Colorado death ruling chills transplant community

It is generally accepted that the actions of one person can sometimes make a difference in the world, but people involved in organ donations are hoping that the recent actions of a county coroner in rural Colorado won't have such an impact.

Montrose County Coroner and paramedic Mark Young sent shockwaves through the organ transplant community when he ruled Sept. 28 that a 31-year-old man's death was a homicide -- the result of his organs being removed at St. Mary's Hospital in Grand Junction, Colo., and not necessarily the result of a self-inflicted gunshot wound to the head. Young said his intent was to address concerns about the differing protocols hospitals use for declaring brain death, but some experts fear that he has made the public less confident in the organ procurement system.

"This has caused a stir around the country that is unjustified and is likely to have a significant negative impact on organ donation," said Robert Sade, MD, of the AMA Council on Ethical and Judicial Affairs and a former member of the United Network for Organ Sharing ethics committee. "The public really needs to be reassured that declarations of death in advance of procuring organs is a highly controlled process and that there are standards in place that are followed in making these declarations."

Young released an Oct. 6 joint statement with Donor Alliance, Colorado and Wyoming's organ procurement organization, in which he said Donor Alliance acted in good faith and the patient was not expected to recover. "The intent of my original statement was to alert the medical community to my perception of differing standards," he said. "What I want to come out of this is a defined standard."

Michael A. Williams, MD, assistant professor of neurology at Johns Hopkins School of Medicine in Baltimore and chair of the American Academy of Neurology's Ethics, Law and Humanities Committee, said brain death declaration standards are basically universal; however, there are variations in the procedures hospitals use to meet those standards.

States use same "template"

J. Adair Prall, MD, a neurosurgeon at Littleton Adventist Hospital near Denver who is on the Donor Alliance board of directors, said the Colorado standard for declaring death -- cessation of heart, lung and brain function -- follows criteria established in 1981 by President Reagan's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, which are used as a template by all 50 states. Standard procedures to determine this loss of function include testing for corneal, cough or gag reflexes, movement in reaction to painful stimuli and testing for any drive or ability to breathe.

More procedures, such as a cerebral angiography measuring blood flow in the brain, can be used as a "confirming test," Dr. Prall said, but additional activities also have "a very high potential" for false positives and are usually used only when patients have a complicating factor such as barbiturates in their system.

Donor Alliance issued a statement saying that at St. Mary's, brain death was declared after clinical observations and an apnea test documenting the patient's inability to breathe without mechanical support. The declaration was reviewed and accepted by Donor Alliance officials and three other physicians.

"This is really cut and dried," Dr. Prall said. "What this seems to represent is a lack of education on the part of a part-time coroner."

Laura A. Siminoff, PhD, a professor of bioethics at Cleveland's Case Western Reserve University and an expert on why people donate organs, said this incident might only cause "a little blip" in donation rates but that it illustrates the consequences of a fractured health care system.

"You go from hospital to hospital and doctor to doctor, and people do different things," she said. "People want to know that, if you're declared dead in hospital A, you'll be declared dead in hospital B."

Dr. Williams said this incident could inspire institutions to review standards and protocols, but he would prefer if the review were driven by physicians rather than hospital legal or risk-management teams.