CMAJ • June 5, 2007; 176 (12). doi:10.1503/cmaj.1060217.
© 2007 Canadian Medical Association or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters

Organ donation after cardiocirculatory death

Mohamed Y. Rady*, Joseph L. Verheijde{dagger} and Joan McGregor{ddagger}

Department of Critical Care Medicine;* Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Phoenix, Ariz.;{dagger} Bioethics, Policy and Law Program, School of Life Sciences and Department of Philosophy, Arizona State University, Tempe, Ariz.{ddagger}

The Canadian recommendations for organ donation after cardiocirculatory death advocate confirming the irreversibility of cardiocirculatory arrest by the absence of palpable pulses, blood pressure and respiration during a 5-minute period of continuous observation by at least 1 physician.1 This criterion does not fulfill the prerequisite requirement of irreversibility for the determination of death.

First, autoresuscitation (the spontaneous return of circulatory and neurological function), also known as the Lazarus phenomenon, has been reported after more than 10 minutes of cardiac electric asystole in humans.2 Second, the presence of electrocardiographic activity without blood pressure (i.e., pulseless electric activity or ventricular fibrillation) does not indicate irreversible cessation of mechanical cardiac activity.3 Third, the applicability of criteria for organ donation after cardiocirculatory death becomes questionable when artificial circulatory and ventilatory support is resumed after death in order to maintain the viability of abdominal and thoracic organs in potential donors.4,5 Extracorporeal circulatory support can lead to the return of neurological function in people who are neurologically intact before cardiac death.6 Mechanical occlusion of coronary and cerebral circulation has been used to try to prevent reanimation during the organ procurement process, without substantial evidence for its effectiveness.5

The timing involved in cardiocirculatory criteria is arbitrary, and the use of such criteria alone to determine death without simultaneous total cessation of all activity in the donor's brain (including the brain stem) during procurement circulatory support will not fulfill the "dead donor rule."7,8 It may be necessary to abandon the dead donor rule to permit the recovery of transplantable organs after cardiocirculatory death.

REFERENCES

  1. Shemie SD, Baker AJ, Knoll G, et al. Donation after cardiocirculatory death in Canada. CMAJ 2006;175(8 Suppl):S1-S24.
  2. Adhiyaman V, Sundaram R. The Lazarus phenomenon. J R Coll Physicians Edinb 2002;32:9-13.
  3. American Heart Association. Management of cardiac arrest. Circulation 2005;112:IV58-IV66.
  4. Institute of Medicine Committee on Non-Heart-Beating Transplantation II. The scientific and ethical basis for practice and protocols. Executive summary. Washington (DC): National Academy Press; 2000.
  5. Magliocca JF, Magee JC, Rowe SA, et al. Extracorporeal support for organ donation after cardiac death effectively expands the donor pool. J Trauma 2005;58:1095-1101.[Medline]
  6. Younger JG, Schreiner RJ, Swaniker F, et al. Extracorporeal resuscitation of cardiac arrest. Acad Emerg Med 1999;6:700-7.
  7. Menikoff J. The importance of being dead: non-heart-beating organ donation. Issues Law Med 2002;18:3-20.[Medline]
  8. Bernat, J.L. Are organ donors after cardiac death really dead? J Clin Ethics 2006;17:122-32.[Medline]




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