of the cases and 3 minutes in the third; most centers' protocols require either 2 minutes or 5. Part of the ethical debate turns on whether this is long enough to be assured that autoresuscitation won't occur, a key component in determining that the absence of cardiac function is total and irreversible. Not to put too fine a point on it, if autoresuscitation can't be ruled out, irreversibility can't be assured, and if the loss of cardiac function isn't irreversible according to reasonable medical standards, the infant donors can't really be said to have died.

A second part of the debate concerns the removal of hearts from patients who haven't been declared brain dead. Most protocols of which I am aware are limited to kidneys; some include other organs, but I am not aware of any others that permit the harvesting of thoracic organs, hearts in particular. Think about it: If the heart's ability to beat (which is in some sense "intrinsic" because it is not tied to brain function) is supposedly irreversible, how can that be true when the heart (in all three cases) is working perfectly well in other bodies three years later? Two conclusions seem inescapable: The donor babies were erroneously declared dead and the traditional "dead donor rule" was abandoned

The debate was prompted by one clinical report, three Perspective pieces, and an editorial in today's New England Journal of Medicine, plus a videotaped discussion among three ethicists. It's unusual for the NEJM to devote this must space to any single topic. Even more unususal -- and a sign of how seriously they take the issues raised by the clinical report -- is their decision to make all five pieces available in full text (rather than abstracts only) for free:

Clinical report:

• Pediatric Heart Transplantation after Declaration of Cardiocirculatory Death M. M. Boucek and Others
  FREE Full Text PDF

Perspectives:

• The Boundaries of Organ Donation after Circulatory Death
  J. L. Bernat
  FREE Full Text PDF Perspective Roundtable
• Donating Hearts after Cardiac Death — Reversing the Irreversible
  R. M. Veatch
  FREE Full Text PDF Perspective Roundtable
• The Dead Donor Rule and Organ Transplantation
  R. D. Truog and F. G. Miller
  FREE Full Text PDF Perspective Roundtable

Editorial:

• Cardiac Transplantation in Infants
  G. D. Curfman, S. Morrissey, and J. M. Drazen
  FREE Full Text PDF Perspective Roundtable

The video discussion is here (requires Flash), along with a transcript.