New guidelines help increase organ donation among troops declared brain dead
By SETH ROBBINS | STARS AND STRIPES Published: December 5, 2010
LANDSTUHL, Germany — Michele Barnett gripped her son’s hand and placed her head against his chest. Keeping him alive were a series of machines that pushed air into his lungs, fed him fluids and kept his heart beating.
A critical care nurse, Barnett knew her son’s prognosis when she first saw the machines: His brain was dead. Jeremy Barnett, a 27-year-old Army sergeant, had been on patrol in Ad Dujayl, Iraq, when a land mine detonated.
Michele Barnett had not left Jeremy’s bedside since arriving at Landstuhl Regional Medical Center, even taking it upon herself to bathe him. But after 15 hours, doctors were preparing in a nearby operating room to harvest her son’s organs, including his heart.
Placing her head against his breast, she listened — one last time — to its thump.
“I didn’t know if I could ever find that person who received his heart,” she said. “And there was a thought that maybe I could hear it beat again.”
Jeremy Barnett died on Feb. 24, 2007, but his heart saved the life of a 51-year-old woman living in Europe. Michele Barnett would never know the woman’s name or the country she lived in.
“It’s a very hard thing to lose your child like this. I still think about him every day,” she said. “But it’s a comfort to know that part of him is still alive, and what better part than his heart?”
Critical in saving the lives of troops in Iraq and Afghanistan, quick battlefield care and air evacuation have also allowed servicemembers whose brains have irreversibly stopped functioning but whose hearts and lungs are sustained artificially to be flown to Landstuhl, where their relatives can say goodbye and organs can be donated to those in need.
Guidelines issued in March by the military’s Joint Theater Trauma System, which provides medical research and guidance for battlefield care, require that all brain-dead patients, when possible, be flown to Landstuhl or stateside hospitals. The military had been flying brain-dead patients from combat zones before the guidelines, but the decision to declare brain death and remove life support downrange was done on a case-by-case basis.
Now, the guidelines keep downrange doctors from having to make the difficult decision of whether to remove life support, and that means more potential organ donors.
The recent wars have made Landstuhl one of the more active donor hospitals in Germany, said Dr. Thomas Breidenbach, the former director of Deutsche Stiftung Organtransplantation’s central region, which oversees transplants in the Landstuhl area. In the past five years, 36 U.S. servicemembers have donated 141 organs to gravely ill patients. Because organs deteriorate quickly and cannot last a transatlantic flight, troops’ organs harvested at Landstuhl are always transplanted in Europe, most often to German patients.
“Each life we can save is important. It doesn’t matter which country they are from,” Breidenbach said. “And we are very grateful that the Americans see it this way.”
What is brain death?
Brain death presents one of the most challenging clinical and ethical dilemmas.
Unlike when a patient is in a persistent vegetative state or a coma, brain death means the brain has completely shut down; all signals from it to the body have stopped, and a person can only live with the aid of a ventilator.
Doctors diagnose brain death through a checklist of about a dozen factors. They assess reflexes, such as blinking, pupil dilation, coughing and breathing, all of which are controlled by the brain stem. Physicians also examine brain wave activity. Or they inject radioactive dye into the patient’s bloodstream and determine whether blood has stopped flowing to the brain — incontrovertible evidence of brain death.
Air Force Dr. (Col.) Warren Dorlac, who helped to develop the new guidelines, said these are “very complex patients.”
“All of them are trying to die on you,” he said, “and keeping them alive can be a very difficult thing to do.”
The guidelines make clear that except in rare circumstances, such as a mass-casualty situation, brain death should not be declared downrange, where doctors don’t always have access to the most advanced imaging technologies.
It is hard to discern who will survive a catastrophic head injury, Dorlac said.
“So we go with a full-court press, do everything we can, and then let it get sorted out down the road,” he said. “We don’t treat anybody as if they are going to die. We assume everybody has the potential to live.”
The guidelines also give family members the opportunity to see their son, daughter, wife or husband one last time before doctors remove life support, an opportunity many say they found difficult but cathartic.
David Barnett, Jeremy’s father, said he knew before arriving at Landstuhl that his son was “gone” and that there was no longer any brain activity. But as he watched his son breathe with the help of a ventilator, the father had to remind himself that his son was dead.
“I had to keep telling myself he is not there,” he said.
An organ shortage
The new guidelines are a potential boon to people waiting for transplants in Germany. Germans donate organs at one of the lowest rates of any nation in the Eurotransplant International Foundation, which includes Austria, Belgium, Croatia, Luxembourg, the Netherlands and Slovenia.
The neighboring Belgians and Austrians donate at rates nearly twice that of the Germans. Only about 17 percent of Germans are registered as organ donors, while nearly 12,000 Germans await organs, according to the foundation. About 37 percent of Americans were registered as organ donors in 2009, primarily through driver’s licenses, and more than 109,000 need transplants.
“We are very short (of organs),” said Breidenbach, “much shorter than in the U.S.”
Dr. Roland Hetzer, director of the German Heart Institute in Berlin, said one of the reasons Germany has a much lower donor rate than its neighbors is that many European countries, including Spain and Austria, have passed laws that make everyone an organ donor unless they opt out. In Germany, like the U.S., people must declare themselves to be organ donors. Yet to do so requires actively registering — the option to donate is not extended when someone applies for a driver’s license, for example, something Hetzer would like to see adopted in Germany.
“We do a lot to convince people, but it’s not so easy,” he said, “because people say it’s against the constitution to even ask.”
Despite national advertising campaigns about the importance of organ donation, false information still persists in Germany, Hetzer said, including myths that doctors will let donors die in order to harvest their organs or that organs will be sold on the black market.
“The attitude toward organ donation is not very mature,” Hetzer said.
One of the hospitals where organ donations have increased is Landstuhl. From January to November, 44 organs were harvested from U.S. servicemembers — the most of any year according to records going back to 2005. In 2009, 17 organs were harvested at the hospital. One of the donors that year was 31-year-old Staff Sgt. Dennis J. Hansen of the 10th Mountain Division.
On his ninth tour, his second to Afghanistan, Hansen was clearing the upper floor of a building in Logar province when a bomb exploded. Buried beneath the rubble, Hansen could not breathe and eventually his brain, deprived of oxygen, died.
His tour would have ended in 14 days. Killed two months shy of his 32nd birthday, Hansen had planned on becoming a drill instructor, most likely ending his combat career.
Bonnie and Dwight Hansen never wavered when it came to the decision to donate their son’s organs, a decision he had expressed to his wife and on his driver’s license. It made no difference to them that his organs would stay in Europe, Bonnie Hansen said.
“Because my background is German-Irish,” she said, “I feel part of him went home.”
Just before noon Dec. 5, 2009, Hansen was wheeled into an operating room at Landstuhl. Even the hospital staff wept, Hansen’s mother said.
“It was a very emotional experience,” she said. “But never once did I regret the decision.”
Guiding the decision
To help families through the hard but lifesaving decision, several staff members at Landstuhl attended a seminar on how to discuss donation with them.
“They react to you,” said Chris Wolf, the psychologist who led the seminar. “They may want to say yes, and one should not prevent it by being ambivalent about the question or treating it as a formality.”
At Landstuhl, more than 85 percent of family members presented with the option of donating a relative’s organs chose to do so, said Kathleen Martin, trauma nurse director. Part of the reason for the high rate, she said, is that all servicemembers are asked to make a choice about organ donation in living wills.
Though refusals are rare, Martin said, they happen for various reasons, including religious beliefs and fears of having a loved one undergo the surgery required to remove organs. But most often, she said, it’s because family members have trouble understanding brain death.
“They feel a warm hand, because the blood is still flowing,” she said. “The face may not be deformed. The heartbeat is still going and the ventilator is huffing and puffing. The fact that they are dead can be hard for them to grasp.”
A Marine’s heart still beats
German law mandates that transplant recipients never discover the names of their donors, nor do family members learn who received the organs, though families do receive a letter listing the age and sex of recipients and some information about their health.
Kristen Forse, whose brother, Marine reservist Sgt. David Smith, was mortally wounded in a suicide attack in Afghanistan’s Helmand province on Jan. 23, stifled tears as she read her letter.
“David’s lungs saved the life of a 58-year-old man,” she said. “He can now breathe easily and is very grateful for it.”
Smith’s right and left kidneys went to two people in their 50s, a woman on dialysis and a man suffering from diabetes. Smith’s liver was divided: a 66-year-old woman received part; the other was given to a 4-year-old boy.
For Forse, the most meaningful gift was her brother’s heart. Smith was 25 when he died; his heart was given to a man only a year older than he was. The young man had been waiting since May 2008, almost a year, for a transplant.
Forse, who named her youngest daughter Sempre in honor of her brother, is content to know that his heart still beats.
“I just hope that the person who received David’s heart knows how special of a heart he got,” she said. “There is not a better heart, or a stronger heart or a bigger heart.”