Beating heart cadaver

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A beating heart cadaver is a body that is pronounced dead in all medical and legal definitions, connected to a medical ventilator, and retains cardio-pulmonary functions. This keeps the organs of the body, including the heart, functioning and alive. [1] As a result, the period of time in which the organs may be used for transplantation is extended. The heart contains pacemaker cells that will cause it to continue beating even when a patient is brain-dead. Other organs in the body do not have this capability and need the brain to be functioning to send signals to the organs to carry out their functions. A beating heart cadaver requires a ventilator to provide oxygen to its blood, but the heart will continue to beat on its own even in the absence of brain activity. [2] This allows organs to be preserved for a longer period of time in the case of a transplant or donation. A small number of cases in recent years indicate that it can also be implemented for a brain-dead pregnant woman to reach the full term of her pregnancy. [2] There is an advantage to beating heart cadaver organ donation because doctors are able to see the vitals of the organs and tell if they are stable and functioning before transplanting to an ailing patient. [3] This is not possible in a donation from someone pronounced dead.[ citation needed ]

Contents

History

The observed phenomena of lifelike qualities after death is not a new concept. In René Descartes' Discourse on the Method , he notes that decapitated animals move and display characteristics of a living body a few seconds after decapitation which was published in 1637. [4] This continued into the French Revolution where it was observed that people who had been beheaded showed movements in facial muscles and hearts could continue to beat for almost an hour past the time of beheading. [5] The guillotine in some cases did not completely sever head from body. In 1875 an examiner named Pierre Jean Cabanis was assigned the duty of making sure a body was truly dead. [4] There were also stories involving beheadings where the victims would stand up and walk around before falling dead. The ambiguity around brain death and true death has followed it to present day. In an effort to clarify some of these gray areas, the Harvard Medical Committee developed criteria for identifying a body as dead in 1968. [4] [5] These criteria required patients to be completely unaware and unresponsive to external stimuli, have no spontaneous muscle movements, and exhibit no reflexive response even when manipulated. They also required that an electroencephalography (EEG) show no signs of activity. [4] The purpose of this report was to encourage physicians to distinguish brain death and irreversible coma from a persistent vegetative state where the patient still has some awareness and cycles through sleep and wakefulness. [6]

In 1971 a similar Minnesota criteria was published eliminating the EEG, repeating the exam after 12 hours, a severe lesion in the brain, and increasing the duration of the apnea test to four minutes rather than Harvard's three minute guideline. Other slight changes in the next decades included the United Kingdom's decision to eliminate the repetition of the exam and change from a duration of the apnea test to specified levels of CO2 in 1976. [5] Later, in 1981 the President's Commission reinstated the apnea test and the repeat exam. In a study done in 1989, only 35% of 195 physicians and nurses involved in organ procurement polled knew brain death criteria. These were not the same nurses and physicians who diagnose brain death. Presently, there is hot debate over the protocol for diagnosing someone as brain dead due to widespread disinformation and misinformation on the internet. [7]

The American Academy of Neurology created a prerequisite and neurological clinical assessment to be used as guidelines for determining brain death published in 2010. [6] To be considered for brain death the body must have a determinant cause of coma, have normal systolic blood pressure, and pass two neurological tests. These neurological assessments commonly consist of an apnea test, reflex tests where the body is manipulated or exposed to a stimulus and does not react, or be in a coma where there is complete unresponsiveness. [6] Cerebral angiography, electroencephalography, transcranial doppler ultrasonography, and cerebral scintigraphy are some of the tests that are used to test if there is any significant brain activity. [6]

Care

Caring for a beating heart cadaver is similar to caring for a living patient. Since the brain has stopped functioning, the hormone levels and blood pressure must be regulated by intensive care unit (ICU) personnel. [8] The protocol for preserving the cadaver aims to prevent infection and maintain adequate oxygenation of tissue. [9] The cadaver's status must be continuously monitored, so that ICU staff can prevent organ failure or quickly operate to save threatened organs. [8]

Organ recovery

A beating heart cadaver is kept alive in order to keep its organs from decaying before they can be transplanted. Surgeons will remove the organs, one after the other, and have them transferred to the recipients' treating teams. [1] The entire recovery process is usually completed within four hours. [9] This process was formerly known as an "organ harvest", but the name has since changed to the milder "organ recovery". [1] Many organs can be extracted, and many lives can be saved by one body. The bodies are generally those of organ donors, who have either given first-person consent to become an organ donor, presumptive consent by not explicitly declining to donate [10] or whose legal next-of-kin makes the decision to donate. [11] Some donated organs are taken from non-heart-beating donors. [12] Organs from brain deaths, however, have a better success rate, and currently most organ donation is from these deaths. [13]

How long the brain-dead person is kept on the ventilator may vary depending on the availability of surgical teams and the wishes of the family of that brain-dead person. An anesthesiologist is regularly present at organ donation surgical procedures, not for pain, but to monitor the vital signs and administer medications to optimize organ harvest. [14] Due to the results of the apnea test if a person lacks the brain function to breathe unassisted, it is concluded that it would also lack the brain function to relay the sensation of pain. [14] The anesthesiologist also ensures that muscle spasms or reflexes do not occur during the procedure. Though the brain may be dead, the pathway that reflexes follow does not pass from the stimulus in the body to the brain. Instead the spinal cord coordinates the knee-jerk reactions of reflexes including pulling back from the pain of putting a hand in an open flame or jerking away from an invasive incision. When the brain is dead these pathways remain intact and the anesthesiologist is present to ensure that these reactions do not complicate the procedure. [14]

Brain death and pregnancy

Pregnancy can be prolonged after brain death. It is then possible to deliver the baby by means of caesarian section. [15] Cadavers have been reported to support a fetus for a period of 107 days. After delivering the baby, some cadavers have subsequently become organ donors. [16] Since 1981 there have been 22 recorded instances of keeping a mother declared brain dead in a beating heart cadaver state until the baby is delivered. [2]

A review of 11 of these unique circumstance pregnancies was conducted in 2000. Four of these cases involved a persistent vegetative state of the mother and in 7 maternal brain death was diagnosed. [17] The women that underwent these gestation periods all delivered preterm an average of 30.5 weeks, where a normal pregnancy is around 35 weeks for full term. [17] The mothers were observed to have severe hypotension once in the brain dead or vegetative state and in all but one case the baby was delivered by cesarian section. It has also been found that by the 24th week of pregnancy intensive care is not as necessary and the mother is more stable than treatment occurring before the 24th week. [17] Common complications involved inability to regulate temperature which is treated with heating and cooling blankets, as well as failure of the endocrine system which is important in maintaining a stable fetal environment. [17] Following the delivery of the baby, organs of the mother are harvested as well. [16]

From an ethical perspective the family and next of kin are often involved in the decision to terminate or prolong the pregnancy. This can be a difficult decision given the level of care required to keep the mothers living for the duration of their gestation which can vary. Intensive care of a vegetative state patient is not usually advised due to the dismal chances of recovery, but in the case that the fetus could survive this care is often justified and administered at the discretion of the family. [14] [17] Intense counseling and advisement by physicians and neonatal experts often accompanies these rare situations. [12]

Ethical debate

Brain death is defined as irreversible cessation of all functions of the entire brain, including the brain stem: coma (with a known cause), absence of brainstem reflexes, and apnea. When doctors take away ventilation systems and patients fail to breathe, move, or show any signs of arousal on their own they are considered brain dead. [14] This test is called an apnea test. The ventilator is taken away and is reconnected only if the person decided to be an organ donor. This definition can create some cognitive dissonance because not responding to stimulation may show a problem with the central nervous system, yet when someone has a beating heart and lungs that will still function with the help of a ventilator it is difficult for some to accept as death. Brain death patients have characteristics of the living and the dead. [3]

Social issues

Organ recovery from beating heart cadavers has remained ambiguous to the public. There is a guideline for organ transplantation consisting of two parts. It states that organ donors must be dead before removing the organs, and removing the organs is not the cause of death. [18] This clause is in place to ensure that organ donation is not exploited to use people purely as a means to an end. However, many believe that even with these guidelines in place the protocol for organ donation still has room for criticism. There is an opinion that negative views from public and medical personnel on this subject tend to stem from a lack of understanding of what it means to be considered brain dead and how these decisions are made, [19] but there are also legitimate concerns relating to the consciousness of the patient. [20] One social issue that is commonly brought up is the potential for conflict of interest for the medical team examining the body. [19] Another issue raising concerns in the organ donation by beating heart cadaver field is the administration of drugs to the patient that prevent clotting prior the donation procedure. These drugs are not beneficial to the patient and are intended solely to help the recipient of the organs. [18] To alleviate some of these social concerns, there has been push for a standard in determining death and creating a normalized system for transplantation in these patients. [19]

Religious and cultural differences

From a religious standpoint, the encouragement of organ donation or acceptance may vary. The Catholic church with input from Pope John Paul II, identified transplantation from beating heart cadavers or living subjects as acceptable if there are no added risks to the donor. [21] This has been widely debated in Japan where the first heart transplant took place in 1968 and the patient died a few months after the procedure. [22] Since then, more transplantation procedures have taken place but it is still a controversial subject. Transplantation in naturalist religions and cultures such as Native Americans, Buddhists, and Confucianists tend to dissuade the use of living donors and transplantation. [21] The body is idealized as a home for a soul and the organs belonging to a person are considered perverse if utilized by another person. No religion specifically outlaws the use of beating heart cadavers or prefers them to non beating heart cadavers. [21] [22] Western cultures more widely accept the use of transplantation by beating heart cadavers than more conservative cultures. [21] The main concern of many religions and cultures is ensuring the body is not objectified or disrespected in harvesting and transplantation of organs. [21]

Cultural references

Award-winning Canadian writer Colleen Murphy's play Beating Heart Cadaver had its premiere in the United Kingdom on 3 April 2011 at the Finborough Theatre, London.

See also

Related Research Articles

<span class="mw-page-title-main">Organ donation</span> Process of voluntarily giving away organs

Organ donation is the process when a person allows an organ of their own to be removed and transplanted to another person, legally, either by consent while the donor is alive or dead with the assent of the next of kin.

<span class="mw-page-title-main">Organ transplantation</span> Medical procedure in which an organ is removed from one body and placed in the body of a recipient

Organ transplantation is a medical procedure in which an organ is removed from one body and placed in the body of a recipient, to replace a damaged or missing organ. The donor and recipient may be at the same location, or organs may be transported from a donor site to another location. Organs and/or tissues that are transplanted within the same person's body are called autografts. Transplants that are recently performed between two subjects of the same species are called allografts. Allografts can either be from a living or cadaveric source.

Brain death is the permanent, irreversible, and complete loss of brain function which may include cessation of involuntary activity necessary to sustain life. It differs from persistent vegetative state, in which the person is alive and some autonomic functions remain. It is also distinct from comas as long as some brain and bodily activity and function remain, and it is also not the same as the condition locked-in syndrome. A differential diagnosis can medically distinguish these differing conditions.

Apnea, BrE: apnoea, is the temporal cessation of breathing. During apnea, there is no movement of the muscles of inhalation, and the volume of the lungs initially remains unchanged. Depending on how blocked the airways are, there may or may not be a flow of gas between the lungs and the environment. If there is sufficient flow, gas exchange within the lungs and cellular respiration would not be severely affected. Voluntarily doing this is called holding one's breath. Apnea may first be diagnosed in childhood, and it is recommended to consult an ENT specialist, allergist or sleep physician to discuss symptoms when noticed; malformation and/or malfunctioning of the upper airways may be observed by an orthodontist.

Prior to the introduction of brain death into law in the mid to late 1970s, all organ transplants from cadaveric donors came from non-heart-beating donors (NHBDs).

<span class="mw-page-title-main">Kidney transplantation</span> Medical procedure

Kidney transplant or renal transplant is the organ transplant of a kidney into a patient with end-stage kidney disease (ESRD). Kidney transplant is typically classified as deceased-donor or living-donor transplantation depending on the source of the donor organ. Living-donor kidney transplants are further characterized as genetically related (living-related) or non-related (living-unrelated) transplants, depending on whether a biological relationship exists between the donor and recipient.

A flatline is an electrical time sequence measurement that shows no activity and therefore, when represented, shows a flat line instead of a moving one. It almost always refers to either a flatlined electrocardiogram, where the heart shows no electrical activity (asystole), or to a flat electroencephalogram, in which the brain shows no electrical activity. Both of these specific cases are involved in various definitions of death.

<span class="mw-page-title-main">Lung transplantation</span> Surgical procedure in which a patients diseased lungs are partially or totally replaced

Lung transplantation, or pulmonary transplantation, is a surgical procedure in which one or both lungs are replaced by lungs from a donor. Donor lungs can be retrieved from a living or deceased donor. A living donor can only donate one lung lobe. With some lung diseases, a recipient may only need to receive a single lung. With other lung diseases such as cystic fibrosis, it is imperative that a recipient receive two lungs. While lung transplants carry certain associated risks, they can also extend life expectancy and enhance the quality of life for those with end stage pulmonary disease.

Organ procurement is a surgical procedure that removes organs or tissues for reuse, typically for organ transplantation.

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The Lazarus sign or Lazarus reflex is a reflex movement in brain-dead or brainstem failure patients, which causes them to briefly raise their arms and drop them crossed on their chests. The phenomenon is named after the Biblical figure Lazarus of Bethany, whom Jesus raised from the dead according to the Gospel of John.

Many different major religious groups and denominations have varying views on organ donation of a deceased and live bodies, depending on their ideologies. Differing opinions can arise depending on if the death is categorized as brain death or cease of the heartbeat. It is important for doctors and health care providers to be knowledgeable about differentiating theological and cultural views on death and organ donations as nations are becoming more multicultural.

Organ transplantation in Japan is regulated by the 1997 Organ Transplant Law which legalized organ procurement from "brain dead" donors. After an early involvement in organ transplantation that was on a par with developments in the rest of the world, attitudes in Japan altered after a transplant by Dr. Wada in 1968 failed, and a subsequent ban on cadaveric organ donation lasted 30 years. The first transplant after the Organ Transplant Law had defined "brain death" took place in February 1999.

Brainstem death is a clinical syndrome defined by the absence of reflexes with pathways through the brainstem – the "stalk" of the brain, which connects the spinal cord to the mid-brain, cerebellum and cerebral hemispheres – in a deeply comatose, ventilator-dependent patient. Identification of this state carries a very grave prognosis for survival; cessation of heartbeat often occurs within a few days, although it may continue for weeks if intensive support is maintained.

Legal death is the recognition under the law of a particular jurisdiction that a person is no longer alive. In most cases, a doctor's declaration of death or the identification of a corpse is a legal requirement for such recognition. A person who has been missing for a sufficiently long period of time may be presumed or declared legally dead, usually by a court. When a death has been registered in a civil registry, a death certificate may be issued. Such death certificate may be required in a number of legal situations, such as applying for probate, claiming some benefits, or making an insurance claim.

Organ donation is when a person gives their organs after they die to someone in need of new organs. Transplantation is the process of transplanting the organs donated into another person. This process extends the life expectancy of a person suffering from organ failure. The number of patients requiring organ transplants outweighs the number of donor organs available.

The current law in Ireland requires the potential donor to opt in to becoming an organ donor. However, it is ultimately up to their family to make the decision whether or not the person is allowed to donate their organs after they die.

Organ transplantation in the Indian state of Tamil Nadu is regulated by India's Transplantation of Human Organs Act, 1994 and is facilitated by the Transplant Authority of Tamil Nadu (TRANSTAN) of the Government of Tamil Nadu and several NGOs. Tamil Nadu ranks first in India in deceased organ donation rate at 1.8 per million population, which is seven times higher than the national average.

Organ donation in India is regulated by the Transplantation of Human Organs and Tissues Act, 1994. The law allows both deceased and living donors to donate their organs. It also identifies brain death as a form of death. The National Organ and Tissue Transplant Organisation (NOTTO) functions as the apex body for activities of relating to procurement, allotment and distribution of organs in the country.

References

  1. 1 2 3 Roach, Mary. Stiff: the Curious Lives of Human Cadavers. New York: W.W. Norton &, 2003. Print.
  2. 1 2 3 Teresi, Dick (2012). The Undead: Organ Harvesting, the Ice-Water Test, Beating-Heart Cadavers – How Medicine is Blurring the Line Between Life and Death . New York: Pantheon Books. pp.  89–92. ISBN   978-0-375-42371-0.
  3. 1 2 Zamperetti, N (2003). "Defining death in non-heart beating organ donors". Journal of Medical Ethics. 29 (3): 182–185. doi:10.1136/jme.29.3.182. ISSN   0306-6800. PMC   1733717 . PMID   12796442.
  4. 1 2 3 4 Saposnik, Gustavo; Basile, Vincenzo S.; Young, G. Bryan (2014). "Movements in Brain Death: A Systematic Review". Canadian Journal of Neurological Sciences. 36 (2): 154–160. doi: 10.1017/S031716710000651X . ISSN   0317-1671. PMID   19378707.
  5. 1 2 3 Daroff, R. (2007). "The Historical Evolution of Brain Death from Former Definitions of Death: the Harvard Criteria to the Present". The Signs of Death. 110: 217–221.
  6. 1 2 3 4 Wijdicks F, Valrelas P, Gronseth G, Greer D (2010). "American Academy of Neurology Guidelines for Brain Death Determination". Neurology. 74 (23): 1911–1918. doi: 10.1212/wnl.0b013e3181e242a8 . PMID   20530327.
  7. ↑ Ward, S (2015). "Beating Heart Cadavers". Georgia Right to Life. Retrieved 20 April 2016.
  8. 1 2 Roach, p. 170.
  9. 1 2 "The beating heart donor". British Organ Donor Society. Archived from the original on 21 December 2010. Retrieved 4 March 2010.
  10. ↑ "Are we in control of our own decisions?". So I want to show you some cognitive illusions, or decision-making illusions, in the same way. And this is one of my favorite plots in social sciences. It's from a paper by Johnson and Goldstein. And it basically shows the percentage of people who indicated they would be interested in giving their organs to donation....Turns out the secret has to do with a form at the DMV. And here is the story. The countries on the left have a form at the DMV that looks something like this. Check the box below if you want to participate in the organ donor program. And what happens? People don't check, and they don't join. The countries on the right, the ones that give a lot, have a slightly different form. It says check the box below if you don't want to participate. Interestingly enough, when people get this, they again don't check -- but now they join.
  11. ↑ Bell, Diane (27 February 2010). "Her donated organs changed lives of many". The San Diego Union Tribune. Retrieved 4 March 2010.
  12. 1 2 "Brain Death or NHBD – Important Distinction". physiciansforlife.org. Archived from the original on 14 November 2013. Retrieved 4 March 2010.
  13. ↑ Whitlock, Jennifer (6 April 2016). "Organ Donation Types". verywell.com. Archived from the original on 5 April 2015. Retrieved 13 December 2016.
  14. 1 2 3 4 5 Gross, Terry. "Blurring the Lines between Life and Death". NPR. Retrieved 23 February 2016.
  15. ↑ Bernstein, I. M.; Watson, M; Simmons, G. M.; Catalano, P. M.; Davis, G; Collins, R (1989). "Maternal brain death and prolonged fetal survival". Obstetrics and Gynecology. 74 (3 Pt 2): 434–7. PMID   2761925.
  16. 1 2 Powner, DJ; Bernstein, IM (April 2003). "Extended somatic support for pregnant women after brain death". Critical Care Medicine. 31 (4): 1241–9. doi:10.1097/01.ccm.0000059643.45027.96. PMID   12682499. S2CID   848593.
  17. 1 2 3 4 5 Feldman, D (2000). "Irreversible Maternal Brain Injury During Pregnancy: A Case Report and Review of Literature". Obstetrical & Gynecological Survey. 55 (11): 708–14. doi:10.1097/00006254-200011000-00023. PMID   11075735. S2CID   1139112.
  18. 1 2 Potts, Michael (2007). "Truthfulness in transplantation: non-heart-beating organ donation". Philosophy, Ethics, and Humanities in Medicine. 2 (1): 17. doi:10.1186/1747-5341-2-17. ISSN   1747-5341. PMC   2000872 . PMID   17718917.
  19. 1 2 3 Bastami, Sohaila; Matthes, Oliver; Krones, Tanja; Biller-Andorno, Nikola (2013). "Systematic Review of Attitudes Toward Donation After Cardiac Death Among Healthcare Providers and the General Public". Critical Care Medicine. 41 (3): 897–905. doi:10.1097/CCM.0b013e31827585fe. ISSN   0090-3493. PMID   23328261. S2CID   1626664.
  20. ↑ Teresi, Dick. The Undead. p. 148. Retrieved 15 December 2022.
  21. 1 2 3 4 5 Bruzzone, P. (2008). "Religious aspects of organ transplantation". Transplantation Proceedings. 40 (4): 1064–1067. doi:10.1016/j.transproceed.2008.03.049. hdl: 11573/113031 . PMID   18555116.
  22. 1 2 Bowman, K.; Richard, S. (2003). "Culture, brain death, and transplantation". Progress in Transplantation. 13 (3): 211–217. doi:10.7182/prtr.13.3.a368158t7662j463. PMID   14558636. S2CID   24985023.
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