User:Kelli Broessel/sandbox

A Beating Heart Cadaver is a body that is pronounced brain-dead and connected to a medical ventilator which keeps the heart beating and other organs viable and functioning. The heart contains pacemaker cells that will cause the heart to continue beating even when a patient is brain-dead. Other organs in the body do not have this capability and need the brain to be functioning to send signals to the organs to carry out their functions. A beating heart cadaver requires a ventilator to provide oxygen to its blood, but the heart will continue to beat on its own even in the absence of brain activity. [2] This allows organs to be preserved for a longer period of time in the case of a transplant or donation. A small number of cases in recent years indicate that it can also be implemented for a brain-dead pregnant women to reach the full term of her pregnancy (Gross, 2003). There is an advantage to beating heart cadaver organ donation because doctors are able to see the vitals of the organs and tell if they are stable and functioning before transplanting to an ailing patient (Zamperetti, 2003). This is not possible in a donation from someone pronounced dead. There is a stigma around beating heart cadavers regarding the accuracy doctors have in pronouncing someone brain dead due to recent discoveries of brain activity in subjects that were classified as “brain-dead” (Saposnik, 2009). In addition, the organ donation world is desperate to widen its pool of donors to meet the ever increasing demand. This is due to the heightened rates of organ destroying diseases in recent years. As diseases progress, the functionality of organs is diminished and for some, a new organ is the only chance of survival. Heart disease, diabetes, and respiratory disease are among the leading causes of death worldwide and each condition could be cured if a new organ is received. However, some argue that using another person’s body purely as a means to an end, dehumanizes the patient (Bastami, 2013). The determination of brain death is still not an exact science with stories of spontaneous recovery of people thought to be brain dead tends to give the concept and the doctors responsible for diagnosis receive a negative social connotation.

History of Beating Heart Cadavers

The observed phenomena of lifelike qualities after death is not a new concept. In Renee Descartes' Discourse on the Methods he notes that decapitated animals move and display characteristics of a living body a few seconds after decapitation which was published in 1637. This continued into the French Revolution where it was observed that people who had been beheaded showed movements in facial muscles and hearts could continue to beat for almost an hour past the time of beheading. The guillotine in some cases did not completely sever head from body. In 1875 an examiner named Pierre Jean Cabanis was assigned the duty of making sure a body was truly dead (Saposnik, 2009). There were also stories involving beheadings where the victims would stand up and walk around before falling dead. The ambiguity around brain death and true death has followed it to present day. In an effort to clarify some of these gray areas, the Harvard Medical Committee developed criteria for identifying a body as dead in 1968 (Saposnik, 2009 & Daroff 2007). This criteria required patients to be completely unaware and unresponsive to external stimuli, have no spontaneous muscle movements, and exhibit no reflexive response even when manipulated. They also required that an EEG show no signs of activity (Saposnik, 2009). The purpose of this report was to encourage physicians to distinguish brain death and irreversible coma from a persistent vegetative state where the patient still has some awareness and cycles through sleep and wakefulness.

In 1971 a similar Minnesota criteria was published eliminating the EEG, repeating the exam after 12 hours, a severe lesion in the brain, and increasing the duration of the apnea test to four minutes rather than Harvard's three minute guideline. Other slight changes in the next decades included the United Kingdom's decision to eliminate the repetition of the exam and change from a duration of the apnea test to specified levels of CO2 in 1976 (Daroff, 2007). Later, in 1981 the President's Commission reinstated the apnea test and the repeat exam. Unfortunately, in a study done in 1989 only 35% of health care physicians correctly identified brain death using these criteria (Ward, 2015). A serious cause for concern. Presently, there is hot debate over the protocol for diagnosing someone as brain dead and there are not currently any enforced standard procedures for assessing a body. The unofficial standards have improved and become more specified in recent years due to the development of medical technology.

The American Academy of Neurology created a prerequisite and neurological clinical assessment to be used as guidelines for determining brain death published in 2010 (Wijdicks et al., 2010). To be considered for brain death the body must have a determinant cause of coma, have normal systolic blood pressure, and pass two neurological tests. These neurological assessments commonly consist of an apnea test, reflex tests where the body is manipulated or exposed to a stimulus and does not react, or be in a coma where there is complete unresponsiveness (Wijdicks et al., 2010). Cerebral angiography, electroencephalography, transcranial doppler ultrasonography, and cerebral scintigraphy are some of the tests that are used to ultimately test if there is any significant brain activity (Wijdicks et al., 2010).

The use of the term "beating heart cadaver" stemmed from the idea that a person considered brain dead no longer has the legal rights of a "patient" and should not be referred to as such (Ward, 2015).

Organ Recovery

How long the brain-dead person is kept on the ventilator may vary depending on the availability of surgical teams and the wishes of the family of that brain-dead person. Surprisingly although it is claimed the brain-dead patient cannot feel pain, an anesthesiologist is regularly present at organ donation surgical procedures(Gross, 2003). Due to the results of the apnea test if a person lacks the brain function to breathe unassisted, it is concluded that it would also lack the brain function to relay the sensation of pain (Gross, 2003). The anesthesiologist's main role is to ensure that muscle spasms or reflexes do not occur during the procedure. Though the brain may be dead, the pathway that reflexes follow does not pass from the stimulus in the body to the brain. Instead, the spinal chord coordinates the knee jerk reactions of reflexes including pulling back from the pain of putting a hand in an open flame or jerking away from an invasive incision. When the brain is dead these pathways remain in tact and the anesthesiologist is present to ensure that these reactions do not complicate the procedure (Gross, 2003).

Brain Death and Pregnancy

Since 1981 there have been 22 recorded instances of keeping a mother declared brain dead in a beating heart cadaver state until the baby is delivered (Gross, 2003). A dead woman in the eyes of the law and medicine, capable of producing life. A review of 11 of these unique circumstance pregnancies was conducted in 2000. Four of these cases involved a persistent vegetative state of the mother and in 7 maternal brain death was diagnosed. The women that underwent these gestation periods all delivered preterm an average of 30.5 weeks, where a normal pregnancy is around 35 weeks for full term (Feldman et al., 2000). The mothers were observed to have severe hypotension once in the brain dead or vegetative state and in all but one case the baby was delivered by cesarian section. It has also been found that by the 24th week of pregnancy intensive care is not as necessary and the mother is more stable than treatment occuring before the 24th week (Feldman et al. 2000). Common complications involved inability to regulate temperature which is treated with heating and cooling blankets, as well as failure of the endocrine system which is important in maintaining a stable fetal environment (Feldman et al., 2000). Following the delivery of the baby, organs of the mother are harvested as well.

From an ethical perspective the family and next of kin are often involved in the decision to terminate or prolong the pregnancy. This can be a difficult decision given the level of care required to keep the mothers living for the duration of their gestation which can vary. Intensive care of a vegetative state patient is not usually advised due to the dismal chances of recovery, but in the case that the fetus could survive this care is often justified and administered at the discretion of the family (Gross 2003 & Feldman et al., 2000). Intense counseling and advisement by physicians and neonatal experts often accompanies these rare situations (Feldman et al., 2000).

Ethical Debate

Just as the history of brain death has evolved over time, so too has its reception by the public. Brain death is defined loosely as the inability to breathe on ones own, with irreversible brain damage (Gross, 2003). When doctors take away ventilation systems and patients fail to breathe, move, or show any signs of arousal on their own they are considered brain dead (Gross, 2003). An apnea test is commonly used to determine brain death. In this test, the ventilator is taken away and is reconnected only if the person decided to be an organ donor. This definition can create some cognitive dissonance because not responding to stimulation may show a problem with the central nervous system, yet when someone has a beating heart and lungs that will still function with the help of a ventilator it is difficult for some to consider that true death. Brain death patients have characteristics of the living and the dead (Zamperetti, 2003). Beyond the organ donor application of prolonging death through the creation of beating heart cadavers, declaring patients in irreversible comas dead is utilized to make space in hospitals for living patients with ailments in need of immediate treatment.

Defining Death

There is little debate that when a heart stops a person is dead in the eyes of the law and medicine and cannot be brought back. The finality and irreversible nature of a death by heart failure is what makes it concrete. There is a difference when the brain is not working but the rest of the organs are functioning and the heart is still pumping blood to viable organs. According to a lawyer who defended this topic, George Annis, once a patient is declared brain dead they are considered dead by the law losing all constitutional rights. The reason this kind of preservation has persisted, is for its contributions to the organ donation supply. When the heart stops, the organs need to be harvested promptly because once blood stops being circulated to these organs they lose their viability due to lack of oxygen (Gross, 2003).

Social Issues

Organ recovery from beating heart cadavers has remained ambiguous to the public. The Dead Donor Rule is a guideline for organ transplantation consisting of two parts. It states that organ donors must be dead before removing the organs, and removing the organs is not the cause of death (Potts, 2007). This clause is in place to ensure that organ donation is not exploited to use people purely as a means to an end. However, many believe that even with these guidelines in place the protocol for organ donation still has room for criticism. Negative reviews from public and medical personnel on this subject tend to stem from a lack of understanding of what it means to be considered brain dead and how these decisions are made (Bastami, 2013). One social issue that is commonly brought up is the potential for conflict of interest for the medical team examining the body (Bastami, 2013). Another issue raising concerns in the organ donation by beating heart cadaver field is the administration of drugs to the patient that prevent clotting prior the donation procedure. These drugs are not beneficial to the patient and are intended solely to help the recipient of the organs (Potts, 2007). To alleviate some of these social concerns, there has been push for a standard in determining death and creating a normalized system for transplantation in these patients (Bastami, 2013).

From a religious standpoint, the encouragement of organ donation or acceptance may vary. The Catholic church with input from Pope John Paul II, identified transplantation from beating heart cadavers or living subjects as acceptable if there are no added risks to the donor (Bruzzone, 2008). This has been widely debated in Japan where the first heart transplant took place in 1968 and the patient died a few months after the procedure (Bowman, 2003). Since then, more transplantation procedures have taken place but it is still a widely debated subject. Transplantation in naturalist religions and cultures such as Native Americans, Buddhists, and Confucianists tend to dissuade the use of living donors and transplantation (Bruzzone, 2008). The body is idealized as a home for a soul and the organs belonging to a person are considered perverse if utilized by another person. No religion specifically outlaws the use of beating heart cadavers or prefers them to non beating heart cadavers (Bowman, 2003 & Bruzzone 2008). Western cultures more widely accept the use of transplantation by beating heart cadavers than more conservative cultures (Bruzzone, 2008). The main concern of many religions and cultures is ensuring the body is not objectified or disrespected in harvesting and transplantation of organs (Bruzzone, 2008). The nature of this uneasily defined concept and the increasing need for new organs have put many religions to the test on their morality associated with mortality.