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The Waiting Game
Organ Transplant Controversy January 2, 1998 |
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Questions answered
in this forum:
Is one way to avoid the ethical mess is to have a "National" society of organ donations? What is the difference between heart and brain death? Is it necessary to use Regitine to preserve organs, and what are its dangers? What is the research/clinical status of alternatives such as artificial organs, animal organs, etc.? Is there something wrong with this constant prolonging of life? Alex McDaniels of Gurnee, IL asks: Is it necessary to use Regitine to preserve organs, and what are its dangers?
Dr. Michael DeVita responds:
Regitine is a drug which expands blood vessels and prevents them from becoming clogged. Open blood vessels are important for organs to survive transplantation. However, regitine is not necessary for organ transplantation to occur. Transplantation does successfully occur when regitine is not used. For kidneys, there does not appear to be much difference whether the drug is used or not. Regitine does improve slightly the chance of success for liver transplants.
Ms. Renee Fox responds:
I believe that Alex McDaniels is referring here to the protocol for obtaining organs from non-heart-beating cadaver donors that was drawn up by the Cleveland Clinic and the LifeBanc organ procurement agency. This consists of a set of procedures for obtaining organs from patients on life support who have suffered a brain injury and lack a neck pulse, with presumably no chance for recovery, but who are not brain-dead. This protocol entails administering high doses or two drugs to the patient-donor – the anticoagulant heparin and the antihypertensive phentolamine mesylate (Regitine) – in order to prevent blood clotting and widen blood vessels so that the organs procured will be optimally viable for transplant. I am not a physician, but as I understand it, these medications provide no benefit or comfort to the patient who is the prospective donor, and there is the possibility that they may mask the continuing activity of the patient's neck pulse. In the case of Regitine, there is the danger that through its secondary effects, it may induce or hasten the patient's death. This protocol has not been carried out, partly as a consequence of the "whistle-blowing: actions of a bioethicist, and a social worker who was a former educational coordinator for LifeBanc, and of the CBS TV news program "60 Minutes."
A 1997 report by the Institute of Medicine on medical and ethical issues in procurement associated with non-heart-beating organ transplantation that has just been issued recommended that because under certain circumstances in certain patients, there is a concern that a vasodilator like Regitine and an anticoagulant like heparin "might be harmful…case-by-case decisions" on their use should be made, and "consideration" be given to "additional safeguards such as involvement of the patient's attending physician in prescribing decisions."
Personally, I find this recommendation too equivocal. I do not believe that it is justified to administer medications to a prospective donor that have no value for his/her treatment, care, or comfort, and may even hasten that person's death. In effect, using these agents in this way entails treating the organs in order to keep them optimally viable for transplantation. Caring for the patient who is donating the organs is subordinated to this goal.
Dr. William Ritchie responds:
Mr. McDaniels:On December 18, 1997, the Institute of Medicine, National Academy of Science, released a report entitled ‘Non-Heart-Beating Organ Transplantation: Medical and Ethical Issues in Procurement. This report, in part, addresses the issue of medications during organ preservation.
In quoting excerpts from the report, the administration of certain medications prior to donor death, in particular the anticoagulant heparin and the vasodilator phentolamine (Regitine) has generated public controversy. These medications have been clinically proven to enhance donor organ quality and graft results and usually can be safely used to increase blood flow and preserve organs. Unfortunately, it has been alleged that they also hasten the death of donors, although no specific instances of occurrence has been reported.
One basic covenant in the practice of medicine is "to cause no harm to the patient." These medications are not normally used in treating patients. For instance, if a patient is suffering intracranial bleeding, the use of anticoagulants or vasodilators could actively cause death. The issue currently being discussed within the transplant community is when these medications should be used, because no national standard exist.
While a few organ procurement organizations currently will use these medications prior to death the majority will administer only after death has occurred. I anticipate a national standard in the near future that will prohibit use of these medications until after death of the potential donor has occurred.
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