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Not Dead Yet: Controlled Non-Heart-Beating Organ Donation, Consent, and the Dead Donor Rule

Published online by Cambridge University Press:  22 December 2009


The emergence of controlled, Maastricht Category III, non-heart-beating organ donation (NHBD) programs has the potential to greatly increase the supply of donor solid organs by increasing the number of potential donors. Category III donation involves unconscious and dying intensive care patients whose organs become available for transplant after life-sustaining treatments are withdrawn, usually on grounds of futility. The shortfall in organs from heart-beating organ donation (HBD) following brain death has prompted a surge of interest in NHBD. In a recent editorial, the British Medical Journal described NHBD as representing “a challenge which the medical profession has to take up.”

Special Section: Open Forum
Copyright © Cambridge University Press 2010

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1. In U.S. nomenclature, Donation after Cardiac Death (DCD) programs.

2. In U.S. nomenclature, Donation after Brain Death (DBD) programs.

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6. This article is primarily a critique of current U.K.-controlled NHBD practice. However, we also hope our discussion will be relevant to debates about NHBD in other jurisdictions.

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8. The time period from when blood perfusion is inadequate to meet the tissue's needs to when the organ is perfused with cold fluids is known as the warm ischemic time. The time period from cold perfusion to transplantation into the recipient is known as cold ischemic time. See note 3, Bernat et al. 2006, for discussion of each of these.

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10. The current recommendations to diagnose death by cardiopulmonary grounds are a minimum of 2 minutes of pulselessness, as documented by an absent arterial line waveform, in the United States versus a minimum of 5 minutes of asystole, as documented by the absence of electrical activity by an electrocardiogram in the United Kingdom. See note 5, Gardiner, Riley 2007; see note 3, Bell 2003 and Bernat et al. 2006.

11. This is of considerable concern in potentially increasing the number of cases of Lazarus syndrome (autoresuscitation). Theoretically, it also might mean that brain function is reestablished. These possibilities in turn place significant pressure on the idea that these patients are dead by either brain or cardiac death criteria, which refer to the irreversible loss of function of these organs.

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19. One of the authors (Gardiner) is an intensive care specialist and has heard this opinion expressed a number of times in conversation at NHBD conferences.

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23. The move in the United Kingdom to secure “family lack of objection” rather than consent suggest that the United Kingdom is moving away from a concern for consent to donation even for HBD.

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