11 June 2008

Near-death donor debate

A man whose heart stopped beating for 1.5 hours, yet revived as doctors were preparing to remove his organs for transplant, is fuelling ethical debates about when a person is dead.

The case of a man whose heart stopped beating for 1.5 hours, only to revive just as doctors were preparing to remove his organs for transplant, is fuelling ethical debates in France about when a person is dead.

The 45-year-old man suffered a massive heart attack and rescuers used cardiac massage to try and revive him without success before transferring him to a nearby hospital.

Due to a series of complex circumstances, revival efforts continued for longer than usual for a patient whose heart was not responding to treatment, until doctors started preparations to remove organs.

It was at that point that the astonished surgeons noticed the man was beginning to breathe unaided again, his pupils were active, he was giving signs that he could feel pain - and finally, his heart started beating again.

Several weeks later, the man can walk and talk.

Situation raises re-animation questions again
"This situation was a striking illustration of the questions that remain in the field of re-animation...and what criteria can be used to determine that a re-animation has failed," says a report on the case, published online by an ethics committee.

The case has stirred debate among medical professionals and daily newspaper Le Monde on Tuesday dedicated a full page to the subject under the headline: "The organ donor wasn't dead."

"What is under consideration here is the status of a person, whether they are a patient who can be re-animated or a potential (organ) donor," said the ethics committee report.

Has this ever happened in SA?
According to The Organ Donor Foundation's Philippa Douglas, it occured once - but it is highly unlikley it will ever happen again.

"I know of only one incident in South Africa where something similar happened. A man was declared brain stem dead and when the transplant team was called in they realised that he was in fact not brain dead and therefore not a viable candidate for organ donation. What is noteworthy is that this was identified by the transplant team and thus the removal of organs did not go ahead," she explained.

This is one of the reasons it's unlikely a situation such as this would ever happen in SA, she said, as here, two doctors, who are completely independent of the transplant team, have to perform detailed tests before a person can be declared brain dead.

"The criteria for brain death are very strictly adhered to and accepted medically, legally and ethically in South Africa and internationally.

"I can assure you that there are international standards for brain stem testing which the medical profession upholds and criteria which are adhered to and I can honestly say that the SA medical professions are very strict in this regard," she stated confidently.

Pilot programme launched
Back in France, the hospital where the man was treated is one of only nine in France that are allowed to perform organ transplants on patients in cardiac arrest, in very specific conditions, under a pilot programme launched in 2007. Elsewhere, organ transplants are possible on other categories of patients under older rules.

The programme, which was approved by the French agency in charge of bioethics, aims to help reduce the number of people waiting for a transplant by making it possible to take organs from new categories of patients.

Le Monde said more than 13 000 people were waiting for transplants in France and 231 people died last year as a direct result of the lack of a donor. The newspaper said the pilot programme had already yielded an extra 60 organs.

In South Africa, 288 solid organ transplants took place last year and 280 in 2006, according to The Organ Donor Foundation. However, they estimated that there are still approximately 1 361 people currently waiting for organ transplants this year.

Committee set up to discuss ethical issues on transplants
Assistance Publique-Hopitaux de Paris (AP-HP), a body that runs public hospitals in the Paris region, has set up a committee specifically to discuss ethical issues arising from the practice of transplants on people in cardiac arrest.

The committee, made up of medical professionals involved in the revival of heart attack patients as well as organ transplants, held lengthy discussions on the case of the man on February 19 and a summary was later published on the AP-HP web site.

"During the meeting, other re-animators...spoke of situations in which a person whom everyone was sure had died in fact survived after re-animation efforts that went on much longer than usual," say the minutes of the committee meeting.

"Participants conceded that these were completely exceptional cases, but ones that were nevertheless seen in the course of a career." – (Reuters Health)

June 2008

Read more:
Brain death: when is it all over?
Brain death not the end
How the mind counters death


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