Monday, January 18, 2010

Life, death, and organ transplantation - Part 1 of 2

Several years ago, when I was a family medicine resident taking overnight call at Lancaster General Hospital in Pennsylvania, I was called to preside over my first - and so far, only - organ donation. A young woman had suffered an irreversible traumatic brain injury in a car accident, and although her heart continued to beat, her breathing was supported entirely by a mechanical respirator. Informed of their daughter's condition, her parents had decided to turn off life support and, in accordance with her previous wishes, donate her heart and other healthy organs for transplanation.

What complicated this decision, from an ethical point of view, was that this woman wasn't brain-dead, by the legal and medical standard prevailing in 2003 and today. Since it is illegal to retrieve a heart from a person who is technically alive, transplant surgeons were prohibited from acting immediately after the respirator was turned off. Instead, they were required to wait until an independent physician pronounced the patient dead based on the absence of a heartbeat, for however long it took for her heart to stop beating. Which is where I came in.

I remember feeing vaguely uncomfortable. Told that I had the option to pronounced death either when I was unable to feel a carotid pulse or when the patient's EKG monitor showed no heart rhythm, I decided on the latter as the more conservative course. I took a position at the head of the bed and a respiratory technician turned off the respirator, then gently extracted the breathing tube. The patient's pulse, which had been about 100 beats per minute, gradually slowed. Five minutes passed, then ten. The crisp upstrokes on the EKG monitor became flatter and more wobbly. The pulse rate fell to 40 beats per minute - well under the normal resting heart rate for all but the fittest of endurance athletes - then stabilized.

The gazes of everyone in the room, including mine, were fixed either on the second hand of the clock on the wall or the pulse rate on the EKG monitor. Fifteen minutes passed, then twenty. The patient's grief-stricken parents, and a young man whom I decided was either her brother or boyfriend, began fidgeting quietly. Doubtless they had not expected the process to take nearly this long. Although the EKG tracing was barely discernible, the monitor was still showing a fluctuating pulse rate between 35 and 39 beats per minute.

I knew that surgeons in the operating room next door were scrubbed, gowned, and ready to operate, and that an ambulance was waiting outside to carry the organs to other dying patients who desperately needed them. Every passing minute deprived of oxygen made those organs less likely to survive a transplant. Thinking about this, and looking at the ashen patient in front of me, I made a decision. I reached down and felt the patient's neck for a carotid pulse. There was none. With one last glance up at the still stubbornly-pulsing monitor, I turned my eyes to the clock on the wall, intoned, "Time of Death: ..." and read the time.

In the next post in this 2-part series, I'll explain why a recent New York Times magazine article brought up this memory of mine.

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