The dead donar rule and how it applies to organ donation after cardiac death

Nitin. K. Sethi, MD

The August 14th issue of the New England Journal of Medicine has a series of perspectives on organ transplantation after cardiac death and how it conflicts ethically with the dead donar rule. It is a fascinating and at the same time complex ethical problem and that prompted me to write this post.

The dead donar rule simply states that a patient must be declared dead before any of the vital organs can be removed for organ transplantation. Death can be defined in two ways. Either it is the irreversible cessation of cardiorespiratory function or simply put when your heart stops you die!!!. Mind you the important word here is irreversible. Death can also be defined as the irreversible cessation of brain function, this is the concept of brain death, a concept now well accepted by caregivers and doctors alike. (See my earlier post on brain death at http://braindiseases.info). In the case of brain death, the patient’s heart may be beating, respiration supported by a ventilator but the brain is so badly damaged that there is no chance of a meaningful neurological recovery.

That all makes sense till now. Ethical problems arise when the dead donar rule is applied to organ donation after cardiac death especially with respect to cardiac transplantation after cardiac death. Hmm getting confused? Let me explain with the help of an example.

Let us take the example of an infant who is overwhelmly sick, the family wants to donate organs including the heart. Studies have shown that the human heart does not auto-resuscitate (meaning start on its own) after 5-10 minutes of cardiac arrest. It does not auto-resuscitate but can be resuscitated by doctors by giving drugs like atropine or by giving electric shocks to it. The infant’s heart stops, the doctors wait for 5 minutes, at times 2 minutes sometimes even less to document that it does not auto-resuscitate (the longer the heart is not beating and not getting blood, it starts to get damaged). The heart is then taken out and transplanted into another infant’s chest cavity. The doctors then resuscitate the heart and restart it in the transplanted infant.

All good you may say but how can you declare the first infant dead on the basis of irreversible loss of cardiac function when that very heart has been transplanted and has successfully functioned in the infant who received it. The dead donar rule gets violated, the first infant was never really dead if the loss of cardiac function was reversible.

As you can imagine opinions are sharply divided on this subject. Some feel that the dead donar rule is violated, while others try to justify it by saying that a heart cannot be legally restarted if resuscitation has been refused by the family in case of infants and minors, so its loss of function meets the defination of irreversibility as commented so eloquently by Drs Truog and Miller in their New England Journal of Medicine article.

I would encourage my readers to read more about this topic in the New England Journal of Medicine or online and I welcome their comments.