Concerns Over New Organ Donor Guidelines Overblown

A recent Washington Post article on the guidelines governing organ donation may have stirred unnecessary alarm, according to medical experts.

The article, published Monday in the Post, says new guidelines from the United Network for Organ Sharing (UNOS) will do away with a suggested two-minute wait time after the donor’s heart has stopped beating to assure death before donation begins.  UNOS has always left the determination of these wait times up to the judgment of individual hospitals, however, and these guidelines won’t change that fact, according to UNOS spokesman Joel Newman.

“UNOS offers guidance on the different elements that hospitals should cover in their own organ donation policies, but the one thing we shouldn’t be weighing in on is how a hospital should be determining when death occurs,” says Charles Alexander, the immediate past president of UNOS and current president and CEO of the Living Legacy Foundation.

“We are there to facilitate donation only after the medical care team has independently determined that death is inevitable,” he says, adding that the article’s wording could produce confusion that in the worst case scenario may discourage patients from wanting to become donors.

“This article is a hysterical and inappropriate reaction to a very minor change in some standards.  There is zero threat to the public well-being in this document,” says Dr. Jeffrey Punch, chief of the section of transplantation at the University of Michigan’s Department of Surgery.

The new UNOS guidelines concern how hospitals and organ procurement organizations should regulate donation after cardiac death (DCD), a less common form of donation that occurs when a patient is not technically brain dead (the most commonly used determinant of death), but has no heartbeat on their own. This kind of donation accounts for about 7 percent to 10 percent of all donations in the United States, according to Alexander.  Each hospital has its own protocol for DCD, but the wait time usually varies from two to five minutes after a true heartbeat is lost.

The confusion over the guidelines’ change to the “two-minute rule” may have arisen because of a change to the reference section of the new UNOS guidelines.  When the guidelines were first made in 2007, the UNOS committee included a reference section that cited past medical literature that suggested two minutes as wait time. This reference section was never part of UNOS’s actual recommendations, however, and was removed from the new guidelines to avoid confusion. As Alexander says, it is for medical professionals to decide, not organ donation facilitators.

What the guidelines do change is the language concerning CDC — they recommend that cardiac death be changed to circulatory death — a change that UNOS feels better represents the medical definition of death defined according to the Uniform Determination of Death Act: an “irreversible cessation of circulatory and respiratory functions.”

Basically, circulation death means that the heart may have some weak activity, but the circulation of blood would never be sufficient to sustain life.

The guidelines also recommend that the organizations that facilitate donation and individual hospitals should determine whether donation would even be a viable option before it is discussed with the donor’s family. Past protocol recommends that donation discussions should begin only after the family decides to withdraw life support.

Some people might fear that this change cuts families out of the donation decision, but the change in protocol is intended to ” to avoid getting the family worked up about organ donation if it really isn’t possible, and to make sure it goes through if it is possible,” Punch says.

Many families “push extremely hard to have their loved one donate organs,” he says.  “They desperately want their loved one’s last function on earth to be saving other’s lives.”

Waiting until the decision to withdraw life support has been made to even begin discussing donation means that “sometimes [it] is not logistically possible for donation to occur,” Punch says.  ”This is tragic for that family, as well as to the recipients that do not benefit.”

Even if it makes it more likely that organ donation would be possible, discussing the idea before the patient has died remains a touchy topic that may scare some donors away, says Dr. Michael Grodin, a professor of health law, bioethics and human rights at Boston University who also commented in the Post article. He worries that any loosening of regulation surrounding donation could break down the “absolute trust” that must exist between donor families and doctors.

“Better to have fewer transplants and absolute trust in the system or not only will there be individual problems but this could actually lead to fewer families willing to donate,” he says.

Alexander was more concerned that the possible alarm and misunderstanding spurred by the Post article could threaten public trust.

“If people misunderstand the message sent in the Post article, we end up losing public trust,” he says. “When we don’t have public trust, there are families that may not opt to pursue organ donation and when that happens, people die.”