OTA position statement on heart donation for transplantation after circulatory death
The article by Tibballs and Bhatia published in the Medical Journal of Australia (MJA) on 21 September 2015 titled ‘Transplantation of the heart after circulatory death of the donor: time for a change in law?’ is a misinterpretation of the law regarding the definition of circulatory death. The legal requirement is for irreversible cessation of circulation, which is defined as blood flow throughout the body. Failure of any number of life-sustaining organs, including the brain, lungs, liver or heart, can culminate in irreversible cessation of the circulation and death of the individual. The fact that one or more of these organs can be transplanted and function in another person does not mean the donor had not died.
Determination of death after cessation of circulation is a common event in medicine. The priority is always the quality of end of life care for that patient, not organ and tissue donation.
Organ and tissue donation occurs in Australia within a legal and ethical framework. This includes the state and territory Human Tissue Acts which provides the legal basis for removal of organ and tissues after death for the purposes of transplantation; the National Health and Medical Research Council’s ethical principles and the National Protocol for Donation after Cardiac Death July 2010 (DCD Protocol).
Death is defined in law by the Australian Law Reform Commission as when there is:
- “Irreversible cessation of all function of the brain of the person”; OR
- “Irreversible cessation of circulation of blood in the body of the person”.
The Commission further agreed that ‘the creation and prescription of techniques of diagnosis should be the responsibility of the medical profession’. They specified that, although it appeared in the context of transplantation, the determination of death should have general application whether or not organ and tissue donation and subsequent transplantation were to follow.
The DCD Protocol was developed to outline an ethical process that respects the rights of the patient and ensures clinical consistency, effectiveness and safety for both donors and recipients. The DCD Protocol is currently under review to reflect emerging evidence and clinical practice such as antemortem intervention, amended terminology from cardiac to circulatory in order to improve accuracy, location of withdrawal of treatment and transplantation of hearts from the DCD pathway.
Organ Donation after Circulatory Death (DCD) is possible in patients in an intensive care unit if treatment is to be withdrawn and the patient’s family subsequently agrees to organ and tissue donation. Death is declared after the circulation has irreversibly ceased with there being no chance of it resuming spontaneously and artificial attempts to restore it not being appropriate in this situation of expected dying. This is identical to the manner in which death is declared in many other patients receiving end-of-life care in hospitals outside of donation; there does not have to be an attempt at resuscitation to demonstrate irreversibility before death is declared. This would be viewed as an infringement upon the dignity of the dying person and possibly an assault.
Heart transplantation from DCD donors is only possible when the heart can be assessed as suitable for transplantation and there is failure of one or more life sustaining organs (including the brain, lungs, liver or heart) which culminates in irreversible cessation of the circulation and death of the individual.
Heart transplantation after DCD commenced at the St Vincent’s Hospital after the release of GL2014_008 Organ Donation After Circulatory Death: NSW Guidelines (the NSW DCD Guidelines) in June 2014 which replaced a guideline issued in 2007. The NSW DCD Guidelines explicitly state that ‘there are no legal barriers to using hearts removed from DCD donors for transplantation provided death of the patient is declared consistent with the law in NSW’.
The DCD heart transplants have been performed following pioneering basic and translational research undertaken by the Victor Chang Cardiac Research Institute and St Vincent’s Hospital. This surgery is the culmination of an extensive research project undertaken by Professor Peter MacDonald, Medical Director of the St Vincent’s Heart Transplant Unit, Head of the Transplantation Research Laboratory at the Victor Chang Institute and Professor of Medicine at University of New South Wales. The St Vincent’s Hospital heart and lung transplantation program is one of the largest and longest running in Australia, and their work contributes to Australia being internationally recognised as a world leader in successful transplantation outcomes and long-term survival of recipients.
To date, there have been six successful transplants of hearts from the DCD pathway in Australia with all recipients having excellent outcomes. These surgeries have been performed by the St Vincent’s Hospital’s Heart Transplant Unit over the past 14 months and represent a significant milestone in the history of heart transplantation as transplant units previously relied solely on donated hearts from brain death patients.
DCD has contributed to Australia’s continued growth in organ and tissue donation and provides an additional opportunity for donation for those patients who have not and will not develop brain death. In 2014 the majority of organ donors (72%, or 271 donors) came from the donation after brain death (DBD) pathway. The remaining 28% (107 donors) came from the DCD pathway.
A response to the MJA article by Australian transplant experts has been published on the MJA Insight website at www.mja.com.au/insight/2015/36/donor-death-dispute