death or something like it

Good discussion on that last post!  It's clearly a topic that many are hungry to talk about, and I think what's becoming increasingly evident to me is that the choices we make with our lives in medicine really aren't any different than the choices people make in any other high-powered field where a lot of people are counting on you.  In some ways, it makes the choices more difficult, but in other ways, the clarity of purpose and the natural inclination to triage makes getting through our days, if not necessarily easy, than at least one where our top priorities are unambiguous.

OK, ready for the next thing to talk about?  And--hey, look.  Usually I don't go hunting around for topics to stick in my craw.  I swear, usually I just wander around with a smile on my face and a song on my lips with little birds braiding my hair, a regular blithe spirit.  Or Blythe Danner.  But then, oh look, one of my partners at work e-mailed me this article from The Wall Street Journal Online.

What You Lose When You Sign That Donor Card
Giving away your organs sounds noble, but have doctors blurred the line between life and death?

An excerpt:

The last time I renewed my driver's license, the clerk at the DMV asked if she should check me off as an organ donor. I said no. She looked at me and asked again. I said, "No. Just check the box that says, 'I am a heartless, selfish bastard.'"

Becoming an organ donor seems like a win-win situation. Some 3.3 people on the transplant waiting list will have their lives extended by your gift (3.3 is the average yield of solid organs per donor). You're a hero, and at no real cost, apparently.

But what are you giving up when you check the donor box on your license? Your organs, of course—but much more. You're also giving up your right to informed consent. Doctors don't have to tell you or your relatives what they will do to your body during an organ harvest operation because you'll be dead, with no legal rights...

...The exam for brain death is simple. A doctor splashes ice water in your ears (to look for shivering in the eyes), pokes your eyes with a cotton swab and checks for any gag reflex, among other rudimentary tests. It takes less time than a standard eye exam. Finally, in what's called the apnea test, the ventilator is disconnected to see if you can breathe unassisted. If not, you are brain dead. (Some or all of the above tests are repeated hours later for confirmation.)

...But [beating heart cadavers--the term used in the article for brain dead patients]...don't receive anesthetics during an organ harvest operation [though they] react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates. Doctors say these are simply reflexes.

...Organ transplantation—from procurement of organs to transplant to the first year of postoperative care—is a $20 billion per year business. Average recipients are charged $750,000 for a transplant, and at an average 3.3 organs, that is more than $2 million per body. Neither donors nor their families can be paid for organs.

It is possible that not being a donor on your license can give you more bargaining power. If you leave instructions with your next of kin, they can perhaps negotiate a better deal. Instead of just the usual icewater-in-the-ears, why not ask for a blood-flow study to make sure your cortex is truly out of commission?

And how about some anesthetic?

(Read full article here...such as it is.)

OK, let me leave off the table now the details of the neuro exam and EEG monitoring and the criteria for brain death.  I can talk about those too of course, but I am not as qualified to do so as some, and, unlike the author, I know better than to ignore my somewhat less than expert grasp of the nuances of the subject material and trumpet my knowledge, whatever its flaws, as the clarion bell of unimpeachable fact.  These issues may be better for a neurologist or neurophysiologist to discuss--one may well be reading this entry now and want to weigh in in the comments section--and, I venture, the author of the article may well have benefitted from talking to such an expert in researching the article himself.  (They're called "cold calorics" or "vestibular caloric stimulation" sir, ask any second-year medical student.  We're not looking for "shivering" in the eyes, even though, yes, ice is cold.  By the way--you see a similar response with warm water.)

What I want to talk about is this accusation that we don't use anesthesia during organ harvests.

WE ALWAYS USE ANESTHESIA DURING ORGAN HARVESTS.

Organ harvests, who for those like the author of the article (OK, I'll stop) are unfamiliar with the terrain of organ transplantation in a hospital setting, are always booked in the operating room, and always booked with anesthesia staffing.  We as the anesthesia team help transport and support the patient, usually from the ICU, vented and on drips, down to the operating room.  We put them on our anesthesia machine, monitor them just as we do any other patient.  We anesthetize them, give them medication, oxygenate them, treat their hyper/hypotension and tachycardia, just like any other patient.  The definition of "pain" lands into some sticky semantic territory--so far as I understand it, "pain" implies a perception and processing that requires some higher brain function, which brain-dead patients by definition lack.  But I don't argue that even brain-dead patients have sympathetic (in the central and peripheral nervous system sense) reaction to nociceptive stimuli, such as surgical incision--and we treat those responses the same as we do in any other patient, often with pain medication.

The hard part is when the surgery is over and we have to walk away.

Because it's not what we do.  We take care of patients, and those who donate their still-working organs after brain death--that is to say, after they themselves have lost all reasonable expectation for meaningful use of those organs--are still our patients.  In some ways, it's harder as an anesthesia practitioner to separate out these patients from the others we take care of--almost all our patients look like they're sleeping, almost all patients under our care require ventilatory support and/or circulatory support, almost all our patients lie completely still and largely unresponsive.  We tend to them with attention, respect, and care, until the very end.  And in the case of an organ harvest, it's the anesthesia providers who are turning off the life support.

And that's hard to do.  It's hard because we respect the patients, respect life and its passage, respect the choices they have made to help others.  To imply otherwise is ignorant and insulting at best--and it is quite flatly an insult, to imply that doctors simply regard patients as a collection of interchangable profitable parts--and irresponsible at worst.

Because the implications and the ramifications of this article and articles like this are irresponsible.  It's irresponsible to write as a voice of expertise (the author has, I believe, written a book on this topic which, SHOCKINGLY, is coming out next week) in a major news outlet on a topic of which you clearly have an imperfect understanding.  It is even more irresponsible to use that platform in a way that has some very real, lasting public health implications for life-saving treatments and therapies for other patients for whom the breadth and depth of the organ donor pool is, quite literally, their last and only chance.

And look, I'm not an idiot--I understand that The Wall Street Journal has, in the past, published incendiary shock-value pieces that have been quite successful in book promotion (Amy Chua's "Tiger Mom" article comes to mind, and I don't deny that, when that particular firestorm hit a month before my own book came out, I wished I had either the subject material or iron-clad balls to generate that particular caliber of self-perpetuating publicity).  But this is about more than selling a bunch of books, or generating a lot of attention, or getting a lot of replay on Facebook.  Because of this article, someone might decide not to donate their organs, and because of that, someone else is going to die.  A real person.  I've met and taken care of many of them.  You may have too.

Again, it comes down to choice--obviously the choice of whether or not to donate ones organs after death is a personal one and should be at least considered seriously.  I know people don't live their lives explicitly to benefit strangers, nor do they usually intend to die toward that same end.  But fact is that this is the moment we're at in the evolution of medicine.  When organs in some patients fail, we sometimes have the ability to transplant in organs from other patients who can no longer use them.  Maybe someday we'll grow organs in jars--no doubt that kind of research is in its infancy or early childhood--but for now, to save and improve lives, this is what we're working with.

I don't wish this kind of decision on anyone, and may we all live happy and healthy to the ripe old age of 100, but the fact of it is, some of us don't.  Death, in the circumstances where organ donation may be an option, is often unavoidable, after the exhaustion of all  other options.  But the choices, the informed choices you make before death with what happens to your body afterwards--well, that's up to you right now.

But know that, whatever decision you make, we as your doctors will take care of you.  Always.  All the way to the end.