Sunday, March 11, 2012

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.

68 comments:

  1. Anonymous6:15 PM

    I saw this article last night. It is so irresponsible, I couldn't even comprehend any editor's decision to run it. The points he makes are so ludicrous that it seems as if he didn't bother to do any research into his subject matter, or he is deliberately trying to provoke a controversy. Your critique is, as usual, insightful and well-written.

    One of my favorite memories of residency (at the same institution that you trained) is that of a 20yo boy who we supported on multiple inotropes and drips in the CCU while he waited for an infection to clear and then a heart to become available. I can't even remember how many times we had to shock him for sustained VT, but I remember that after each time he would thank us and his mother would cry outside his room. My fellow coresidents and I went to visit him in the CTICU after his transplant, and he gave us the biggest smile one could smile while still on a ventilator and a giant thumbs up sign. We all cried and hugged when he finally left the hospital.

    Sign your donor cards, people. Your organs are useless in the ground.

    ReplyDelete
  2. Thanks for your post and reply to this WSJ article. I read the excerpt in your post, and am disturbed by how casually and dismissively the author treats the entire process. It's scary how something this inaccurate and biased can find itself published in something as widely read as the WSJ, and sad that it will almost certainly affect someone's decision to be an organ donor.

    On a more positive note, I recently read an article from the NYT (which I bet you've already read!) on the largest chain of living kidney transplants:

    http://www.nytimes.com/2012/02/19/health/lives-forever-linked-through-kidney-transplant-chain-124.html?pagewanted=all

    Even as a surgery resident who's done transplants, I still marveled at the process, and the generosity and grace of all the people making up the chain.

    ReplyDelete
  3. I'd like to propose a question, something I've always wondered whether or not was true, because it would be a huge deciding factor in whether or not I choose to continue to be an organ donor (though, for now, I am currently listed as one, and my spouse has been informed of my decision).

    I've heard previously that organs are typically harvested only from people that are considered to be in near-perfect health. Is this true? Would a heart be declined from a donor that has high blood pressure? Lungs denied from a donor that has asthma? Corneas denied from a person with macular degeneration? I assume it would fall under the same category as denying a liver from an alcoholic. How does UNOS and organ harvesting teams decide on the general health of the donor, and whether or not to accept/reject the organs offered?

    No one ever talks about this. They just ask you if you want to donate or not. I donate blood as it is, but I'd love to be able to do more if that situation presents itself. However, as we (the general public) grows older, continual (but minor) health issues arise. It's something I've always wondered about, and even OrganDonor.gov is vague on the topic.

    ReplyDelete
    Replies
    1. Anonymous11:22 AM

      Just thought I'd cut and paste the specific response to this issue from the Mayo link that another poster posted in case anyone wants to read the response after the question:
      "Myth: I'm not in the best of health. Nobody would want my organs or tissues.
      Fact: Very few medical conditions automatically disqualify you from donating organs. The decision to use an organ is based on strict medical criteria. It may turn out that certain organs are not suitable for transplantation, but other organs and tissues may be fine. Don't disqualify yourself prematurely. Only medical professionals at the time of your death can determine whether your organs are suitable for transplantation."
      link: http://www.mayoclinic.com/health/organ-donation/FL00077

      Delete
  4. Anonymous9:17 PM

    Hear hear dr au

    ReplyDelete
  5. Anonymous11:13 PM

    anmorata, here is a link to the Mayo Clinic website:
    http://www.mayoclinic.com/health/organ-donation/FL00077

    Thank you, Dr. Au for this post. The WSJ (as well as the NYT) is fast losing credibility with their willingness to publish anything to get a response. I am glad to see you writing more on current events (probably because I agree with you!).

    ReplyDelete
  6. Wanda8:18 AM

    I agree with every word you have written. The author of the article mentions the whole profitability of organ harvesting and that is the one area where I somewhat have an issue with. Everyone gets the opportunity to turn a profit from organ harvesting with the exception of the family - they get a fat hospital bill. Maybe it sounds creepy to think the family should get a cut of the take, but at the very least the monies should be applied to the bill or maybe the funeral expenses. Why should everyone along the chain profit from this except the one person you gives the most?

    ReplyDelete
  7. Michelle! Please black out your birthdate and signature from your driver's license. No identity theft!

    And thank you for responding to this article, which seems to me on par with all the anti-vaccination "facts" out there.

    ReplyDelete
  8. I'm an organ donor! I will always be grateful for the heart my biological mom received. Even though her body eventually rejected the heart, it allowed my dad to have extra time with my mom and my mom extra time with her 2 small children.

    ReplyDelete
  9. Michelle PLEASE consider sending a response to the WSJ. Their decision to run this piece is as dangerously ignorant as the author himself. I'm completely disgusted.

    ReplyDelete
  10. Anonymous2:18 PM

    The 'profit' argument doesn't really cut it. In the NHS, no money changes hands for organs. Though I do feel it important to maintain informed consent, rather than 'presumed' consent. A decision as important as this, is one that needs to be thought about, and actively made. Otherwise, you run the risk of resentment and anger.
    As ever, well put Dr Au.

    ReplyDelete
  11. Anonymous2:20 PM

    Do remove your signiture! However, interestingly, it does look somewhat like torsade de pointe!

    ReplyDelete
  12. Brava! Well said!! This is the second irresponsible article in the name of book promotion from the WSJ/NYT arena I've read/head about recently! The other, by William J Broad, was for the promotion of his book, "The science of yoga" which was horribly laced with inaccuracies and opinion. I find it very interesting that these authors use the pursuit of money and excess profit to malign the wellness and healthcare industry, while they are publishing outrageous and horribly flawed articles in the name of boosting book sales.

    ReplyDelete
  13. Professional Patient here- meaning I have a chronic, auto-immune disease and right now, dealing with my upteenth fissure. This blog has made me laugh so hard that I am in tears. Both for pain and pleasure! Thank you! I blog at flopbott.blogspot.com

    I love the way you write and will be getting your book and telling all of my Dr. friends (those who could acually do med school while I became a patient) to buy this book!!!!!!!!!!!!!

    ReplyDelete
  14. Anonymous5:16 PM

    Of course this article isn't factual, it is meant to be inflammatory, generate press and sell a book. As someone who does both the procuring and transplanting of organs, I have never participated in a procurement where anesthesia wasn't used, or that the family didn't 100% support the decision. Obviously, this article is going to be denounced by the medical community. The only problem is that the "layperson" isn't going to believe us. A quick glance at the WSJ comments section proves this. For some reason, many non-medical folks out there seem to have this opinion that doctors do not have their best interest at heart. That is simply not the case. An article like this can do enormous harm to the transplant community and the hundreds of thousands of people waiting for available organs--people who often feel terrible that they are waiting for someone to die to give them a chance at life. But it does terrible damage to the sense of security people feel then they unwillingly enter a hospital after a traumatic injury. Michelle already pointed out the lack of facts, which only gets worse when you read the entire article, but on top of that people will read more into it and what this article says is "Don't trust the money hungry, cold and uncaring doctors, they'll say anything to benefit their other patients over you." I do hope that someone responds and that the WSJ publishes it because this is such a tragedy. Michelle, I think you would be a fine person to do so.

    ReplyDelete
  15. Outre9:29 PM

    Of course the author doesn’t mention that though the hospital+provider fees may charge 750K, after the insurance’s customary/negotiated fees adjustment, that number may well be half that amount, IF that.

    I can go with the hospital bill getting written off/charged to receiver’s insurance but getting a ‘cut’ of the ‘profit’ will likely lead to some shady business and every third removed cousin or whatever coming out of the woodworks to get a cut of the $.

    “I swear I didn’t see uncle Bill backing out of the driveway! Oh the guilt, how am I going to live with myself for the rest of my life... Oh by the way, he’s mentioned he wanted to be an organ donor, everything he said, he said he didn’t care if they took everything. I’m glad some good can come out of this, I can’t believe I didn’t see him"

    ReplyDelete
  16. Thank you, Michelle. A beautiful response to an ugly piece of propaganda.

    ReplyDelete
  17. @Anmorata: there's very few diseases that absolutely exclude a person from being a donor. At first thought, they're AIDS and cancers. Hep B and Hep C are very decisively turning into relative contra-indications, which means they can sometimes be transplanted anyway, for example into an already infected recipient. Mostly anything else is up to the receiving specialists to decide on: a fatty liver of a 60year old may not be a match for the 20year old recepient who's not in acute liver failure and can wait a while longer, but it would be accepted at least for inspection for an older patient in acute liver failure about to die in the SICU. It may still get rejected once the receiving surgeon actually sees it and has his own pathologist take a look, but it's not rejected right off the bat simply for not being perfect. Same goes for any other organ: it's an interplay of the condition of any specific organ and the intended recipient, and sometimes takes a while, and a lot of people and tests, to determine. And even if one organ, like the liver, is unacceptable, others, like the kidneys, may still be very much acceptable. So almost none should count themselves unacceptable as a potential donor simply because they have a few health problems that everyone accumulates with age.

    None can tell you or your family in advance what precisely will be harvested and if all harvested organs will really end up transplanted. We have some idea based on the general medical condition, age and the tests we run, but harvesting is finalised in the OR, with help from pathology once we see organs. Actual transplanting is finally decided on in the receiving hospital once the organ is viewed by them and assessed for their candidate.

    I hope that helps a bit.

    As for the original article... sickening. Innit funny how the people accusing us of being cold-hearted money grubbing bastards are precisely the ones who use articles like this to promote themselves and their products, oblivious to the damage this may cause.

    ReplyDelete
  18. OK, this is going to sound like spam, but -- Thanks for the informative article.

    I don't have the medical background to know how much rubbish was in that WSJ article, and it's only luck that I read your blog and know to watch out for it! I hope the WSJ gets a response (more potent than a comment on the site) re the inaccuracies in the article and prints a retraction.

    ReplyDelete
  19. Anonymous10:51 PM

    My father received two liver transplants at Emory University in 2007/2008. Thanks so much for writing this - there are so many amazing people in the transplant space and we were witness to an amazing team who treated their patients and I'm sure, the donors, with the utmost in respect. Thanks for clearing this up, I hope as many people get to read this as they did the other article. Shame on the WSJ!

    ReplyDelete
  20. Two things:

    (1) Seems like the WSJ likes to publish incendiary articles by authors coming out with news books (c.f. Tiger Mothers, French parenting, and now this).

    (2) Your post reminded me of an article on organ donations in China. It's not an easy read though. (http://www.weeklystandard.com/articles/xinjiang-procedure_610145.html)

    ReplyDelete
  21. I too am an organ donor, and I will tell you, when I was asked if I wanted to be one at the age of sixteen upon receiving my first license, my answer was a quick, easy "YES." I didn't even think about it; I didn't have to. Did I want to give my organs to someone else? Happily, because by the time I am able to, I will not even care if they are still in my body...I will be dead. Since I was a kid, I have wanted to be a donor. Since I learned that you could take a dead person's heart and put it into a live person to save them, I was all for it. No thought needed.
    I can certainly understand how it could be a big deal, something someone may need to consider when thinking of their end-of-life plans. But, for me, it isn't even a question and I feel like this is probably true for a lot of people. When in life do we really get to make a difference and SAVE a life? Very rarely, unless we have that type of job or calling, and most of us don't. So, save a life, donate an organ--or five. :)
    By the way, I love your book and your blog. This was an excellent post.

    ReplyDelete
  22. But why be an organ donor at all when you can be revived with Dr. Sibly's Re-Animating Solar Tincture - So use this to prevent death from 1793.
    http://thequackdoctor.com/index.php/dr-siblys-re-animating-solar-tincture/

    ReplyDelete
  23. Obviously this guy hasn't read "This Won't Hurt a Bit (And Other White Lies)," because, if he had, he would have read the entire passage about "The Harvest," in your *Anesthesia* Residency. Maybe I should sent him a copy, with that passage bookmarked and highlighted?

    By the way, let me just take this opportunity to tell you, that I LOVED your book.

    ReplyDelete
  24. I personally feel more comfortable not having the organ donor label on my drivers license. Instead, my next of kin know that I am willing for my organs to be used, but that I would like them to take whatever steps make them feel comfortable in the process. This blog post does encourage me to write my wishes down, though. I would hate for my organs to be wasted just because no one remembered what I wanted.

    ReplyDelete
  25. Very thought-provoking. Thank you.

    ReplyDelete
  26. Anonymous11:56 PM

    Dr. Au, thank you for this post.

    I'll never forget my first organ procurement. I was apprehensive, which was odd, because I was already toying with the idea of gen surg residency, so I hung back a little and waited at the edge of the OR instead of trying to make myself useful. I watched as anesthesia wheeled the donor in. Already intubated (duh?)with eyes taped, he was 19, with a mickey mouse tattoo on his arm and long, brunette, Jesus-lookin' hair, the victim of an apparent heroin OD. I was struck by how much he looked like my friend's kid brother; how much he looked like every other patient I'd ever seen, naked and waiting for surgery. We treated him like any other patient.

    I scrubbed, we opened, and in 10 minutes, I saw, without exception, the most beautiful organs I'd ever seen. Organs that would go on to do something else and maybe, just maybe, save a life.
    So much of surgery is taking out disease, or "making do" with funky anatomy and awkward exposures. So little of it is witnessing the glory of what the body is and how it hums along without any real input from us. That night, I finally understood what it meant to be a donor - and decided never to allow my stuff to go to waste. I tell my family now that I'm an organ donor, because "I've worked too hard on this ticker to let it go to waste" - and I hope it makes them consider.

    ReplyDelete
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