A Straight Dope Classic from Cecil's Storehouse of Human Knowledge

How do they decide when you're dead enough to be an organ donor?

December 4, 1987

Dear Cecil:

A few weeks ago a friend of mine had a motorcycle accident and tore himself up a bit. He was unconcious for about a week. During this time his parents signed away his organs in case of death. A few days after that, the doctors lost all hope for recovery and suggested that he be removed from life support. He was removed, then he died, then he was gutted.

My question is, how dead do you have to be before the MDs start eyeing your organs? I refuse to donate my organs for fear that I might be salvaged for parts before I've been given a sporting chance at recovery. Also, who all can sign a person's organs away?

Cecil replies:

Sorry about your buddy, Les. Can't say as I blame you for being a little queasy about "organ harvests," as doctors call them. Even a surgeon friend of mine says they're weird.

This isn't going to make you feel any better, but chances are parts of your friend weren't very dead at all when they began dissecting him. Most likely, in fact, his heart was still beating and he was still breathing with the aid of a ventilator. If he were stone cold, his organs would have deteriorated too much to be usable.

What was dead was his brain. The classic transplant donor is a motorcycle accident victim who has suffered severe head injury while the rest of him remains intact. Brain death can be determined several ways: a "flat line" EEG (little or no electrical activity in the brain), "doll's eyes" (eyes remain fixed straight ahead when the head is moved), no response to ice water squirted in the ear, etc. A neurologist and/or neurosurgeon is almost always consulted before the declaration of brain death is made.

What keeps doctors from deciding you're worth more dead than alive is the fact that the ones who determine you're transplant material aren't the same ones who stand to benefit financially from your demise. The attending physician notifies the organ bank only after he or she has decided your case is hopeless. The organ bank then notifies the transplant team, which sends surgeons out to collect the goods.

It's fairly common to notify the organ bank of a potential donor before the patient is legally declared dead because of the time that's required for transplant preparation. But once in a while people in the organ procurement business really jump the gun. One of Cecil's sources recalls getting a call from a transplant coordinator who was shopping around a potential donor's parts. When asked how soon the donor would be ready, the coordinator replied, "I don't know, he's still breathing" — without the aid of a ventilator. This brought the conversation to an abrupt halt. You can't declare somebody dead if he's still breathing on his own. Fortunately, transplant coordinators aren't the ones who decide about these things.

If you don't agree in advance to become an organ donor, either by signing a donor card or the back of your driver's license, donation can be authorized by your next of kin. Right of priority is set by the Uniform Anatomical Gift Act: (1) your spouse, (2) a son or daughter over the age of 18, (3) either parent, (4) any adult brother or sister, or (5) the party who will take custody of your body at death. As a practical matter, even if you signed a donor card, virtually no organ bank will take you without the unanimous consent of your immediate family.

An organ harvest ain't pretty. Time is of the essence; there may be several surgical teams, each waiting to remove a different part. So the body is simply sliced open. The blood vessels for each organ are tied off, preservative solution is pumped in, and the organ is removed. Depending on what's needed, the liver, kidneys, pancreas, corneas, heart, and even bones and other items may be taken out. When everybody is done, the anesthesiologist switches off the ventilator, and you watch what's left of the patient die. The process is brutal, but the alternative is to do nothing. In that case not only does the potential donor die, so do the would-be recipients.

A question of sensitivity

Dear Cecil:

In response to your column on organ donation, it amazes me that someone who knows virtually nothing about a sensitive medical issue like this feels compelled to disseminate such biased information. Especially when that information is neither accurate nor appropriate.

In case of irreversible brain death, organ donation is offered to grieving families as an alternative which creates some solace and comfort in an otherwise abominable situation. It turns a senseless death into life. The families are approached by skilled medical professionals trained in ths process and sensitive to their grief. The donor, in all cases, has been declared clinically brain dead (legally deceased) before any procurement activities are carried out. And finally, when the procurement takes place, it is done in the operating room under sterile conditions with the utmost respect afforded to the donor.

The reward to the grieving families is the knowledge that otherwise terminally-ill patients suffering from end-stage organ failure can receive a second chance at our most precious commodity — LIFE.

Cecil replies:

I know this is a touchy issue, but it's simply not true that no "procurement activities" take place before the declaration of death. The former transplant coordinator for a major university medical center tells me that in a significant percentage of cases he got word about a potential donor before the donor was declared dead. He didn't regard this as particularly scandalous, and neither do I. Apart from saving time, calling ahead saves doctors the trouble of having to bother the family if it turns out the potential donor's organs aren't suitable for transplant. Physically taking charge of the body is a different matter. Most transplant coordinators won't even go to the hospital until the donor is officially dead for fear of looking like vultures.

I'm sure transplant surgeons are respectful, but an organ harvest is one event where neatness isn't a priority when it comes to opening up the body. Instead of making, say, a six-inch incision to minimize scarring, the donor is "peeled wide open," says a surgeon who's been there. (See "An Improved Technique for Multiple Organ Harvesting" by Starzl et al, Surgery, Gynecology & Obstetrics, October 1987, for a technical description.) It has to be that way — there's no time for the aesthetic niceties. The organs themselves, of course, are treated with TLC. You get stitched back together for the funeral, same as with an autopsy.

I'm not against organ donation or organ harvests. I think everybody should sign the back of their driver's licenses. But I don't deal in euphemism when discussing the subject.

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