Hello and welcome to the gifted life podcast where we have conversations about organ tissue and eye donation and transplantation. You can always find us guys at thegiftedlife.org. Tell your friends. I'm Laurie Steele.
I'm Joey Boudreau. And I'm Nala Schwab. Here's what we'll be hearing about today. Yeah, of course we'll be continuing that conversation with Dr.
Angie Wall by the biggest change in donation in decades in RP. This time we'll be talking about a little bit of the legal and ethical considerations surrounding it. And also people trained to save lives aren't necessarily trained to support grieving families. So we're going to talk a little bit about how we can do that.
Yeah, lots of discuss here on the Get to Life podcast. Stay tuned. And here on the Get to Life podcast, as Joey said, we're continuing that conversation learning from the brilliant Dr. Wall.
Yes, we are. And of course, last episode we talked a little bit about the more nuances and the details of the process itself of NRP. This time we'll be talking a little bit of the legal and ethical considerations around that. So let's give it a listen.
Welcome in everyone, our guests for part two of our normal thermotemic regional perfusion NRP podcast for the gifted life. Dr. Angie Wall, she's been gracious enough to give us time to talk about in our last episode DCD, the donation pathways that they're out there and then the biggest change, what we believe in donation over the last, I don't know, 20 plus years is NRP, normal thermotemic regional perfusion. And we're lucky enough to have one of the premier experts on multiple subjects on this matter.
Dr. Angie Wall, she is a bioethicist and she is also an abdominal transplant surgeon at Baylor Simmons Transplant Institute in Dallas. Welcome back, Doc. Thank you so much.
Well, we are so lucky to have you. And I know if anyone has it, listen to our last episode, please go back and listen to that one. It was a fantastic episode just explaining donation in general, but really how NRP has completely changed the game in donation. And Dr.
Wall, I consider one of the pioneers in this in the NRP portion. And the fact that you have the bioethical background in addition to the transplant surgeon background makes you, I know, Kirsten mentioned in the last one, makes you a unicorn in the field. So we talked a lot about the process and everything, but there are other considerations. You can't just make a big change in donation without looking at it from every angle possible, which is where you come in.
So can you tell us a little bit about what considerations that you guys had in place and then how you guys started moving forward with it? Absolutely. So I actually was introduced to NRP by a colleague who asked me about the ethical consideration. So I didn't start NRP from a clinical standpoint.
I actually started looking into it from an ethical framework lens. And so to begin with the NRP process as discussed in a prior episode, it follows the same process as standard DCD organ donation up until the point of the decision of what to use for perfusion. So the questions that have been raised about NRP have to do with what defines death, what defines life and what potential harms can occur during the NRP procedure. So we'll start with what defines death.
So in DCD donation, the way that death is defined is by cardiopulmonary criteria, meaning the individual's heart stops beating and they stop breathing. It's usually in the opposite order. They usually stop breathing. And then because there's no oxygen going anywhere, the heart stops.
But then we wait for an observation period, which is usually five minutes, and confirm that yes, indeed, this individual has stopped breathing and their heart has stopped beating. That by definition meets the criteria for death by cardiopulmonary criteria, meaning heart and lung criteria. That is both a legal definition and a medical standard of death. So some individuals have asked, is that person really dead at the time that you start procurement?
I think that the general consensus is that yes, we are comfortable saying that an individual is dead and will remain dead in a DCD procurement if we pronounce death based on cardiopulmonary criteria and have a five minute observation period where we make sure that auto resuscitation does not occur. So some of the questions about NRP have been, is this individual truly dead? And because of the fact that it follows the exact same process as standard DCD donation, there is a general agreement that yes, this individual is dead. Now the second question that arises is, do they remain dead?
Does NRP do something to the person or to the organs that reverses the concept of death, that reverses that pronouncement? And this is particularly geared toward what's called the racco abdominal NRP because in the racco abdominal NRP, after the pronouncement of death and the start of the organ procurement, what happens is that when oxygenated blood is started back to the organs for transplantation, the heart restarts. And when the heart restarts the question as well, is this person now alive because their heart is beating again? Notably, we can also have the heart restart on a machine outside of the body with DCD donation.
And there have not been the same ethical concerns about the heart restarting outside of the body versus inside of the body. While it probably looks, it does look different as to where the heart restarts. I think that from an ethical standpoint, there's no difference. We know that the heart can and does restart when we provide oxygen to it, even after an individual has been pronounced dead by cardiopulmonary criteria.
And what we need to recognize is that the cardiopulmonary criteria of death is a reflection of the fact that that individual, their body is no longer functioning in a coordinated manner toward keeping their person alive. Each individual organ can be to some extent resuscitated, but the entire person is no longer functioning in a coordinated manner. And so whether or not the heart restarts is the same question of whether you can restart deliver or whether you can restart the kidneys. Any organ can be refused and can be used, but that coordinated effort toward keeping the individual, having the individual be alive as a person is not present and will not occur again.
So whether the heart is restarted in the body or outside of the body, I think, is one of the questions that has been a real challenge for some individuals who believe that if the heart restarts in the body that this person is now alive. I would argue that it is just another one of the organs and when you get when you give oxygen to blood to the heart, then it's going to restart whether it's inside the body or outside of the body. The third objection or ethical concern about NRP is even if we all agree that this individual is dead at the time of procurement and that they remain dead even when we refuse the individual organs for transplantation, is there any risk of harm? And the particular harm that we worry about is, is there any way that oxygenated blood that we're running to the organs for transplantation may get to the brain, may repurfuse the brain in a way that leads to an experience of donation, meaning is there any possibility of consciousness or awareness that organ donation is happening.
So we have some studies on a porcine model of DCD or pig model of DCD that shows that when we clamp the blood vessels that come off of what's called the aortic arch or the main blood vessels that go up to the brain in a DCD model in pigs, there is no resumption of any electrical activity in the brain. There's a study out of NYU that has looked at Doppler flow in NRP donors, which means blood flow using ultrasound, and that has shown in a small series that there is no blood flow to the brain. And there is some upcoming data out of the Spanish team that has looked at invasive flow monitoring that they will hopefully be reporting soon about their findings in terms of brain blood flow. But the bottom line is that all the data that we have gathered to date indicate that there is not flow to the brain during the NRP procedures.
To add to all of those pieces that there's no more flow going to the brain, when you think about it, and I've obviously had a lot of conversations with our staff and with public and with people who have questions about NRP in general, for years when you recovered organs for DCD, after the time of the five minute observation, your first thing that you would do was access the aorta, access the vessels, and then cannulate, put a cannulate in, clamp above the cannula, and then flush a cold perfusion. That's it? That's the gist of it. This is the same thing.
You're using a different perfusion. Perceageally, it's not different. The only thing that we really don't do anything very much differently other than put a cannula in the intra-Vena cava, and we do that so that we complete the circuit so that we bring blood out of the vena cava and we put blood into the aorta. In a standard DCD, you just cut the vena cava and you allow the blood to drain.
You don't have to put a cannula in. So all in all, the process is very similar. It's established that by normal medical means, the patient has passed. Prior to that, and I know we talked about this in the last episode, but prior to that, the family has decided, and you talked about this, the family has decided independently of any donation discussion that their loved one did not want to live.
Either their loved one didn't want to live in a persistent vegetative state, or they decided at that point that they wanted to withdraw support. So the withdrawal is decided independently. Correct. And then the death is established by normal medical means, and in a five minute period takes place, and in the same procedure, except for a different type of perfusion.
So if I'm missing any of that, did I miss any part in that, I guess? No, not at all. But what I will add is that when I think about ethics, you think about the baseline, right? So you think about what are the things that would make this ethically unacceptable, and those are sort of the objections or the things that make something ethically unacceptable.
And then the question is, well, what would make this ethically obligatory, or ethically better than doing what we typically do, but then the standard process? And so the two comments I would have on that is, number one, the opportunity for organ donation is higher when NRP is used. Organ utilization rates are higher. We've seen studies from Spain that demonstrate that, and there's a recent study from Chris Kremen colleagues that showed that organ utilization was higher with NRP donors.
So the likelihood of organ donation goes up if you utilize NRP versus rapid recovery. And then the second thing is that recipient outcomes are better. And so if you have a process that is ethically acceptable, that has a higher rate of actually allowing for organ donation to occur, which is what the family wanted and what the potential donor wanted, and you have better recipient outcomes, then what I would argue is that this is not just like a thing that we can do, but it's potentially something that we should be doing for every donor. I couldn't agree more, Dr.
Wal. I work with a team that approaches families, and I can tell you that it means a lot to the families when they know we are trying everything to optimize their loved one's gifts. They want good outcomes. They want their loved one to be able to share the gift of life.
And so I couldn't agree more. I feel like it's, you know, I feel like the real ethical consideration is why aren't we all doing it? I fully agree. Well, once again, Dr.
Wal, I cannot thank you enough for sharing your time, your expertise, and your passion with us. Well, thank you so much for giving me the opportunity to talk with you guys about NRP. You're on the Get to Life podcast, guys, taking a moment for mental health. Yes.
And we always learn a bunch of great tips from Nyle. I'm always looking forward to this part of the episode. So what you got for a three Nyle? Oh, thanks, Joey.
I'm just wondering what's happening like that. Keep it coming. Keep it coming. Keep it coming.
I've put a really great article from a website called What's Your Grief? And it's called Supporting Grieving Families Tips for R-Ins and Others on the Frontline. And it just got me thinking about how when we go into hospitals, because someone knows how to save a life, doesn't necessarily know how to support someone who's grieving. And the OBO, our LOPA, I mean, we're provided a lot of training because that's what we do is support families.
But I think it's, you know, just in general populations, it's very difficult sometimes for some people to know what to do to support grieving families. So some really good tips. And one is just really kind of separating comfort versus support and comfort. You know, we're not always there to comfort a family because we don't make it better, but we can provide support.
And I think that that really kind of takes some pressure off to allow us to just be there to look at how we can better help this family in the situation. And you think about grief, some of the emotions that go with grief in the hospital needs to be just learning about the loss of their loved one, their shock, numbness, disorganization, disbelief, and such, and yarning denial, anxiety, panic, fear, explosive emotions. So all of that going on, that's a hard place to be when you're standing in front of them. And you also are very, very busy with the other jobs of caring for other patients.
So it's one thing is to just kind of slow down. You can always take time to go and refresh yourself. You can Google really quick something about like, how can I support a family? But it's looking for ways of what do they need at that time.
And I think about like, how do you think about what comes next? Because maybe that family's not thinking about what comes next. And that would mean, is there something I can call that I can call to support you? Is it your best friend here?
Is your person here? What about a funeral home? Have you ever experienced a loss to help them start thinking about what it is that they need? You really do have to go.
You have to look for your comfort with your conversations and knowing what your comfort is. But to be silent can be harmful. So expressing that you don't know what to say, but you're there for them. And what does that look like?
Do you need more time to be with your loved one? Would you like me to get to water? I mean, I always go back to Maslow's hierarchy, which is, you know, your safety first. Do you need water?
Do you need water? Do you need water? Do you need water? Do you need water?
Do you need water? Do you need water? Do you need water? Do you need water?
What do you need? And then another one is just, do they need a chat lens? Do they need a social worker? Just asking them, do you know what you need?
And a lot of times they're going to, you know, families don't because their minds whirling. Did you see something floating and it was talking about grief groceries? This is when something happens. Everybody's like, if you need me, like I'm here, but you don't know what to ask for.
Like, I was like, this makes so much sense. And so they said, their friend that was states away, they just ordered groceries, like pre-made groceries, and they just had it delivered to their door. So they didn't have to see anybody interact, but it was like grief groceries. Like that's what I do for others now.
Like that's how I support. And I thought, oh, that's pretty cool. That's a great idea. It is.
And so, you know, I think about that. And I've had a few, especially my wife's family, had a few people pass over the last year or two. And I think about, of course, training that we get and a lot of it is, you talked about Maslow's hierarchy and needs. People, so I would focus on that, honestly, because people, they don't tend to those things.
Those are the first things that's funny that you stop doing. You're not drinking water. You're not eating. You're not sleeping.
You're not eating all of these things that you've got to do for safety and for yourself, just at its core, are kind of forgotten about. So I think that was my focus, and I think that's what I think about more often because I know that it's something that's forgotten. You know, I love that, Joey, because you're clinical. And so you're thinking from a clinical aspect, what your body needs, what you need.
And so, to be a frontline worker, to walk up to someone in a hospital room, and to say, hey, I brought you some water. You may not be thirsty right now, but you need your body needs it. And like, Lori, I love how you're bringing in what people in the community need. And so, we immediately, when we have a friend or someone we love that's lost someone wants to help.
And so, grub, yeah, people need groceries. Grub, my friend gives grub, what is it called? Grub Hub Cards? So they can just order food from when they're ready.
But these are all great things. And it's thinking, it's thinking, what do they need going to step beyond of just saying, how can I help? Yeah. When I was in my grief, a lot of people called the first three months, right?
And then it kind of tailed off, but I don't even know what to ask, or like, because you're just sitting there, but I wouldn't have thought of groceries, or I was trying to survive and exist. And another way is asking them what they like to share about their loved one, saying their name. And I tell you, the best teachers in life are the people who are going through it. And I tell you that there was, we had a family and we were about five years out from their loss and I said the son's name instead of the father's name.
And I said, oh, I'm so sorry. And he said, no, no, no. He said, I love hearing my sons. I hear that.
Say it as much as you want. He said, I love when somebody sees me and they, they call me my son's name. And he said, I see it all over them. They're like, I'm so sorry.
And he's like, mhmm. And so, we, we sometimes tend to want to project what we're thinking onto a family instead of just being honest, talking with that family in our comforts, I mean, within our comfort and just being there for them and letting someone know, you know what, I don't know what to say right now, but I'll be outside the door. And if you do think of something that you need, you ask. Otherwise, I'm going to come back in and I'm going to check on you again.
So just again, letting them know what's ahead of them. And that's, that's something really wonderful that you can always do. Doctor will be in about three hours. So these are tips for frontline workers.
Anything that you're doing that you can, you know, is coming in four hours, six hours, letting that family know because when you're in a state of just shock, knowing what's ahead is helpful. Those are just some things to think about. Like I said, it's, it's important to learn as much as you, well, I didn't say that, I'm going to say it now. I mean, I think anybody that is caring for grieving families, we need to learn more about grief.
We need to talk more about grief. We need to share more about grief because we're a country that it doesn't sometimes know what to do with grief. So, thanks for listening in. I like the tips.
You have something you'd like us to cover here on the gift to life. We ask that you email us. I always love to hear from you. Email us at info at thegiftedlife.org.
In our question and answer segment today, I'm an organ donor, but plan on doing a whole body donation. I see that they won't accept me if my major organs are removed other than the eyes. What should I do? So, we're glad that you asked that question and we do want to explore that a little bit, Joe.
Different programs have different criteria. So it's important that a couple of things, one, that you make sure that you, that you followed up with, with them or if you want to donate both to make sure that you can donate organs as well as getting, donating your body to science. You can look at other options, there are different research and education options out there as far as donating your body to science. So you have to explore different options, different programs to see which ones fit you need the most.
Now, it is important also to let your family know as we say, an organ donation in general. Make sure your family knows what you wishes are. And if saving a life through donation and transplantation is the priority, then of course, we will adhere to that request as well. Keep in mind, we don't just recover organs for transplantation.
We do also recover organs for research as well. Organs and tissues, not only the lives that are saved through the transplantation, many other lives, thousands and thousands of other lives are changed through some of our research opportunities and research programs through LOPA as well. So, long story short, make sure your family knows what your wishes are. Make sure you've explored all of the programs out there so that there may be one out there that fits all your needs.
And then make sure you're keeping up with their changes because they do change as time goes on what they'll allow us to carry and what they don't. Good answer, Joey, thank you. And if you have a question, give us a call. 504-648-34-7777.
In every episode of the Gifted Life we honor a hero. Today's hero is Natasha Marie Krause. And we learn about Natasha from her family. My sister was overwhelming in her sincerity and generosity.
We love and miss her, but cherish that she was able to bring comfort to others. Rest easy, baby girl. And now we pause and say thank you to Natasha for the gift of life. And that is going to do it for episode 219 of the Gifted Life just wow, right?
Amazing. We want to thank you for listening and learning with us today. And remember, this is a reminder we like to put out there you can register as an organ and tissue donor anytime, register me.org. We learned a lot today.
We did. And we hope you guys learned a lot as well. We certainly appreciate Dr. Wall coming on and providing two episodes.
This is such an important topic. Really we can keep talking about it. Right. And it will probably have her own again in the future because this is groundbreaking territory for donations.
So special thanks for her to come on. I like it. The best place to find us guys and we really hope that you share our podcast, especially the topics that we've been covering so we can learn as we go. You can find us on our website thegiftedlife.org.
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You can also follow us on both Twitter and Instagram at GiftedLifePod. Our ask is that you go out and do something you would normally do to help us make life happen. Thanks for listening. This is a production of the Louisiana Organ Procurement Agency or LOPA.
The Gifted Life is hosted by Lori Steele, Joey Buetro and Nala Schwab. Our executive producer is Kirsten Heinz. Producer is Shalom Caraway and we are recorded, engineered and mixed, and are coming to Louisiana Studio by Troy Perez.