Faculty Peer Reviewed
DEATH, be not proud, though some have callèd thee
Mighty and dreadfull, for, thou art not so;
For those whom thou think’st thou dost overthrow
Die not, poore death, nor yet canst thou kill me.
From rest and sleepe, which but thy pictures bee,
Much pleasure, then from thee, much more must flow,
And soonest our best men with thee doe goe,
Rest of their bones, and soul’s deliverie.
Thou art slave to Fate, Chance, kings, and desperate men,
And dost with poyson, warre, and sicknesse dwell,
And poppie, or charmes can make us sleep as well,
And better than thy stroake; why swell’st thou then?
One short sleepe past, wee wake eternally,
And death shall be no more; death, thou shalt die.
All of us have fears and uncertainties surrounding the end of life. When will I die? How? Where? How much warning will I have? Will I have accomplished everything I set out to do? What will become of me after death?
While thoughts regarding the end of one’s life are inherently personal, it is a physician’s role to help patients clarify their goals and to take care of the logistics necessary to ensure that patients’ wishes are respected. Among the most challenging and misconception-ridden end-of-life subjects is that of organ donation, and yet it is also the one with the most potential for hope.
Organ transplantation gives patients suffering from fatal conditions such as kidney failure from diabetes, liver failure from primary biliary cirrhosis, or congenital heart abnormalities a chance at a healthier and longer life. The donor can be living, as in the case of someone donating to a close relative in need, or donations can be made after a person has passed away, in which case the recipient is usually not known to the donor. The most commonly donated major organs are kidneys, livers, and hearts.
In New York State, people can designate themselves as potential posthumous donors by checking a box when registering or renewing their driver’s licenses, after which their licenses will be printed with “Organ Donor” and their names will be added to the national donor registry.[1,2] People also have the option of registering as donors online or by mail.
When an organ donor has been pronounced dead, the hospital will call the closest one of 59 federally-designated organ procurement organizations (OPOs)–independent non-profit organizations that coordinate the transplant process. By federal law, hospitals must report all deaths (donor or otherwise) to the local OPO. The OPOs are then responsible for confirming a patient’s wish to be a donor, assessing whether the person is able to be a donor, then evaluating measures such as the patient’s blood and tissue types to determine possible recipient matches. The recipient or recipients are the next matching patients on the national computerized waiting list. The order of patients on the waiting list is determined by standardized algorithms that take into account medical urgency and time waited, with no role played by other factors such as financial or celebrity status.
For me, the question of whether to designate myself as a potential organ donor was an easy one. As a medical professional, I have (1) devoted my life to helping people live as well as possible, and (2) invested so much in time, loans, sweat, tears, and stress-induced gastric ulcers towards fine-tuning my brain, that existence would not be worth much to me upon brain death. Facetiousness aside, when my mind and my strength are no longer able to make life better for other people, why not let my body continue to save lives? This is likely the mindset of other organ donors as well. Inherent in our decision, however, is a great deal of trust in the healthcare system. Understandably, when it comes to a dramatic decision such as having one’s organs removed, many people have concerns. Some common concerns include the following:
What if I’m not really dead?
By New York State law, before a patient can become an organ donor, brain death must be confirmed on two separate instances, hours apart, by two separate physicians, neither of whom is involved in the transplantation process. The declaration of death must include absence of brainstem reflexes, absence of respirations with a PCO2 >60 mmHg (no drive to breathe), absence of motor responses, and documentation of the etiology and irreversibility of the unresponsiveness, and may include additional confirmatory testing if deemed appropriate. These criteria for declaring death are more stringent than for patients who have not designated themselves as potential donors. Furthermore, unlike coma, in which limited brain function is still intact and the patient may eventually “wake up,” there have been no documented cases of revival after brain death.
Will my organs be given to alcoholics or drug abusers?
Although potential donors cannot specify the race, sex, age, or religious affiliation of their potential recipients, all possible organ transplant recipients are screened before being admitted onto the waiting list, and those with current drug or alcohol abuse problems are disqualified from being on the list.
Will I get less care in the hospital if people know I’m a potential donor?
As always, the priority when a patient enters the hospital is to save that patient’s life. Every hospital strives to minimize fatalities. Higher mortality rates are not in the best interest of any physician or hospital. Furthermore, the physicians who attend to patients in the hospital are not the same doctors who are involved in the transplant process; they have no knowledge of who the next transplant recipient might be. Compatible matches are often miles away, so they have no reason not to save the patient in front of them in favor of an unknown potential recipient.
It is no surprise that organ donation can be challenging to approach in discussion; for many, it is an uncomfortable subject that is further laden with the subtleties of legal writ. Yet think of all the benefits of overcoming that hurdle of discomfort: hope for the child with a congenital heart disorder, or the ailing diabetic who is someone’s father, brother, sister, mother, or friend. The technology is present to do much good through organ transplantation. Overcoming the gap between the crucial need for transplants and the dire shortage of donors largely comes down to a matter of allaying fears.
With organ donation, all of us–regardless of whether we’ve received a medical education, regardless of our physical strength, regardless of the circumstances of our lives–equalized by our common fate, have the opportunity to face pompous Death eye-to-eye and say with strength and dignity, “Death, thou shalt die.” Regardless of our beliefs about what becomes of us at the end of our lives, with an understanding of everything we can do beforehand and with hopes of all the good that may come afterwards, death can die in its power to make us feel helpless or afraid. It is the role of physicians to help empower our patients in that way.
Commentary by Dr. Susan Cohen
Tracie Lin’s article highlights a number of important issues for physicians and health providers. The first is the idea of reframing, a concept we borrow from mental health professionals. The focus is not on the health providers’ feelings of failure in the setting of a death but rather on our ability to continue to help the patient, family, and larger community in some way. This ongoing help comes with clear communication about options, one of which is organ donation. Another important factor raised by the author is the potential for mistrust in the health care system that may impact a family decision about organ donation. This mistrust is real and often valid and we mustn’t forget that. We must not take a patient/family decision personally. Our job is to help inform and offer the information needed to make choices consistent with the beliefs and values of that patient and family. Sometimes their answer will be what we recommend or what we would do ourselves (donating organs to help another person, signing a DNR order, consenting to a biopsy) but sometimes it will not. Lastly, while the current guidelines for determining brain death are for 2 examinations by qualified providers spaced at least 6 hours apart, there is literature and movement to support changing this protocol to 1 examination. Lustbader and colleagues reported in Neurology that the actual time interval between exams is not 6 hours but closer to an average of 19 hours. In addition, they note that no second exam changed the outcome, diagnosis, or prognosis. However, the viability of organs for donation does decrease over time; consent for donation decreased with the increased time interval to declaration of brain death. We must balance a desire to encourage protocols more useful to organ donation with our responsibility to grieving families and recognize a sometimes warranted mistrust of our own system.
Tracie Lin is a 4th year medical student at NYU School of Medicine
Peer reviewed by Susan Cohen, MD, Department of Medicine, NYU Langone Medical Center
Image courtesy of Wikimedia Commons
1. New York Organ Donor Network. www.donatelifeny.org. Accessed June 14, 2011.
2. Organ and Tissue Donations. New York State Department of Health. http://www.health.state.ny.us/professionals/patients/donation/organ/ . Accessed June 14, 2011. Revised July 2011.
3. Guidelines for determining brain death. New York State Department of Health http://www.health.state.ny.us/professionals/doctors/guidelines/determination_of_brain_death/docs/determination_of_brain_death.pdf. Published December 2005. Accessed June 14, 2011.
4. Lustbader D, O’Hara D, Wijdicks EF, et al. Second brain death examination may negatively affect organ donation. Neurology. 2011;76(2):119-124.