The Professor Merry Lecture: Endings and Beginnings

Merry AF

Organ transplantation has become an established andworthwhile treatment for many otherwise intractable conditions inmany countries around the world. For example, over 4000 patientshave benefited from heart or lung transplants (or both) since thefirst heart transplant in Australia or New Zealand was carried outin 1984. However, there is thought to be a worldwide shortage ofdonors relative to the number of organs needed. Many people,notably many of those involved with situations in which organdonation might be possible, value the opportunity to contributeorgans. This has led to interest in expanding the criteria for donation.Standard criteria donation (SCD) involves the formal diagnosisof brain death, and conservative criteria for donor eligibility.Extended criteria donation allows slightly more liberal eligibilitycriteria, thought acceptable in light of improved results in SCD.In donation after cardiac death (DCD), an alternative approachto increasing the pool of available donors, a formal diagnosis ofbrain death is not required. The formal diagnosis of brain deathis very reliable, but prognosis in less definitive manifestations ofsevere brain damage is less so, as illustrated by numerous anecdotalreports. There is a tension between providing enough timebetween withdrawal of treatment and declaration of death forreasonable confidence to be maintained in the process of DCDand the desirability of keeping warm ischemic time to a minimumin the interest of organ survival. In Australia and New Zealand,DCD is undertaken only in the context of planned withdrawalof support in intensive care units (Maastricht category 3). Therehas been a considered and carefully implemented approach toDCD, and the educational initiatives associated with its introductionmay have had incidental benefit to the SCD program as well.It is, nevertheless, important that all involved are cognizant of thepractical and ethical issues at stake.
References:Merry AF The Professor Merry Lecture: Endings and Beginnings JECT 2011;43:17-22
Institution(s):University of Auckland, Auckland New Zealand