Portal de Periódicos da CAPES

Transplant Interrupted

2016; Lippincott Williams & Wilkins; Volume: 265; Issue: 2 Linguagem: Inglês

10.1097/sla.0000000000001839

1528-1140

Joseph R. Scalea, Joshua D. Mezrich,

Ethics and Legal Issues in Pediatric Healthcare

The day-to-day lives of transplant surgeons are filled with unplanned operations, patients with severe illnesses that blur the lines between life and death, and firsthand experience with the incredible gift of organ donation. Despite the unbelievable selflessness we see every day, the role of fate or some higher power is rarely considered relevant. We simply respond to individual circumstances and we take care of the patients. But every now and then, we encounter a patient who makes us question the role of some sort of higher purpose. The following true story is one such example. On a quiet Sunday, my family was taking advantage of a slow transplant weekend. My wife and I were holding hands watching our toddler unsteadily walking (really stumbling) toward the playground in our neighborhood. It was so calming to watch him experience the world around him, so filled with interest and joy, not yet touched by all of the disease and tragedy that we see at the hospital. These thoughts were abruptly interrupted by the sound of bone slamming against a car trunk. Two blocks away, the dull “thwack” was clearly audible above my 1 year old's babbling on our Sunday afternoon walk. As I snapped in the direction of the gut-wrenching noise, I saw a motorcycle. It was sliding across pavement. Its single headlight, barely attached, shined bright as it bounced along unpredictably. I ran toward the wreckage that was coming to a smoky, smoldering stop, and my eyes focused on the image of a man with a rapidly increasing pool of blood around his head. I was fearful this fallen rider was a goner, but it did occur to me that we were only 1 block from the hospital, and perhaps our proximity would play to his advantage. A young college student was already on the scene. He lifted the bike off the fallen riders’ legs. “Stop” I shouted as I saw him pull up the rider, limp, to a sitting position. “We need to control his spine,” I instructed. We positioned him gently on his back on the roadway. A third person appeared in my peripheral vision. She was a postcall pediatric resident on her way home. The pediatrician held C-spine, while I stabilized his airway by jaw thrust. His respirations were weak and he appeared agonal. Another person appeared. It was, a friend of mine, Kevin. Kevin, an anesthesiologist, on his way into the hospital for night-call, felt his radial pulse. It was palpable. We did a brief neuro examination, attempting to elicit a response. Nothing. He was motionless. He had dolls’ eyes. The blood pool behind his head was growing, as was the backed up line of cars to my right. A woman was on the phone with 911. People were gathering on the side of the street, watching the events as they unfolded. The all-business paramedics, Emergency Medical Technicians, and firefighters arrived. They seamlessly got him on a backboard and in the ambulance in what seemed like seconds. Kevin, the pediatrician and I shared a communal glance, which implied “thanks” and “we’ll see” and “it doesn’t look good,” without saying a word. Grand rounds was the following Monday, and I was presenting. The title of my talk was “Innovations for Organ Donation.” As I entered the hospital, my mind was waffling between slides for my noon talk and my experience from the day prior. Before morning rounds, I found myself in the intensive care unit (ICU) asking about my patient from the field. He was alive. But he was sick, very sick. At grand rounds, we discussed DCD, or donation after circulatory death. DCD is 1 of 2 ways patients can donate organs. Most patients donate after brain death. Less frequently, patients who are not yet brain-dead donate organs through DCD. In this scenario, once treatment is withdrawn, the patient's blood pressure and heart rate decrease as the patient dies. Accordingly, to successfully donate organs by DCD, the patient needs to die quickly, within 1 to 2 hours. As many of one-third of attempted DCDs are unsuccessful because patients do not die quickly enough.1 Even when successful, DCD organs may function poorly, leading to fewer recovered organs, more retransplants, and even death.1,2 Nevertheless, we use DCD organs, because there are simply not enough organs to go around. A few days later, my phone rang. Chronically on call, I half-listened as I heard about a potential donor. It was a gentleman injured in a motorcycle collision. Chills ran down my spine. He was not brain dead. My patient was to donate by DCD, and it would be here in my hospital. After watching the motorcycle collision, stabilizing his C-spine and airway, following-up in the ICU, and giving rounds about my research on this exact condition, I would be tasked with removing the fallen rider's organs. This was an extremely emotional realization. Because transplant surgeons are removed from donor care until they are either declared dead or the decision to stop providing life-supporting care and move toward DCD donation has been made, the appropriateness of whether or not I should proceed with the donation procedure required not only introspection but also discussion with the organ procurement organization and the chief of transplantation. Because it would have been nearly impossible to predict my patient in the field would have ended up in my future care, we reasoned it was appropriate to proceed. Every scenario surrounding organ donation is different, but inevitably each involves some tragedy: nonaccidental trauma, falling off roofs and downstairs, car accidents, and biking misadventures. But the gift of organ donation provides the donor's family the only positive event amidst absolute disaster. Despite the emotional gravity of these circumstances, the technical aspects can be quite routine for those of us practicing transplantation. Focusing on the technical aspects of the organ procurement blunts the true weight of what we do. Indeed, it is probably what allows us to function day-in and day-out. The fallen rider was not part of a routine. Scrubbed in sterile gown, mask, and gloves, I looked far different than I did during his resuscitation a week prior. As I watched the clock tick from minute-to-minute after his life support measures were withdrawn, I found myself again trying to help this fallen rider. However, this time I was trying not to save his life, but to abide by his final wish before death—to save the lives of others he would never get the chance to meet. Today, he needed to die quickly. It was my patient's aim to donate his organs. Indeed, he signed up for the registry independently. He made the selfless decision to save lives at the end of his own. Although he had a devastating, unrecoverable neurologic injury, he did not meet “criteria” for brain death. Accordingly, our only chance to fulfill his final wish was to attempt DCD. Unfortunately, he did not die quickly enough to successfully donate. After all he had been through and after all his family experienced, we were unable to use his organs for transplantation. We failed to fulfill his final wish. Of course, he did ultimately die—they all do. He just did not die fast enough. He returned to his room in the ICU, wherein the machines were turned off, and his family sat with him while his blood pressure dropped, his organs died one by one, until finally his heart stopped. Sadly all of those organs, which only got the chance to live a few decades, would work no longer. We in transplant know they could have worked so many more years. For others on my team, these were fairly routine events. For me, however, this was very different. I felt as though I was supposed to be a part of this man's life. Our patient was a beloved son and referred to his dad as “Pops.” He was known as a local go-to handyman. He idolized Brett Favre and loved watching Aaron Rodgers carry the Packers to a Sunday victory. He was a die-hard Ted Nugent fan, although “Pops” did not understand the appeal of heavy metal. He cared deeply for others, so much so that he signed up on the donor registry, a fact that his family discovered after the accident—a truly selfless act that prevented his loved ones from having to guess whether he would have wanted to donate. I was destined to meet the fallen rider. The reason for meeting is not completely clear. Perhaps our interaction was intended to inspire me to double-down on my research efforts (which it has), and to continue to explore more ways to help potential donors succeed in donating organs at the end of their lives. Perhaps what I was supposed to learn from the experience was more personal. Maybe I was destined to see how short life can be, and that I should spend more time on family walks, to hold my wife's hand more often, and maybe to live more than 3 blocks from the hospital. I do know that meeting the fallen rider has helped me to embrace, rather than shy away from the true emotional gravity of what we do in transplantation.