Australasian Anaesthesia 2011 - Australian and New Zealand ...

The Last Frontier: Donation after Cardiac Death (DCD) reaches Western Australia 103The Last Frontier: Donation after Cardiac Death (DCD) reachesWestern AustraliaDAVID SIMES, MB BS, ECFMG, FANZCA, FCICMDavid Simes is an anaesthesia-trained Intensive Care specialist with an interest in organ donation. The AustralianGovernment’s organ donation reform agenda created new positions in the national and regional branches ofDonateLife, Australia’s national organ and tissue donation agency. Dr Simes was seconded to the agency to helpintroduce DCD to the last bastion of medical conservatism in Australia’s organ donation network.INTRODUCTIONThere have now been more than 200 donors after declaration of cardiac death in Australia, allowing more than 300people to come off dialysis and extend the duration and quality of their lives, and more than 60 people with respiratoryfailure to have an otherwise unavailable chance to experience sometimes decades of quality life. 1New South Wales and Victoria have been the DCD leaders in Australia, followed by Queensland, South Australiaand the Australian Capital Territory.A notable exception has been Western Australia.The drive to pursue DCD comes from the outcome data showing at least equally good medium term results forkidney donation 2 , and, surprisingly, superior medium term outcomes for young lung transplant recipients from DCDdonors compared with DBD donors. 3 Well-selected donors for liver donation have also resulted in a smaller numberof good liver transplant outcomes after DCD.Given the immeasurable relief of human suffering and prolongation of life resulting from the worldwide engagementin DCD, WA’s reluctance to participate has been remarkable.CRAZY PRESS AND CONFUSION“Hospitals take organs before brain death”: was the headline in the West Australian newspaper on May 18, 2011, 4sending alarm and confusion through the people of Perth. The article was probably referring to DCD. In just a fewfront page paragraphs, the article managed to squeeze in the obnoxious term “harvest” twice, cast doubt on thedeclaration of both brain death and cardiac death, and throw in the opt-in-opt-out debate. And DCD was suddenlyfront page news.SO WHAT IS DCD?The concept is easy: after your heart stops beating, and after a period of invasive and non-invasive monitoringobserved by two senior medical practitioners, you may be declared deceased by these two doctors on the basisof your prolonged non-responsiveness, apnoea and circulatory arrest.If your organs have not suffered too much damage during this progression to circulatory arrest, your kidneys,liver and lungs may work in someone with those failures, and it may be possible for you to be taken to an operatingtheatre and have those organs posthumously removed for donation.Sounds very similar to…how we declare death already: unresponsiveness, apnoea and no central palpablepulse. Isn’t that how we’ve always declared death?It is. But it’s the disconcerting swiftness to operate just after declaration of death, our worry about getting itwrong, the concern that the patient’s circulation might re-start and the misperception that doctors may be seen tobe acting to facilitate organ donation rather than optimising the patient’s chances of survival, that has causedconcern.Back to the article, “hospitals take organs before brain death”. The headline is both confusing and inaccurate.By the time you’ve had a completely arrested circulation for fifteen minutes or more, added to a protracted periodof hypotension and any pre-existing brain lesion, you will have lost all brain activity for some time. “Brain death”won’t be declared, just as we don’t declare brain death on people who are found deceased on the hospital wards,at home or in the cemetery. You are deceased based on the absence of signs of life.So cardiac death is simpler than brain death, and easier for families to accept. Cardiac death is regular death.Brain death was the controversial death that needed specific legal sanction, 5 and continues to be debated by sometheologians and ethicists.So, organ donation after “cardiac” death...that doesn’t sound extraordinary at all.How could that possibly be controversial?And what could possibly go wrong?HISTORY OF NHBD (NON-HEART-BEATING DONATION)/DCDThe very first human kidney transplant was performed in Kiev in 1933, a donation after cardiac death. It sufferedrejection and failed. For the next two decades, immunological naïveté and organ rejection thwarted transplantsuccess. 6Only 57 years ago (1954), the first successful human living donor kidney transplant took place, from 24 year oldRonald Herrick, to his twin brother Richard. 7 The donor, Ron Herrick, died less than a year ago in 2011, while hisbrother survived for 8 years. The donor pool was tiny: a twin with two functioning kidneys donated to his geneticallyidentical brother, getting around any DNA differences in the era of inadequate immunosuppression, in a procedurewe might now call directed altruistic living donation.