PEDIATRICS Vol. 122 No. 5 November 2008, pp. e967-e974 (doi:10.1542/peds.2008-1210)
ARTICLE |
Survey of Pediatricians' Opinions on Donation After Cardiac Death: Are the Donors Dead?
Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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OBJECTIVE. There has been debate in the ethics literature as to whether the donation-after-cardiac-death donor is dead after 5 minutes of absent circulation. We set out to determine whether pediatricians consider the donation-after-cardiac-death donor as dead.
METHODS. A survey was mailed to all 147 pediatricians who are affiliated with the university teaching children's hospital. The survey had 4 pediatric patient scenarios in which a decision was made to donate organs after 5 minutes of absent circulation. Background information described the organ shortage, and the debate about the term "irreversibility" applied to death in donation after cardiac death. Descriptive statistics were used, with responses between groups compared by using the 
2 statistic.
RESULTS. The response rate was 54% (80 of 147). In each scenario, when given a patient described as dead with absent circulation for 5 minutes, 
60% of respondents strongly agreed/agreed that the patient is definitely dead, 50% responded that the patient is in the state called "dead," and 56% strongly agreed/agreed that the physicians are being truthful when calling the patient dead. On at least 1 of the scenarios, 38 (48%) of 147 responded uncertain, disagree, or strongly disagree that the patient is definitely dead. Although the patients in the 4 scenarios were in the identical physiologic state, with absent circulation for 5 minutes, 12 (15%) of 80 respondents did not consistently consider the patients in the state called "dead" between scenarios. Fewer than 5% of respondents answered strongly agree/agree to allow donation after cardiac death while also answering disagree/strongly disagree that the patient is definitely dead, suggesting little support to abandon the dead-donor rule.
CONCLUSIONS. Most pediatrician respondents were not confident that a donation-after-cardiac-death donor was dead. This suggests that additional debate about the concept of irreversibility applied to donation after cardiac death is needed.
Key Words: death • donation after cardiac death • end of life • organ donation • pediatrics
Abbreviations: DCD—donation after cardiac death • CPR—cardiopulmonary resuscitation • SA/A—strongly agree or agree • D/SD—disagree or strongly disagree
There are efforts to increase the supply of organs as a result of increasing length of the transplant waiting lists and increasing mortality while on these waiting lists. One way to improve supply is to allow organ donation after cardiac death (DCD). After death is pronounced by using cardiocirculatory criteria, a consenting patient would allow his or her organs to be removed for transplantation.1,2 Some surveys have suggested public and medical support for DCD.3–6 Although at first DCD would seem ethically defensible, it has turned out to be surprisingly problematic.7
A central problem with all DCD practice is determining when death has occurred. Death is defined as the irreversible loss of the integration of the organism; when death occurs, the organism is irreversibly dis-integrated.8 According to currently accepted standards, there are 2 ways to determine that this final state of death has occurred: brain death and cardiocirculatory death.8,9 By using either of these determinations, the state is death when it is irreversible.
Several professional societies, including the Society for Critical Care Medicine and the Institute of Medicine (in 3 separate reports), have argued for a weak construal of irreversibility, whereby the state will not be reversed (ie, there is a do-not-resuscitate order).1,2,10–13 This construal is actually based on the premise that loss of circulation ought not be reversed, rather than will not be reversed. Other individuals argue for a stronger construal, whereby the state cannot be reversed even when resuscitation is attempted.14–19 By the weak construal of irreversibility, patients in the identical physiologic state are dead or alive on the basis of their location and prediction of a future event (attempted resuscitation). By current DCD protocols, 1 patient whose heart has stopped for 2 minutes (in Pittsburgh14 and according to the Society of Critical Care Medicine11) or 5 minutes (in Canada1 and most sites in the United States11–13) or 10 minutes (in some parts of Europe13) is pronounced dead for organ donation, whereas another identical patient whose heart has stopped for 10 minutes and then has cardiopulmonary resuscitation (CPR) is not pronounced dead and survives. If irreversible means "not capable of being reversed" then, after 10 minutes of absent circulation, without the intention to intervene, the patient's prognosis may be death, and the physiologic state may be dying.7,14,19–21 There are >30 case reports of the "Lazarus phenomenon" in which a patient is found to have spontaneous circulation, sometimes with good neurologic outcome, after having been declared dead minutes earlier on the basis of absent circulation.7,22–24 With resuscitation attempted, absent circulation for >10 minutes may be reversible and not associated with inevitable brain death.25–27
We set out to determine whether pediatricians agree that the patient who undergoes DCD is truly dead. We hypothesized that different ways of asking this question would reveal whether these pediatricians believe that the patient who undergoes DCD is dead.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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Questionnaire Administration
All pediatricians who are affiliated with the Stollery Children's Hospital were mailed the survey. A cover letter emphasized the need to read the background information before answering the questions and that "the questions are not concerned with the decision to be allowed to die. In each ‘scenario,’ the decision to be allowed to die has already been made and, thus, is not relevant to the questionnaire." Nonresponders were sent the survey at 3-week intervals for up to 2 additional mailings.
Questionnaire Development
The survey was modified from our previous survey of university student opinions about DCD.28 To generate the items for the questionnaire, we searched Medline from 1980 to 2005 for articles on DCD. This process was followed by collaborative creation of the background section and questions for the survey by the authors. Pilot testing of the survey was done by nonmedical, university-educated lay people (n = 9) and an ethics professor at our university. Each pilot test was followed by an informal semistructured interview by 1 of the authors to ensure clarity, realism, validity, and ease of completion of the questionnaire. After minor modifications, the survey was approved by all of the authors.
Questionnaire Content
The background section described the organ shortage and explained that organ donation after death pronounced by cardiocirculatory criteria is possible and, with consent, is done 5 minutes after absent circulation. Also described were autoresuscitation (and the Lazarus phenomenon), the construals of irreversibility, the lack of brain death after 5 minutes of absent circulation, and the potential unconscious conflicts of interest of the physician (Table 1). 1,2,7,10–20,22–24,29–33 We presented 4 patient scenarios. Each scenario was followed by the same 5 statements to be answered on a 5-point Likert-type scale. Each question referred to decisions after 5 minutes of absent circulation, the currently accepted time of death in DCD protocols. The final page of the survey asked some general questions and comfort level in responding to the survey (Table 2). The study was approved by the health research ethics board of our university, and return of a completed survey was considered consent to participate.
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Statistics
Anonymous data were entered into a computer database (Microsoft Excel [Microsoft Corp, Redmond, WA]). Responses were analyzed by using standard tabulations. Variables expressed as percentages were used to report the proportion of respondents with different answers. The responses of 2 predefined groups of pediatricians (transplant specialties including gastroenterology, pulmonology, cardiology, and nephrology versus all others) were compared using the
2 test, with P < .05 without correction for multiple comparisons considered significant. For comparisons, responses were divided into 3 categories: strongly agree or agree (SA/A), uncertain, and disagree or strongly disagree (D/SD). For the question about the state of the patient, the 3 categories were (1) dead, (2) as good as dead, and (3) dying, not dead, or alive. |
RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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During the academic year 2006–2007, the questionnaire was mailed to 147 pediatricians. The response rate was 80 (54%) of 147. The pediatricians had been in practice for <5 years for 18 (23%), 5 to 10 years for 19 (24%), and >10 years for 40 (50%). Of respondents, 41 (51%) were male, 54 (68%) were subspecialized, and 11 (14%) were in transplant specialties (with a response rate of 58% [11 of 19]).
Responses to the Scenarios: All Pediatricians
The responses to each of the questions are shown in Table 3. When given a patient described as dead according to DCD protocols, 60% of pediatricians responded SA/A that the patient is definitely dead, 50% responded that the patient is dead, and 56% responded SA/A that the physicians are being truthful when calling the patient dead. More than 70% of all respondents were willing to allow donation of organs at the 5-minute time of absent circulation, except for scenario 4 (Table 3). Of respondents, 68 (85%) responded SA/A that DCD should be allowed on at least 1 scenario, and 38 (48%) responded uncertain or D/SD that DCD should be allowed on at least 1 scenario.
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Although the patients in the 4 scenarios were in the identical physiologic state, with absent circulation for 5 minutes, 8 (10%) of respondents did not consistently consider the patients definitely dead between scenarios (Fig 1). Similarly, 12 (15%) respondents did not consistently consider the patients in the state called "dead" between scenarios (Fig 2). On at least 1 of the scenarios, 38 (48%) responded uncertain or D/SD that the patient is definitely dead. More respondents were uncomfortable with allowing DCD for the patient in the scenario or a family member in scenario 4 (although there was no difference in their response to the questions about whether the donor would be dead).
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, those who responded that the patient was in that state; 
, those who responded that the patient was not in that state.
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Responses to the General Questions: All Pediatricians
The majority, 78 (98%), responded SA/A that "organ donation is an admirable life-saving practice that should be strongly encouraged." When stated, "You know enough about the criteria of death to judge whether the patients in the scenarios are definitely dead," 48 (60%) responded SA/A, 18 (23%) were uncertain, and 12 (15%) responded D/SD. When asked, "If the patient in the scenarios was not definitely dead when surgery for organ donation started, then the surgery to obtain the donated organs is what actually killed the patient. Had you thought about it this way when you answered the survey?" 51 (64%) responded "yes," and 28 (35%) responded "no." This argument had not been suggested in the background information. When the survey stated, "Considering this argument, the decision in the scenarios to donate organs 5 minutes after the heart stops should be allowed," 48 (60%) of 80 responded SA/A, 22 (28%) of 80 were uncertain, and 9 (11%) of 80 responded SD/D. The responses to the same question before the given argument (excluding scenario 4) were as follows: SA/A 182 (76%) of 240, uncertain 36 (15%) of 240, and SD/D 19 (8%) of 240 (P = .018).
More specific questions were asked about the timing of pronouncing death (Table 4). For those who responded SA/A to allow DCD at 5 minutes on at least 1 scenario, if the law stated that the patient was not dead until 15 minutes after circulation stops, then 27 (40%) would still consider the patient definitely dead at 5 minutes, whereas only 17 (25%) would still allow the donation to start at 5 minutes. Fewer than 5% of respondents answered SA/A to allow DCD while also answering D/SD that the patient is definitely dead.
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Responses of Pediatricians in Versus Not in a Transplant Specialty
There were no differences in the survey response rate or in the responses to any of the questions between the 11 pediatricians in a transplant specialty versus the 69 who were not in a transplant specialty.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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There are several important findings from this study of pediatricians' opinions regarding DCD. First,
60% of the respondents consider the patients in the DCD scenarios dead, and 56% consider the physicians truthful in describing the patients as definitely dead. Second, in 15% of cases, respondents were inconsistent in considering patients in the different scenarios as dead, despite their identical physiologic state of absent circulation for 5 minutes. In at least 1 of the scenarios, 48% responded uncertain or D/SD that the patient is definitely dead. Third, many (35%) respondents had not considered the following possibility: if the patient was not dead, then organ donation is what killed the patient. After considering this possibility, only 60% of all respondents responded SA/A that DCD should be allowed after 5 minutes of absent circulation. Finally, although most (85%) respondents answered SA/A that DCD should be allowed on at least 1 scenario, only 3.8% were willing to allow DCD despite responding D/SD that the patient was definitely dead, suggesting support for the dead-donor rule. These results have important implications for public policy. Previous surveys of health care workers and the public are not directly comparable to our survey (Table 5). 3–6 These surveys did not communicate that the ethical concern of when to declare a person dead, with irreversible cessation of circulation, is central to the debate regarding DCD. There is a significant difference between asking whether organs can be donated after death and asking when death has occurred. Consistent with these other surveys, we found that a majority (76%) of respondents responded SA/A with the statement that "the decision to donate organs 5 minutes after the heart stops should be allowed" (excluding scenario 4), yet only 60% responded SA/A to this same statement (P = .018) when asked to consider the possibility that "if the patient in the scenarios was not definitely dead when surgery for organ donation started, then the surgery to obtain the donated organs is what actually killed the patient." If a patient is not dead when organ harvest begins, then some may still argue that the organ harvest is not the cause of death, because the patient would surely be dead some minutes after harvest begins (well before, eg, death from kidney failure occurs); however, we believe that the surgical incisions, with removal of kidneys (liver and possibly lungs and heart), attendant blood loss, and organ preservation techniques have a high risk for hastening death and preventing any possibility of autoresuscitation.
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Some of the background information provided may be considered controversial (Table 1). The information contained the following: "From studies of a total of 108 adult patients, we know that none had their heart restart on its own after 2 minutes.10,11,29 However, there are many case reports of a patient's heart restarting on its own 5 to 10 minutes after it could not be started with CPR in the hospital (called the ‘Lazarus phenomenon’). In these cases, some of the patients have survived with good brain function."7,22–24 They were also given that, "to legally diagnose death, a doctor should know that the heart has stopped irreversibly.8,9 Some think this should mean that the heart cannot restart on its own (cannot autroresuscitate).1,2,10–13 They argue that because a decision has been made to not try to restart the heart with CPR, it is autoresuscitation that is important. Others think irreversibility means that the heart cannot be started even if we try.14–19 For example, if we try to restart a heart with our modern medicine and CPR, even after 10 to 15 minutes of no heartbeat, often the heart can be restarted and the patient survives.25–27 They claim it does not make sense that 1 patient whose heart has stopped for 5 minutes is pronounced dead for organ donation, while another identical patient whose heart has stopped for 5 minutes and has CPR is not pronounced dead and survives."7 We believe the information is accurate and reflects an honest interpretation of the debate concerning the ethics of DCD.
This survey indicates that when death is defined as the irreversible absence of circulation, it is not clear that a weak construal of irreversibility is acceptable. Across the 4 scenarios, 38 (48%) of 80 responded uncertain or D/SD on at least 1 scenario when told, "at this time point, 5 minutes after his heart stops, this patient is definitely dead." This point has been argued by ethicists and philosophers, many of whom suggest that irreversible means "not capable of being reversed." Accordingly, after 5 or 10 minutes of absent circulation, without the intention to intervene, the patient's prognosis is death, and their physiologic state is dying.7,14,19–21
We do not believe that the frequent response that DCD should be allowed was based on a decision to ignore the dead-donor rule. We did not ask respondents whether they agreed with the consideration that organ harvest is what kills the donor. It is possible that those who allowed DCD despite this argument (60%) did not agree with the argument. Similarly, we did not ask respondents whether DCD should be allowed if the donor is not dead. On each scenario (Table 3), 59% to 78% responded SA/A to allow DCD, and 84% to 89% responded SA/A or uncertain that the donor is definitely dead, suggesting support for the dead-donor rule. On each scenario (Table 4), only 3.8% of respondents answered SA/A to allow DCD and D/SD that the patient is definitely dead, again suggesting support for the dead-donor rule. Furthermore, we did not present the complex ethical, religious, and legal implications of abandoning the dead-donor rule.
The strengths of this survey include the acceptable response rate (54%) and the rigorous survey development methods, including pretesting confirmation of the clarity of the questions and possible responses. Limitations include the absence of open-ended questions and possible discrepancies between stated behavior and actual practice when faced with DCD clinically. Because this survey targeted pediatricians at our hospital, it may not be representative of pediatricians elsewhere. Nevertheless, for similar questions, the results of our survey are remarkably similar to other health care worker surveys regarding DCD (Table 5).3–6 Some surveys showed that many health care workers and designated requestors for organ donation were not comfortable that the DCD donor is dead.33,34
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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We believe that these limitations do not affect our main conclusion. We found that, among the surveyed pediatricians, there is far from uniform acceptance that the DCD patient is dead or that DCD should be allowed. In the least, this survey suggests that additional debate about the concept of irreversibility as it applies to cardiocirculatory death is needed. We suggest that when considering DCD and when asking for consent to DCD, those involved be fully informed of this debate. This is important if we are to follow the dead-donor rule.35
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APPENDIX |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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Scenario 1
A 15-year-old boy was in a motor vehicle collision. Two weeks after the injury, he is still in a coma. The neurologists think that he will have very profound brain damage if he survives. He needs life support with a ventilator and inotropes. This boy told his parents a few times in the past that if he were ever in a coma and going to have severe brain damage, then he wanted them to let him die. The doctors discuss this request with the family, and they decide to take him off life support and let him die. The parents say that he always wanted to donate his organs after he dies. The doctors tell them that this is possible. He can be taken to the operating room and have the life support stopped. Five minutes after his circulation stops, he will be pronounced dead. Then surgeons could make incisions to recover both of his kidneys for organ donation. The family decides that this is what the patient would have wanted.
Scenario 2
A 15-year-old girl has had bleeding in her brain from a brain aneurysm. After 2 weeks in intensive care, she has recovered with severe disability. The doctors say that she will never be able to walk or feed herself. Although she can speak a few words with people, she has severe brain damage. Two weeks later, she develops severe pneumonia from choking on her food. She is taken back to intensive care and needs life support with a ventilator and inotropes. The doctors think that she may not survive this pneumonia even with the ventilator. The girl's parents say that she told them several times before her brain aneurysm that she would not want to live if she had severe brain damage. The doctors discuss this with the family, and the family and doctors decide to take her off life support and let her die.
The family says that she always wanted to donate her organs after she dies. The doctors tell the family that this is possible. She can be taken to the operating room and have the life support stopped. Five minutes after her circulation stops, she will be pronounced dead. Then surgeons could make incisions to recover both of her kidneys for organ donation. The family decides that this is what the patient would have wanted.
Scenario 3
A 5-year-old girl was hit by a car crossing the street. It is now 2 wk after the injury, and she is still in a coma. She needs life support with a ventilator and inotropes. The doctors tell the parents that she may never wake up, and, if she does, that she will not be able to walk or feed herself and will have profound brain damage. After discussion with the family and doctors, the parents decide that it is best for the patient to take her off life support and let her die.
The parents ask whether the girl can donate her organs. The doctors tell the parents that this is possible. She can be taken to the operating room and have the life support stopped. Five minutes after her circulation stops, she will be pronounced dead. Then surgeons could make incisions to recover both of her kidneys for organ donation. The parents decide that this should be done.
Scenario 4
A 16-year-old boy was in a car collision and has had a severe injury to the cervical spine. This has left him permanently and completely paralyzed from the neck down and unable to breath on his own. He has had a tracheostomy so that he can be on a ventilator permanently. Two months later, he discussed with his parents that he does not want to be kept on a ventilator. He tells them that he wants to be taken off the ventilator and allowed to die. He tells them that he does not want to live paralyzed and on a ventilator. The patient and his parents discuss this with the doctors, and it is decided to do what he wishes and take him off the ventilator and allow him to die.
The boy says that he wants to donate his organs after he dies. The doctors tell him and his family that this is possible. He can be taken to the operating room and have the ventilator stopped. Five minutes after his circulation stops, he will be pronounced dead. Then surgeons could make incisions to recover both of his kidneys for organ donation. The boy and his family decide that this is what they want to be done.
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FOOTNOTES |
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Accepted Jul 29, 2008.
Address correspondence to Ari R. Joffe, MD, Department of Pediatrics, 3A3.07 Stollery Children's Hospital, 8440 112 St, Edmonton, Alberta, Canada T6G 2B7. E-mail: ajoffe{at}cha.ab.ca
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject DCD may increase organ donation and reduce transplant list mortality. When absent circulation is irreversible and, hence, constitutes death is controversial. Most DCD programs pronounce death after 2 to 5 minutes of absent circulation.
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| What This Study Adds Pediatricians are not comfortable that absent circulation for 5 minutes is the irreversible state of death, which suggests that additional debate about the concept of irreversibility as applied to DCD is needed.
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REFERENCES |
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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