Organ donation is a very complicated and involved process. The essential part of this process is organ procurement or the process of taking organs out of the organ donor body.

According to the “Dead Donor Rule” the donor should be declared dead prior to organ donation rather than dying as a result of donation. Otherwise, it would be unethical or even criminal to harvest the organs.

How do you define death for organ donation?

The patient may be pronounced brain dead prior to donation. This means that no brain activity or measurable blood flow to the brain can be detected. The diagnosis of brain death is usually made on clinical grounds with an optional confirmatory test like a nuclear medicine brain perfusion scan.

If the patient is not brain dead, donation is still possible via a “Donation after Cardiac Death” (DCD) protocol. The essence of this approach is for the patient to be pronounced dead based on the cessation of circulatory and respiratory functions, assuming that brain death is imminent after that.

In the real world if DCD is pursued, the patient would be taken to the Operating Room where life support will be removed. The physician will have to document the cessation of the respiratory function and mechanical asystole (lack of heart contractions) for 2 to 5 minutes depending on the Hospital protocol.

Mechanical asystole means a lack of heart contractions and circulation. The patient still might have electrical activity in the heart. Lack of heart contractions associated with the electrical activity (pulsless electrical activity) is sufficient to declare death.

Lack of cardiac contractility is documented by the absence of Doppler flow over the arteries, absence of blood flow through the aortic valve on a cardiac ECHO, or by documenting the lack of circulation by an invasive arterial cannula.

The usual sequence of events, once the life support is removed, is respiratory arrest leading to cardiovascular collapse. The lack of breathing and circulation should be observed for at least 2 to 5 minutes before organs should be taken. This is necessary to assure that an “auto-resuscitation” or spontaneous return of vital functions does not occur.

This is a somewhat superficial and simplified review of the declaring dead process for organ donation. Educating the public about organ donation, death and organ procurement is an essential step to improve the rate of consent for organ donation.

Following guidelines, rules and protocols is a must when you are taking care of the ICU patients. Yet, invariably, family’s wishes and concerns will change the way you treat your patients, even the sickest ones. Medical care doesn’t stop even after you pronounce the patient brain dead (see image above). If the family is interested in organ donation you have to “keep the body going” so that somebody can get a “second chance” by getting those organs. The one question that always comes up when dealing with a potential organ donor – are we being aggressive enough in “recruiting” eligible organ donors? Are we taking away somebody’s hopes for better life or even survival when taking “No” for an answer?