Summer 2009 - British Columbia Transplant Society

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donation after cardiac death In separate interviews, Dr. David Landsberg, director of renal transplant at St. Paul’s Hospital in Vancouver, and Dr. Jeff Zaltzman, his counterpart at St. Michael’s Hospital in Toronto, said revisiting DCD as a means of organ procurement was driven by the public. Dr. Landsberg said families of patients (usually suffering catastrophic brain injury) were seeking “an outcome which they felt . . . gave meaning to that person’s life and their death.” The first DCD procedure in Canada was performed in June, 2006, at the Ottawa Hospital. The family of a 32-year-old woman, Sara-Beth Therien, having decided withdrawal of life support was their best option, asked doctors to follow through on her wishes to become a donor. At the time, the woman’s father was quoted as saying DCD marked “a new era for organ donation in this wonderful country and that makes (our daughter) a pioneer.” Some detractors of DCD have gone so far as to suggest doctors caring for patients—usually in intensive-care—might abandon efforts to save patients too soon. Medical personnel stress, though, that the aim of all doctors is to extend life—not cut it short as a convenience. Dr. Landsberg is among those and says it’s important people realize the clear-cut and separate obligations of the attending physician and the transplant team. “We’re not involved in any of the discussions with the family about life support or its withdrawal. It’s only when they (the ICU team and the family) have made the decision to withdraw life support is there even a consideration whether that person is a candidate for DCD.” He underscores the point that withdrawing life support is a decision made in the interests of the patient and family. “Regardless of DCD or no DCD, withdrawal of life support is what’s going to happen. The decision is made regardless of whether that person is going to be an organ donor. “We [the transplant team], ethically, legally and morally will not be involved until the patient has actually died.” One concern mentioned by some detractors of DCD is the administering of drugs that, while not of any help to the patient, are intended to preserve organs. For example, an anti-clotting medication could be injected. That decision must be made by the ICU physician and not the transplant team. Dr. Landsberg says such medications are not administered until the withdrawal of life support at St. Paul’s, while Dr. Zaltzman says St. Michael’s has administered anticlotting drugs just prior to withdrawal. Dr. Zaltzman says ICU doctors might also decide to administer so-called “comfort measures,” such as morphine for pain. “These (measures) have the possibility to hasten death,” he said, “but they are exercised for comfort; not with the idea of DCD.” He admits, though, that pre-death medications “add a level of complexity” to an already complex subject and those arguments against the administering of such medications are not “completely invalid.” For now, the success of DCD is reflected in the numbers. By the beginning of this year, 45 such procedures had been performed in Ontario since the first in mid-2006. Quebec has had limited experience, with fewer than 10 performed so far. During that three-year period, DCD organs at one point accounted for 17 per cent of kidney “The reality is that ventilators are being turned off. Why would you not turn that into a potentially positive situation?” –Dr. David Landsberg and liver transplants in Ontario. The figure could one day reach 20 per cent, says Dr. Zaltzman, but he feels the figure will likely level out to somewhere around 12 to 13 per cent; still an impressive number. Dr. Landsberg says he feel strongly the public in general has faith in the medical system. “I believe most families trust the medical system,” he says. “They believe everyone is working [for] the patient and not looking ahead to some potential donor. “Only when it is no longer in the best interest of the patient to be maintained on life support is consideration given to its withdrawal.” He accentuates, too, that withdrawal of life support happens in hospitals around the world every day. “The reality is that ventilators are being turned off. Why would you not turn that into a Page 4 Transplant Times 2009
potentially positive situation? I can’t believe the public believes doctors are (withdrawing life support) so the patient can be a donor. Our focus is to save peoples’ lives; not end them.” He wonders whether the hard questions surrounding withdrawal of life support are not more challenging to the medical community than the general public. “When breathing has stopped and the heart has stopped, most people accept the fact that person is gone.” The timing between a patients’ death and the retrieval of organs has also become an issue drawing strong opinion. In the US and parts of Europe, transplant teams have begun retrieval of organs as soon as 75 seconds after pronouncement of death, although the generally accepted waiting period seems to be five minutes. Advocates of DCD support this approach, referring to a sometimes disputed claim that no person has ever revived after losing a heart beat for more than 60 seconds. After much deliberation, St. Michael’s Hospital decided it would wait 10 minutes after declaration of death; St. Paul’s Hospital chose five minutes. Both of these waiting periods are far more conservative than used in other countries and Dr. Zaltzman would like to see the 10-minute rule now practised at St. Michael’s Hospital lowered, saying there is no “scientific merit” in the extended wait time. Dr. Landsberg agrees, saying the difference between two, five or even 10 minutes is “splitting hairs.” TT clinic Above from left to right: Kathleen Collin (Pharmacist), Dr. Mina Matsuda-Abedini (Nephrologist), Kelleigh Graham (16-year-old kidney transplant recipient), Jessie Ahuja (Registered Nurse Clinician) New Multi-Organ Transplant Clinic at BC Children’s Hospital Helps Kids and Parents A new multi-organ transplant clinic at BC Children’s Hospital opened its doors to pediatric patients and their family members in January 2009. The clinic provides access to specialized health care providers for over 120 BC children who have received an organ transplant. “Previously, care for these patients was provided in a dispersed manner at the hospital with kidney transplant recipients being followed in the renal clinic, and cardiac, liver and bowel transplant recipients being followed in their respective clinics,” said Dr. Douglas Matsell, division head of nephrology and the multi-organ transplant clinic at BC Children’s Hospital. “Patients are now seen by a specialist and interdisciplinary team members on the same visit so there is an opportunity for urgent consultations to occur should any complications be discovered.” Carmen Carriere, mother of a heart transplant recipient, worked at educating the BC Ministry of Health Services on the challenges faced by pediatric transplant patients, and advocating for this cohesive transplant clinic at BC Children’s Hospital. “Children who have had a transplant still face a number of issues. It’s incredibly important to have a clinic like the one at BC Children’s to provide on-going care,” said Carriere, whose daughter Brynn McKenna, is a seven-year-old heart transplant patient. The clinic addresses the most urgent needs and ongoing management of patients who have had a kidney, heart, liver or bowel transplant. The multi-organ transplant clinic was made possible through $288,000 in annual funding from the Ministry of Health Services through the PHSA and BC Transplant. In addition to being followed by their specialized transplant physician the clinic will also provide patients with access to expanded nursing, pharmacist, social work, dietitian and psychology support. TT Page 5 Transplant Times 2009
Page 1 and 2: A BC Transplant publication Summer
Page 3: organ donation kidney donations and
Page 7 and 8: kidney transplants. This next phase
Page 9 and 10: the only child in the dialysis room
Page 11 and 12: T-Shirts $15 Order a t-shirt today!

Summer 2009 - British Columbia Transplant Society

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