Organ Donors are Still Alive, Not Anesthetized?

A Facebook meme claims that donors are alive and able to feel pain as their organs are harvested.

  • Published

Claim

Organ donations occur while the donor is still alive, paralyzed by intravenous medication but not anesthetized.
Example
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Organ Donors are Alive when their Organs are HarvestedPrior to 1968 a person was declared dead only after their... Posted by The illusion of Science on Thursday, October 1, 2015
I saw a Facebook post about how organ donors are kept alive, without anesthesia when organs are harvested. Is this true? I am an organ donor, and I have a signed DNR that has been witnessed and approved by family members. I don't really mind suffering for a small amount of time while all of my worthwhile organs are harvested, even if it is without anesthetic. Are these claims true, though? If so, is it because getting an anesthesiologist would be a time constraint, or for some other reason? If it is true, why?
Collected via Facebook and Reddit, December 2015

Rating

What's True

Organs are donated under a variety of circumstances; as medical technology advances, novel procedures (such as living donors) have broadened the scope of organ donation.

What's False

That there is evidence organ donors who are clinically dead, brain dead, or have experienced cardiac death can feel pain during organ donation.

Origin

On 1 October 2015, the Facebook page “The illusion of Science” published the above-reproduced status update.  The meme claimed organ donors are injected with a paralyzing agent prior to the harvesting of organs, but not anesthetized.

That Facebook page appeared to take a skeptical view of science, scientists, and scientific consensus; its “About” tab stated:

All scientific knowledge comes from a process of trial and error – a messy guessing game, that involves many false starts and much stumbling. Scientists first make an educated guess based on their observations … Much Scientific Theory is nothing more, than Scientific consensus in the collective opinion of the community of scientists in a particular field of study. There is no requirement for consensus. Scientific truth, or any other truth can’t be achieved by consensus.

Many people automatically confuse Science and Technology with progress. Progress serves and benefits humanity, which science and technology not always do.

The popular myth is that science and scientists are objective and neutral, but funding usually comes from the federal government or from industry. Rarely is this about “pure” science. There are objectives. The public welfare is far down the list as a consideration.

On 17 October 2015, the above-reproduced Facebook post was submitted to Reddit’s r/askdocs forum. The original poster expressed that while they were fearful of the meme’s claims, it wouldn’t affect their decision to donate organs. The subreddit r/askdocs is one of several arranged to connect Reddit users with professionals in any given field. The moderators of that subreddit required doctors to verify their credentials before receiving official tags:

If you are a medical professional who wishes to become a verified contributor to this subreddit, please message the moderators with a picture of your medical ID, student ID, diploma, or other form of verification. Please block out personal information, such as your name and picture.

The top-rated reply came from a Redditor tagged “Physician”; that user primarily participated on the r/askdocs subreddit, providing a variety of medical answers to questions from fellow redditors. They explained:

There are two ways you can be an organ donor: heart beating and non heart beating (or perhaps three: a living donor donating a kidney or part of his liver)

Let me illustrate with a case a I saw a couple of weeks ago: a middle aged healthy man falls of the stairs and immediately lost consciousness. I see him in the ER with a wide pupil not reactive to light. CT scan shows bleeding in and around the brain. Neurosurgeon cuts a hole in the patients skull to keep him alive and he is admitted to the ICU. In the ICU, the patients is kept sedated and intubated. We make CT scans that show that the hemorrhage and swelling have grown, and that there are large areas of the brain that show ischaemic changes: damaged tissue due to insufficient blood flow.

We talk with the patient’s wife and discuss that her husband will be severely disabled if he ever regains consciousness. We decide that we want to withdraw care and discuss organ donation, to which the wife consents. The patient is not brain death: parts of his brain still work. In this case, we turn off the ventilator and remove the breathing tube. The patient still gets pain medicine and sedatives. If he dies within 2 hours after withdrawing care, we will wait ten minutes after the time of death. Then, the body will be moved to the OR to remove the organs for donation. So: no extra suffering in this typical non heart beating donation.

In heart beating donation, the patient is brain death. Brain death patients certainly can’t suffer or feel pain.

The user’s assertion that patients who are brain dead cannot feel pain or suffer is generally accepted within the medical community. Patient literature from Brigham & Women’s Hospital titled “Understanding Brain Death” [PDF] stated:

Brain dead patients look asleep, but they are not. They do not hear or feel anything, including pain. This is because the parts of the brain that feel, sense, and respond to the world no longer work. In addition, the brain can no longer tell the body to breathe.

In a separate comment the user elaborated upon their background and area of practice, and answered further questions about patient care in the time leading up to organ donation:

I’m an MD, working in neurology … [Medical science knows] quite a lot [about brain death]. Brain death is a very specific condition. We know for sure that brain death patients are dead: their body just remains somewhat alive because we intubated them and hooked them up to a ventilator. Even with these treatments, it is hard to keep patients in this state for long. Your brain is quite important to remain alive.

Brain dead patients have no chance of being crippled, severely disabled or being in a vegetative state. They are dead. Their bodies are just somewhat alive due to the treatments we give.

[Brain dead patients feel] Nothing. Just as much as a dead (as in: in a coffin) person would … The protocol [for diagnosing brain death] somewhat differs for each jurisdiction, but usually involves:

  • Checking if you can diagnose brain death in this state (so no sedatives being administered, normal blood pressure and temperature, etc.)
  • doing a clinical examination to check if brain stem reflexes are absent
  • do ancillary testing, usually involving either checking if there is electrical activity in the brain with an EEG or checking if there is blood
  • flow to the brain with imaging. Electrical activity and/or blood flow must be completely absent.
  • as a final test: see if the patient tries to breath if you stop the ventilation

Many of the nuances of organ donation’s scope hinged on the scenarios under which an individual might donate organs. Living donors were exempt from the meme’s claims, for obvious reasons. Brain death is the most common scenario under which organs are harvested; cardiac death is less common. A public information document issued by the University of Miami Miller School of Medicine explained:

Donation after Cardiac Death (DCD) is another way in which a person can help to save lives through organ donation. It can occur when a patient has a non-survivable, irreversible, severe brain injury but does not meet criteria for the diagnosis of brain death … it may be possible for that person to be an organ, eye and tissue donor … Once the heart stops and death is pronounced by a doctor who is not a member of the organ recovery or transplant teams, it may be possible to recover abdominal organs (liver, kidneys, pancreas) for transplant. This like any other surgery is a very delicate and careful procedure. Organ donation can only occur if the death happens rapidly. Once organs have suffered a lack oxygen and blood flow for an extended period of time, they are not suitable for transplant.

That document also addressed the question of whether patients in cardiac death feel pain during organ harvesting procedures:

After a patient dies, he or she no longer feels pain. Organ recovery occurs only after a patient is declared dead.

A similar document [PDF] supplied by the University of Wisconsin-Madison Health department reiterated that cardiac death patients are incapable of feeling pain after death has occurred:

Organ and tissue recovery does not take place until after the patient’s heart stops beating and they are declared dead by a physician. When someone is deceased, they cannot feel pain or suffer.

Biomedical ethicists assess, debate, and research the ethical considerations surrounding organ donation on an ongoing and extensive basis. Cardiac death patients by far generate the largest number of questions and ethical quandaries; however, those topics centered largely around when a patient can and should be declared dead, whether or not they are an organ donor.  The question is far less “whether” than “when,” as ethicists are deeply concerned with whether any one patient can be spared despite a grim prognosis.

This conundrum was explained in a 2001 piece in the New Yorker titled “As Good as Dead”:

From the beginning, transplant practice has been governed by a simple, unwritten rule: no matter how extreme the circumstances, no matter how ill or injured the potential donor, he must die of some other cause before his vital organs can be removed; it would never be acceptable to kill someone for his organs. But, ideally, a donor would be alive at the time his organs were harvested, because as soon as the flow of oxygenated blood stops, a process called warm ischemia quickly begins to ruin them. By the nineteen-sixties, as doctors began to perfect techniques for transplanting livers and hearts, the medical establishment faced a paradox: the need for both a living body and a dead donor.

Another portion of that article illustrated the public confusion outside the medical community with respect to brain death versus standard death:

”It took us years to get the public to understand what brain death was,” Nathan said. “We had to train people in how to talk about it. Not that they’re brain dead, but they’re dead: ‘What you see is the machine artificially keeping the body alive . . .’ ” He stopped and pointed to my notebook. “No, don’t even use that. Say ‘keeping the organs functioning.’ ”

Virtually every expert I spoke with about brain death was tripped up by its semantic trickiness. “Even I get this wrong,” said one physician and bioethicist who has written extensively on the subject, after making a similar slip. Stuart Youngner, the director of the Center for Biomedical Ethics at Case Western Reserve University, thinks that the need for linguistic vigilance indicates a problem with the concept itself. “The organ-procurement people and transplant activists say you’ve got to stop saying things like that because that promulgates the idea that the patients are not really dead. The language is a symptom not of stupidity but of how people experience these ‘dead’ people—as not exactly dead.”

While it’s true that bioethics in medicine remained fluid around the handling of organ donation, many questions hinged on management of the window during which organs might be harvested. However, claims regarding pain are less common. Dr. Richard Freeman, chair of the Department of Surgery at Dartmouth Medical School, told NPR in 2012:

That’s essentially the situation, but the person – it’s not even legal. It’s physiologically this person is dead. So before there was ventilators, there was never this issue because once your brain stopped functioning to make you breathe, the oxygen stopped being delivered to the organs, and your heart stopped.

But now that we have ventilators, it becomes important to understand other ways that the person dies, and you can maintain oxygen to the organs through the ventilator after they’re dead, and that’s precisely what happens in this situation.

… The sensation of pain requires upper-level brain function, and as we said, the apnea test proves that there is no upper-level brain function. And so it is not possible if somebody has been declared brain-dead by the apnea test or other tests that we use for there to be pain to be experienced.

The meme’s fundamental misinterpretation occurred in the outset, where it asserted organ donors are “alive” during harvesting. Nothing could be further from the truth, and the area isn’t gray. In 1981, all states adopted a form of what is known as the Uniform Determination of Death Act:

An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.

A bioethicist to whom we posed this question provided the following response to the larger debate over whether organ donors are “alive” when their organs are harvested:

Under the law, vital organ donors have to be determined to be dead before organs can be removed, meaning that they have either had their heart stop permanently or been determined to be brain dead. Brain dead individuals are legally dead; they are in a state of irreversible coma, will never regain consciousness or have a meaningful recovery, and cannot experience pain. The tests done to confirm that someone is brain dead check many different things, including that there is no drive to breathe and no response to noxious stimuli (such as a gag reflex). Although there are some famous cases of brain dead individuals gestating fetuses or persisting on ventilators for years, there has never been a person who was accurately determined to be brain dead who regained consciousness or recovered.

As such, a donor is always dead, whether it is cardiac or brain death. No living patients are ever subjected to organ harvesting. Machines such as ventilators ensure organs do not deteriorate during the procedure. Due to the nature of organ harvesting procedures, firm declarations relating to pain management are difficult to come by. However, credible medical literature stated that organ donors are generally incapable of feeling pain once they’ve ceased functioning to the point death has been declared.