Thread by @WesElyMD

1/🧵Serious question:
Is it ok to CLAMP OFF blood vessels to a human brain to stop cell function & get organs for transplant?

A new procedure does this to ensure no blood reaches a person’s 🧠 as surgeons take organs from freshly ‘dead’ bodies. Discuss.

bit.ly/3tEZhtl

2/ We all want to relieve the suffering when people are dying of failing kidneys, lungs, hearts.

Transplant can be a great solution.

As a transplant physician myself, I directed lung transplantation at #Vanderbilt.

I worry this new approach is a breech of the dead donor rule.

3/ The “dead donor rule” (DDR) says donors must be determined dead according to established legal/medical criteria PRIOR to procurement of vital organs.

What if there are doubts?

Like ongoing neuronal activity?

Can we take it upon ourselves to stop blood flow?

My letter:👇

4/ Importantly, the Dead Donor Rule mandates that we can’t DO anything (eg, like clamping blood flow) to ensure death.

This figure shows how in the OR clamps are put on large blood vessels taking🩸to the brain which completely blocks them in case there’s ongoing brain activity.

5/ In this case, the notion is…“We’ve already pronounced these people dead…BUT…they are ‘warm and dead’ and there’s likely still blood flow since it’s all so fresh, so let’s just clamp blood vessels to be totally sure brains gets no oxygen.” -ish.
 
We need to talk about this.

6/ Most donors are determined dead on neurological criteria: the irreversible cessation of all functions of the entire brain.

In response to a shortage of “brain dead” donors, vital organs are increasingly procured from donors declared dead by DCD.

Demand is pushing barriers.

7/ Protocols for “Donation after Circulatory Death” (DCD) are growing to involve a wide variety of patients (suffering from diseases) who aren’t “quite dead yet” until withdrawal of the life support.

This is where NRP comes in…a “noble” goal to expand the pool of organs?

8/ In my opinion, confusion about this procedure, which is called NRP (normothermic regional perfusion), revolves around the ambiguity of the use of the terms circulation & resuscitation.

Generally, when we use extracorporeal membrane oxygenation (ECMO)…

9/…to supply the human body with systemic circulation, it is for the purpose of resuscitation and sustaining life.

In the circumstances of use of ECMO for NRP, are these two practices suddenly completely distinct?

10/ The crux of the authors’ argument, bit.ly/3JEH3h6 that I’m responding to in tweet #1 is that the person has been declared dead, and, therefore, reestablishment of circulation w ECMO is only to preserve the organs...

BUT…

11/ BUT part of NRP is to ADD a unique intervention.

OCCLUSION of brain circulation (clamping 🧠 blood vessels) to prevent possibility of brain activity, which would obviously create (as the authors write) new “questions around circulatory determination of death.”

Precisely!

12/ Again, DDR states a patient cannot be killed by (or for) organ procurement.

To justify this added procedure of clamping brain circulation, the authors are compelled to explain:

“The brain remains a ‘black box’ & the degree or extent of neuronal death cannot be ascertained.”

13/ In NRP, clamping blood flow is obviously done to ensure brain death, yet authors repeatedly state DDR is not violated because a patient has been declared dead.
 
Since brain death is, by definition, the cessation of all brain activity, isn’t this “circulatory” logic? 🤷‍♂️

14/ Isn’t the desire to do this revelatory that we are pushing ethical limits?

“We think they’re dead but they’re not dead enough to make us comfortable so we need to clamp those blood vessels, too, to be sure??” 😳

15/ fin
Primum non nocere. First do no harm.

SERIOUS QUESTION:
Do you believe that this procedure to clamp cerebral circulation to cut off flow to a human brain is worthy of more consideration before we “update the legal definition of death?”