Wall, Stephen P. MD; Goldfrank, Lewis R. MD
As emergency physicians, we are accustomed to witnessing untimely deaths from those presenting in cardiac arrest, for whom resuscitative efforts all too often fail. After the death, we experience an emotional session with the family, describing how their loved one died, despite all our efforts at resuscitation.
On many occasions, family members inform us that their loved one is an organ donor, and they inquire about whether this wish may be carried out. Unfortunately, this request is almost invariably denied because there is no mechanism to preserve and recover organs from those dying of unexpected cardiac arrest inside or outside the hospital.
Our frustration is heightened when one considers that more than 10,000 patients a year die or become too sick to receive organ transplants while waiting, and despite all efforts to date, this number has increased annually, with many dying in emergency departments.
Those of us seeing these unfortunate fates firsthand would consider organ donation a logical step after an unexpected cardiac arrest results in death, both to fulfill the wish of those willing and to meet the needs of those waiting. Until now, this notion was not even considered possible until recent advances in Spain and France proved the great potential to increase organ donation if the system permitted individuals and their families to donate, regardless of where or how death occurred.
Facilitating this approach also would prevent those 100,000 Americans from dying while on the waiting list. Although most transplantations in America currently occur from donations by the 10,000 to 15,000 people who meet brain death criteria, the 350,000 to 450,000 patients developing cardiac arrests, most of whom succumb, lead to less than 1,000 annual donations in America.
In 2006, the Institute of Medicine published a report that recounted how Spanish investigators had seemingly solved the problem. (“Organ Donation: Opportunities for Action,” National Academies Press; 2006; ebook available free at http://bit.ly/NAPorgan.) After unsuccessful treatment for cardiac arrest in the field, individuals who had agreed to donate could be rapidly transported by EMS, with the consent of the family, to a hospital serving as a procurement center. Similar success was later described in Paris in 2009. (Crit Care 2009;13:R141.)
Based on this information, investigators at the University of Pittsburgh School of Medicine (EMN 2011;33:1; http://bit.ly/EMNorgan) and a consortium of investigators from the New York University School of Medicine, Bellevue Hospital Center, the New York City Police Department, the New York City Fire Department, the Office of the Chief Medical Examiner, and the New York Organ Donor Network applied to the Health Resources Services Administration (HRSA) Division of Transplantation to replicate such efforts in the United States. Both groups received grants to establish systems permitting organ preservation and donation following failed resuscitation from unexpected cardiac arrests. The Pittsburgh group was charged with considering those cases presenting to the ED while the New York Uncontrolled Donation after Circulatory Determination of Death study group would consider only those stated to be deceased in the field by EMS, according to standard guidelines.
In New York City, the effort has been remarkably complex because the stakeholders are diverse, and the clinical problems demand meticulous collaboration to minimize warm ischemia time. The ethical debates surrounding death determination also need to explain how the protocol follows the “dead donor rule,” and how the resuscitative and preservation teams are separated to maintain faith that potential donors were appropriately cared for prior to considering organ donation.
The absence of a defining legal statute further complicated matters, necessitating proof of prior first-person consent by the deceased and that the procedures to be performed were consistent with current law and regulations. These constraints dramatically limited the population of potential donors. Despite these challenges, we received great support from all stakeholders, which led to a comprehensive pilot program projected to last six months in the field.
While few if any organ donation opportunities may be realized in this six-month pilot, we have already achieved many objectives by bringing the program to fruition. We secured community, professional, and governmental stakeholder support, provided public and professional education, clarified regulatory and statutory requirements, and developed a robust regionalized infrastructure necessary for organ recovery from those declared dead from an unexpected cardiac arrest in the field.
One of our most important accomplishments has been the collaborative effort among our diverse stakeholder groups (including those from transplant and emergency medicine, fire department and EMS, police, medical examiner, and the Organ Donor Network), which informed team action plans, created a shared vision for success, provided clarity and articulation about how to translate theories into action, and devised a means to act purposefully while collecting and analyzing data in an iterative fashion.
As we move forward, we are monitoring to ensure that no change in usual EMS care is happening while the organ preservation unit is active. We hope to learn a great deal about our human encounters with the deceased individuals' families immediately following death. We also hope to have one or more individuals who meet our rigorous criteria for transplantation following failed cardiac arrest in their homes so we may provide kidneys to those waiting, and if that is successful, have the potential to consider livers.
This concept, if accepted and modified, may extrapolate the promising results from Spain and France to the United States. It is obvious that if Americans wish to address the disparity between donors and the growing numbers of those on the waiting list, we will need a mechanism similar to the ones underway in Pittsburgh and New York. We need to address our organizational deficits; donation after neurologic determination of death and live donation will not meet societal needs, despite all efforts to improve the numbers from these programs. Donation after controlled circulatory determination of death has proven only to increase the organ donor pool marginally. Currently about the same number of people die each year on the waiting list as there are donors fitting brain death criteria. The result is that about 18 Americans die every day.
Opportunities for organ donation realized after uncontrolled circulatory determination of death are essential to alleviate this gap between supply and demand. We believe that investigatory improvements on the European and American models will be essential to meet our promises to those in need of organ transplantation. The role of Emergency Medical Services and emergency departments will be vital in achieving these goals, which are essential to meet the needs of all of us who wish to donate and those who need this altruistic act to improve life or continue to live.
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