Single-centre experience of donation after cardiac death

To the Editor: The donation after cardiac death (DCD) procedure used by Coulson and colleagues1 is ethically problematic and is not, as claimed, re-implementation of the practice followed before brain-death organ donation protocols were introduced. First reported in 1992, the more precise term is controlled donation after cardiac death or controlled non-heart-beating organ donation.2 What is controlled is the timing, mode and criteria of death, and its location (operating theatres). The threshold medical decision is to remove life-support and allow the patient to die. The aim of the procedure is to seize the opportunity to procure a particular kind of death within a particular time frame for organ transplant purposes. The procedure fails if the patient survives past the point for organ viability (usually 60 minutes).

Ethical concerns with this procedure include crossing the line between managing dying and inducing death, turning a grim prognosis into a self-fulfilling prophecy, denying the ventilator-dependent patient their chance of survival, distorting the treatment paradigm and using patients as a means to an end.3 In addition, protocols vary with regard to warm ischaemic times, drug regimens, criteria of death, and stand-down periods. Such variables can be, of themselves, ethically problematic. Coulson and colleagues’ study illustrates some of the problems. The final doctor did not concur with the threshold call that “prognosis was futile” in two patients. One underwent reinstitution of active therapy and subsequently returned to work. The procedure failed in eight of 28 patients despite careful selection of candidates, allowing 90 minutes to criteria of death and the inclusion of two people thought to have been dead before life-support was removed.