The Ugly Organ

September 13, 2005 8:48 AM

Is it a smart idea to keep a donor sticker on your license? I've heard rumblings....

that, due to the nature of long lists of organ transplants, there won't be as much effort to save you if you're on the brink. I don't have any EMT friends, but a doctor I spoke with was pretty ambivalent about giving me a clear answer. I've heard this fluttered around from several different people, so if anyone can shed some light on the reality of this situation, I'd like to know.

posted by Mach3avelli to health & fitness (32 comments total)

I think the answer would depend on whether EMT companies and receiving hospitals get a cut of the money if an organ donor dies on their hands (assuming this is about money rather than some twisted form of goodwill).
posted by rolypolyman at 8:52 AM on September 13, 2005

Anecdotal: My brother was an EMT. I've never heard any such thing.
posted by cribcage at 8:58 AM on September 13, 2005

Do you really think that people who have dedicated their lives and taken an oath to save people's lives wouldn't try to save yours, the person in front of you before a likely annoymous person on a donor list?

I'm not saying it's not possible, but I find the chance remote.
posted by agregoli at 9:03 AM on September 13, 2005

person in front of THEM, sorry.
posted by agregoli at 9:04 AM on September 13, 2005

Yeah, it's definitely about $$.
posted by Mach3avelli at 9:06 AM on September 13, 2005

Donation myths and facts - top of the list. Donation FAQ number 4 - it's often still up to your family even if you do carry a card.

Don't buy such myths. Carry a card, sign on to registers or do whatever necessary in your locality.
posted by edd at 9:08 AM on September 13, 2005

EMTs and the trauma physicians in the ER don't get paid more if you die and get harvested. More the reverse. If you die under their care and they can't demonstrate that they gave the appropriate standard of care, they get (rightly) sued to oblivion. Hell, they're probably going to get sued even if they do everything right and someone dies under their care, it's just that the plaintiffs will be less likely to win in those cases.

You'd have to be a complete fucking moron to risk that just to help some random person who isn't your patient and who you've never met maaaybe get a compatible organ or maybe not. And most physicians are not complete fucking morons.
posted by ROU_Xenophobe at 9:14 AM on September 13, 2005

The United Network For Organ Sharing manages the Organ Procurement and Transplantation Network, which is the big gorilla of organ transplant waiting lists. Both are highly respected non-profit organizations.

Yeah, hospitals that perform transplants make a lot of money off of such procedures, but to argue that a hospital administrator bribes EMT's (or doctors) to let patients die in order to facilitate transplants -- which due to the national nature of the donor list will likely take place at hospitals hundreds of miles away -- defies believability. Just because you die in Sacramento doesn't mean your organs will go to Sacremento donors; if you're an EMT in Sacramento and you let a patient with a donor card die, who exactly is going to pay you extra? The hospital in Milwaukee that performs a heart transplant later that night? The Organ Transplant Mafia?

When you think this through, it doesn't hold up. Or, on preview, what ROU_Xenophobe said.
posted by junkbox at 9:20 AM on September 13, 2005

(Wondering why that doctor gave him an ambivalent answer)
posted by rolypolyman at 9:29 AM on September 13, 2005

(Wondering if it was just perceived as an ambivalent answer)
posted by PinkStainlessTail at 9:35 AM on September 13, 2005

Considering they're working for the medical profession, I would think subconciously they would be taking BETTER care if you because they would respect you more for being a good person and helping others if you die.
posted by shepd at 9:36 AM on September 13, 2005

Nope.

Having worked for my area organ procurement organization (full disclosure: as an AA, but you see and learn a lot, even at that position), this is actually one of the biggest myths.

A donor card is not a legally binding contract - it's merely an expression of your wishes. After an individual dies (under very specific circumstances, generally involving a closed-head injury and remaining on artificial support - part of the reason there are so few donors), then a transplant coordinator/requestor will meet with the family, including the Next-of-Kin. They'll spend several hours a)doing a combination grief support/getting to know the decedent, b)taking a med/soc history and c)hopefully convincing the family that donation is the right thing to do, and the decedent would want to help others. (c) changes depending on what philosophy the OPO follows. From my wording, you can guess what my OPO's philosophy is...)

If the family does not consent, the TC/Requestor is then out of the picture and the decedent goes to the ME (if the death was suspicious), or is released to the funeral home. [I'm covering organ donation here, not the easier/more common tissue donation.]

If the family does consent to donation, an ER time is arranged, and a transplant surgeon is called in. The TC/Requestor is always present at organ retrieval, and stays with the body throughout the process. From there, there's a very long, very complex system for getting the organs out to those who need them most. ALL costs for the donation surgery are swallowed up by the federally-funded OPO, including paying the hospital for ER time, transplant surgeon, etc.

Basically - yes, the DMV is contacted to find out if the potential donor has expressed wishes to donate, but this is done by the OPO. They are not contacted unless the attending nurses conclude that recovery is impossible, but that the patient is a potential organ donor. The hospital would make plenty of money anyway, the transplant surgeons are generally very well-paid and aren't exactly suffering for work. The only thing extra that hospitals recieve is a pretty sheet of paper saying how many donors they had in a given month. And this is all aside from the fact that no-one in health care worth their salt would break the Hippocratic Oath to let someone die on the possibility that their family will choose to donate.

Sorry to go on, but my time at the OPO really affected me, and I'm pretty passionate about organ donation, and education about it.
posted by kalimac at 10:24 AM on September 13, 2005

Man, did you guys ever see that episode of "the X-Files" where they were harvesting organs from poor Chinese immigrants? They would hold like a 'raffle' and pick an organ randomly, but in the end it turned out they had the whole thing rigged.

Personally, I doubt they'll even check to see if you're a donor until after you expire. They might make more of an effort to keep your organs alive if you go brain-dead until all the paperwork could be sorted out.
posted by delmoi at 10:47 AM on September 13, 2005

Obligatory Monty Python reference: "`Ello, we've come for your liver."
posted by scratch at 11:10 AM on September 13, 2005

My issue with the organ donor card is that it is not binding.

This ambiguity results in the hospital sending people to try to talk the grieving relatives into going against the decedent's wishes if they've elected not to donate. Generally, this adds a burden of guilt to the relatives either way. ( Choose between: "I'm a horrible person for telling the doctor he couldn't save a patient with John's liver," or, "I'm a horrible person for not respecting John's last wishes." )

It's a ghoulish confrontation that would be avoided if the card was taken as the final word on the matter.
posted by Crosius at 11:41 AM on September 13, 2005

due to the nature of long lists of organ transplants, there won't be as much effort to save you if you're on the brink.

An obscene slander.

SF author Larry Niven wrote a few stories about a 21st-century "organlegging" trade; see The Jigsaw Man particularly. It was a crime, but only to actually kidnap someone for their organs. Society, on the other hand, progressed to the point where it accepted the death penalty for traffic offenses, because it increased the supply of organs.

That said, there are problems with the gaming and arbitrage of supply and demand. The Body Brokers details how for-profit entities make money moving organs (not just hearts and kidneys, but things like skin and bone marrow) around the country, even as the entire thing is "properly" managed by non-profits. The great failure here isn't that people are suffering or -- your implication -- euthanized for their organs, but that a common resource is being exploited for its scarcity.

Note that it must be a common resource. You can't pay people for their organs; that's against medical ethics. So you can't just say they should share the profits with the people whose organs are transplanted. The entire medical community is very leery of creating, shall we say, the wrong sort of incentive.

I'm a donor, it's on my license, and my entire family knows (and agrees). The new ad campaigns say both steps are important. Personally, I'm more disturbed at the idea that anybody would outright refuse to be a donor for other than religious reasons.
posted by dhartung at 12:28 PM on September 13, 2005

Personally, I'm more disturbed at the idea that anybody would outright refuse to be a donor for other than religious reasons.

Refusing to be a donor for religious reasons is stupid, too.

But to answer the original question I've heard rumblings that, due to the nature of long lists of organ transplants, there won't be as much effort to save you if you're on the brink: bullshit.
posted by Optimus Chyme at 12:50 PM on September 13, 2005

Harvey Klawans, in one of his books about his long tenure as a neurology professor at Rush, describes a chilling case.

A man was brought into the Rush ICU after a brainstem stroke, presumed brain-dead due to his complete lack of responsiveness on the neuro exam. The cardiac surgeons were in the ICU, in the room, discussing removing the patient's heart and transplanting it into the guy in the next bed. This was apparently during the very beginnings of cardiac transplant surgery and they were eager to do the case.

Klawans examined the guy and noticed his frantic up-and-down eye movements. He was awake, conscious, able to hear the entire conversation, and frightened to death. Klawans diagnosed the "locked-in" syndrome from his pontine hemorrhage; he eventually got better and he was able to recount his terror on hearing the surgeons' plan to remove his still-beating heart.

This kind of story is the exception, not the rule, but it's a bit strong to call it an 'obscene slander.' Modern organ procurement agencies, however, go to great lengths to ensure the timely and accurate diagnosis of brain death before organ transplantation; and every neurologist involved in such work is aware that they are the ultimate safeguard to prevent such inappropriate organ harvesting.

As for me, I'm with Evel Knievel - I intend to keep my remaining remains to myself.
posted by ikkyu2 at 1:01 PM on September 13, 2005

I intend to keep my remaining remains to myself.

That is, unfortunately, impossible. By the time they qualify as your remains, there is no yourself to keep them to.
posted by kindall at 1:19 PM on September 13, 2005

I'm sorry ikkyu2, but sharing that story was bordering on irresponsible. Not only is that an exception to the rule if indeed it ever happened (you know full well how neurologists are enamoured with passing along anectdotes about locked-in syndrome), it had to have happened long before the current organ donor system was in place.

As others have suggested, in the vast vast majority of cases, medical interventions are entertained and performed on people for whom these interventions are essentially futile at the end of life (this is regardless of their organ donor status). The system as it is currently designed generally involves going through the transplantation network, and performing a near tedious series of investigations to ensure that the patient is in fact a good candidate for organ donation, before the transplant surgeons are even brought into the picture. The risk of bumbling such a decision is universally recognized, and while those involved in the process are unlikely to profit from it directly, they are certainly aware of the medical-legal risks of approaching such a situation carelessly.

Let me say this explicitly: it is a major breech of ethics if the physicians caring for a potential donor are also caring for a potential organ recipient. That's precisely why not only do we now have intermediaries in the process of organ procurement, but also algorithms relating to the definition of brain death. To misdiagnose someone as brain dead, when they exhibit spontaneous eye movements, are blinking, and have reactive pupils (as in locked-in syndrome, correct me if I'm wrong ikkyu2) would be massive malpractice.
posted by drpynchon at 2:08 PM on September 13, 2005

I wasn't going to say anything about ikkyu2's story, but drpynchon guilted me into it -- not only is that locked-in story irrelevant to today's discussions about organ donation for a whole slew of reasons, but it doesn't even stand up to today's method of determining whether a patient is brain dead. Brain death exams are very exacting, and a locked-in patient would never, ever be confused for a brain-dead patient, because the exam would pick up that the locked-in patient isn't brain dead.
posted by delfuego at 2:11 PM on September 13, 2005

This country is so suit-happy that there is a greater likelihood that your organs would go to waste becuse they tried so hard to save you, even after it was a lost cause. The medical profession has a lot of flaws, but this isn't one of them. Be a donor. Get the sticker on your license.

Every time you worry about it, think about the tragedy of someone dying because they need a kidney. 17 people die each day waiting for transplants that can’t take place because of the shortage of donated organs.
posted by theora55 at 2:47 PM on September 13, 2005

What I want to know: Is a police officer less likely to give you a ticket if you have the OD sticker on your license?
posted by trevyn at 2:51 PM on September 13, 2005

You've got to be kidding, ikkyu2.

There are so many people on organ donation waiting lists that die while on the list--please, please donate your organs.
posted by gramcracker at 4:44 PM on September 13, 2005

What I want to know: Is a police officer less likely to give you a ticket if you have the OD sticker on your license?
posted by trevyn at 2:51 PM PST on September 13 [!]

Or perhaps more likely; if you have such callous disregard for keeping your body intact after death, you might not have much regard for keeping it intact before death, and you might be a more risky driver.

Truth be told, I was wondering the same thing...
posted by Rothko at 4:48 PM on September 13, 2005

I'm legally single and twice 21, my closest relative is my sister who's busy raising a 9 year old and helping take care of our mother in a nursing home and so won't be able to take care of me if I can't, so I don't foresee anybody raising a stink about my donor sticker. What I want to know is, will the combination of a donor sticker and a Living Will pretty much guarantee they'll let me go gentle like I'd clearly want, or should I tattoo "DO NOT REVIVE" across my chest too?
posted by davy at 7:12 PM on September 13, 2005

Note, also, that once EMTs and paramedics start a treatment, they cannot stop treatment -- only an MD can make that call.

Most EMT/EMS systems in North America are based on "Scoop and Run" -- get the victim on a bed, get his ass to the doc. First rule of trauma: Treat with diesel. The docs in the trauma center need to have you as fast as possible to save you -- the "Golden Hour," so EMTs want to get you on the bus, then off the bus, as fast as possible -- the "Platinum Ten Minutes."

So, once the decision has been made to start treatment, the EMT's aren't going to stop, since another rule is "Nobody dies in the unit (Ambulance.)"

People die on the scene, or they die in the emergency room, but they're never dead in the back of the van.

Hell, the EMT's aren't even going to look at your wallet. That's one reason why if you need it, you better be wearing that bracelet that mentions things like "I die fast if..."
posted by eriko at 7:16 PM on September 13, 2005

I'm sorry ikkyu2, but sharing that story was bordering on irresponsible.

I suggest that you are mistaken. Those stories are out there. They are true stories - as a neurologist I've seen worse myself with my own eyes. If you try to suppress stories like this, the questions they engender, and the open discussion of the issues, the result will be that people are not going to trust you or your organ donor program, and they are not going to want to donate their organs or those of their loved ones.

Incidentally, my reasons for not wanting to donate my own organs are personal and have nothing to do with this issue. Gramcracker and others would do well to recall that organ donation is a choice a person can make, and must not be coerced.

Also, locked-in patients have reactive pupils, spontaneous upgaze and, sometimes, downgaze, but they can't blink and they sometimes have no ability to produce lateral eye movements. This and other neurologic diagnoses are easy to miss on the clinical exam, especially if patients like this fall asleep, and that's one of the reasons why current brain death standards adhere to those recommended by the 1977 President's Commission on Brain Death. Electrocerebral silence during a prolonged EEG recording, or, more commonly, zero cerebral perfusion on a single-photon-emission cerebral tomography study are part of the confirmatory test.

People interested in these questions should understand that we now have reliable, tested technologies that can determine the diagnosis of brain death; which do not involve a fussy little man standing over the bedside trying to invoke the absence of spontaneous upgaze, oculocephalic response, corneal reflexes, cold-water calorics, gag reflex, cough reflex, and the apnea test.

And you meant 'breach,' not 'breech.' I think. Unless you meant to say that the affair was the ass of medical ethics, which would also be true.
posted by ikkyu2 at 7:32 PM on September 13, 2005

The story was in Toscanini's Fumble, by the way, if I recall correctly. Klawans is a good writer and I've never understood why he never got the kind of press Oliver Sacks did. Maybe there can be only one.
posted by ikkyu2 at 7:35 PM on September 13, 2005

I suggest that you are mistaken. Those stories are out there. They are true stories - as a neurologist I've seen worse myself with my own eyes. If you try to suppress stories like this, the questions they engender, and the open discussion of the issues, the result will be that people are not going to trust you or your organ donor program, and they are not going to want to donate their organs or those of their loved ones.

I see. Your recommendation for counseling patients on organ donation involves starting off with a one in a million horror story that does not in any way reflect the reality of modern day organ donation. Ok then...

In your own clinical experience have you ever seen anyone receive less medical care or rescuscitative measures based on the fact that they were a known organ donor?

And also, I'm still under the impression that the classical teaching is that blink is usually preserved with locked in syndrome, but that's off topic.
posted by drpynchon at 9:22 PM on September 13, 2005

In your own clinical experience have you ever seen anyone receive less medical care or rescuscitative measures based on the fact that they were a known organ donor?

No, certainly not. Getting back to the original poster's question, I feel pretty confident that this would never happen. Doctors love the organ's original owner as much as we do its prospective recipient.

I personally would hate to be the living being standing between a transplant's surgeon ego and Glorious Renown, though.

The corneal reflex can be preserved in locked-in syndrome, particularly the pontine variety, but it isn't always. (The relevant synapse: tracts from the sensory nucleus of V terminating on the facial nucleus, is right there at the level of the lesion.) It is preserved in thalamic locked-in syndrome, but who cares about the thalamus?!

Voluntary blinking, however, is usually disrupted owing to dysfunction of the same cortico-spinal and cortico-bulbar tracts that are responsible for all the other disruptions. At some point you have to step back and consider what your definition of locked-in syndrome is; I don't consider it locked-in when lateral eye movements are present, for example.
posted by ikkyu2 at 11:07 PM on September 13, 2005

I personally would hate to be the living being standing between a transplant's surgeon ego and Glorious Renown, though.

The man, he speaks the truth...
posted by kalimac at 3:42 PM on September 14, 2005