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Doctors try a controversial technique to reduce the transplant organ shortage
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It’s late on a Friday afternoon at the Nashville International Airport when Dr. Marty Sellers hops out of a van and strides towards a small private jet idling on the runway.
Sellers and his organ retrieval team from Tennessee Donor Services are flying to Chattanooga to try to recover a liver and two kidneys from an organ donor.
"We’re doing an NRP recovery," says Sellers, referring to normothermic regional perfusion, a new kind of organ retrieval procedure Sellers calls "revolutionary."
"It replenishes the oxygen deprivation that the organs incur during the dying process," says Sellers. "If we recover the organ and put it on ice in an oxygen-deprived state, it’s not as healthy when it gets into the recipient. And this way, it’s actually recovered in a healthier state so that when it does get to the recipient it’s more likely to work."
NRP is generating excitement as an important innovation that produces more, high-quality livers, kidneys, and hearts that could help alleviate the chronic shortage of organs. More than 100,000 people are on waiting lists for organs, most for kidneys, and 17 are estimated to die every day because the number of available organs hasn’t been able to keep pace with the demand.
About half of the nation’s 56 organ procurement organizations have already started using NRP and more are planning to start soon, according to the Association of Organ Procurement Organizations.
But NRP has sparked an intense ethical debate. The American Journal of Bioethics dedicated a recent issue to the controversy over whether the technique blurs the definition of death. "I think the procedure raises very major ethical and legal issues," says Alexander Capron, a bioethicist and lawyer at the University of Southern California. "I find it disturbing."
But Sellers and others defend the approach. "It's a very powerful strategy for reducing the organ shortage and helping to improve outcomes," says Brendan Parent, a bioethicist at the NYU Grossman School of Medicine.
Sellers and his team recently agreed to let an NPR reporter and photographers shadow them while they attempted NRP organ recoveries. This is believed to be the first time a journalist has done that in the U.S., according to the AOPO.
"Hope you know how special this is," says Jill Grandas, Tennessee Donor Services’ executive director. "Because of NRP, we're able to save more lives. It's a game changer."
After death, a pump restores circulation
There are two ways someone can be declared dead and become an organ donor. One is when someone is brain dead because they’ve suffered some kind of total, irreversible brain injury, such as from a stroke or motorcycle accident. The second is when someone is declared dead because their heartbeat and circulation have ceased permanently, such as when a family decides to withdraw life support.
That’s where NRP comes in. After a patient has been declared dead because their heart and circulation have stopped, a surgeon quickly attaches a special external pump to their heart or elsewhere in the body. That restores blood flow and sometimes the heartbeat to keep organs supplied with oxygen-rich blood.
"So when we put them on ice to be transported to the recipient center, the organs are in a healthier state and therefore when they get into the recipient they perform better immediately and long term," Sellers says.
"It not only increases the number of organs available for transplant, but it also improves outcomes for those organ recipients," says Dr. Colleen McCarthy, who heads the AOPO.
But critics say restarting circulation reverses the very condition upon which the person has just been declared dead.
"The bottom line is that NRP violates foundational ethical norms around the determination of death and should not be pursued," says Dr. Matthew DeCamp, a bioethicist at the University of Colorado who helped write a policy statement opposing NRP for the American College of Physicians, the nation's second largest doctor group.
The surgeon also clamps off blood flow to the brain to prevent resumption of brain activity. But that step raises questions too, including whether some blood might still be getting through to restore some neurons.
"The worry is if there were some brain blood flow that certain parts of the brain could potentially continue functioning and then the person wouldn't be dead," says Dr. James Bernat, a professor emeritus of neurology at Dartmouth Geisel School of Medicine. "I don't think it would be conceivable that they would be awake. But from a point of view of 'Is the donor dead or not?' it would require zero blood flow to the brain to prove that."
Sellers and others dismiss those concerns as overstating the risks and understating the benefits of NRP.
"It’s irrefutable that we are not causing any increased deaths with NRP. And we are saving more lives with NRP," Sellers says. "And if you can argue with that, I don’t have much to say to you. I don’t want to oversimplify it, but it’s life or death. And while people are discussing the pros and cons of it, people are dying."
An urgent trip foiled by delays
When Sellers and his team arrive at the Erlanger Baroness Hospital in Chattanooga, there’s a snag. The operating rooms are full with emergency cases. Organ retrievals are a lower priority.
The organ retrieval scheduled for 7 p.m. has been delayed by at least four hours. It’s already been a very long week for Sellers. This would be his seventh NRP attempt in five days.
The team retreats to a nearby office to wait and orders a takeout dinner. Finally, several hours later, it looks like one of the operating rooms will open up. So the team heads back to the hospital to change into scrubs and camp out in a surgeons lounge, where a panel of video screens on the wall show what's happening in each operating room.
Once an OR becomes available, the team heads there to get ready for the organ retrieval procedure.
Meanwhile, hospital staff silently line the hallway for an “honor walk.” The donor is slowly wheeled past them on the way to a room adjacent to the OR where doctors will remove her breathing tube. Her family quietly walks behind her bed.
The donor is Karen "Susie" Phillips, 66, a great-grandmother from Murphy, N.C., who suffered a head injury in a car accident a week and half ago. Her family decided to withdraw life support after doctors concluded there was no chance she would regain consciousness. They also wanted to honor her decision years ago to donate her organs in case of death.
"This means a lot to this family. They are very supportive of this patient’s wishes to be a donor," Karen Howell, a coordinator with Tennessee Donor Services, tells the team in the operating room. "We will keep you informed with what’s happening over there, should she pass within the time frame to allow her to share her life with others, which will be 90 minutes."
It’s a tense wait for the team. If the donor doesn’t stop breathing on her own within 90 minutes, her organs won’t be usable. If her breathing ceases in time, everyone will wait another five minutes just to be sure.
"The two nurses will say: 'She has passed,' " Howell says. "We’ll utilize the five minutes of observation time to roll in here. The nurses will make sure at that five-minute mark that there’s been no autoresuscitation. And then will move forward with the recovery."
Autoresuscitation is when a patient spontaneously starts breathing again on their own, which would also cancel the procedure.
Another member of the transplant team, Preston Lambert, reads what’s called an “I want you to know” message from the family.
"Susie was a very spirited, spitfire lady that always spoke her mind no matter what. A lady that loved her children, grandchildren and great grandson with all her heart. A lady that lived her life the way she wanted without caring what anyone else thought," Lambert reads. "Her granddaughter Eleanor loves her very much."
Next, Sellers briefs everyone on the plan.
"When we restore blood flow to the liver and the kidneys, the heartbeat will resume. Doesn’t mean that the heart is coming back alive. It just means that what we have done is actually working. So it doesn’t mean that you guys were wrong when you made your declaration," Sellers says. "But I don’t want anybody to be alarmed when you see the heartbeat resume."
It’s well past midnight when the team gets word that the donor’s breathing tube has been removed, starting the 90-minute clock ticking.
"The patient has officially been extubated at midnight-40," Lambert announces. He then begins regular updates detailing her vital signs.
"First set of vitals at time of extubation,” he says. “Heart rate: 115. Blood pressure: 150 over 65. [Mean arterial pressure]: 93. Respirations: 29. Saturating at 96%."
Everything seems to be going as expected.
"Blood pressure is steadily going down. It’s noticeably lower than it was when we started," Sellers tells me. "Death will be when it’s zero. Yeah. And if it’s going to get to zero the sooner the better. Because that’s less total amount of time the organs are deprived of oxygen."
The team mills around, checking equipment, chatting.
"Thirty-minute mark: Heart rate 106. Blood pressure 84 over 40. MAP: 33. Saturating at 76%," Lambert says.
But then, the donor's vitals start to plateau. The mood gets tense. Another hour goes by. The donor is still breathing on her own.
The 90-minute mark quietly passes. The organ retrieval is canceled. The patient is wheeled back into her hospital room.
"She had enough cardiac function to be able to withstand the withdrawal of the life support," Sellers explains. "So she was able to breathe some on her own and blood pressure was good enough for long enough to where we exhausted the time limit that she could be a donor."
This happens about a third of the time, Sellers says.
"For us, it’s disappointing,” he says. “But for the donor family, and particularly the recipients who were expecting to get a life-saving organ, it’s more devastating."
Beth McDonald, the donor's daughter, said that the experience was an emotional roller coaster for the whole family.
"It was a pretty big disappointment. It was very heartbreaking," McDonald, 44, of Murphy, N.C., said afterward. "I don't want it to appear that I was disappointed that my mom didn't pass away. I just wanted her journey to be peaceful. And to be able to carry on her legacy through that wonderful gift that she wanted to give. I kind of felt like her legacy just went with her, and she didn't get to leave a piece of herself behind in such a special gift for someone else."
McDonald's mother did eventually die, but she lived another week.
"I felt like she was hanging in limbo," McDonald says.
This case illustrates the many ways it’s so hard to get enough organs for transplantation, despite everyone’s best efforts. It also shows why some doctors like Sellers are trying everything they can to improve the odds.
"We don’t do anything until the donor has been declared dead by all acceptable medical and legal standards,” Sellers says. “We certainly would not be doing anything if we thought it was unethical. NRP does not cause any additional death. And not doing NRP causes many, many unnecessary and avoidable deaths. We are saving lives. NRP can eliminate deaths on the waiting list. That would have been science fiction just a few years ago."
The transplant team tries again
Less than a week later, NPR is invited back to shadow Sellers and his team as they try again.
Sellers is walking a nurse through his checklist of surgical tools in an operating room in another hospital, this time in eastern Tennessee. The hospital did not want to be named to protect the donor’s identity.
"So as I’m cranking open the sternal retractor, you get ready to hand me the curved mayos," Sellers tells the nurse.
Sellers and his organ recovery team flew in from Nashville this morning to try again to retrieve a liver and two kidneys from another donor.
"As I’m cranking it open, I should tell you,” Sellers says. “But in the chaos of it, I might not be very verbal."
He soon discovers that this hospital doesn’t have the saw he needs to open the donor’s chest. So everything’s suddenly on hold. It’s nerve-wracking.
"The family’s on hold. And it’s obviously an emotional time for them,” Sellers says. “The recipients are on hold. They were expecting to take the liver recipient to the OR at a certain time today, and now it’s going to be significantly later."
Finally, about a half-hour later the right saw arrives. The donor’s bed is wheeled from intensive care to a room near the operating room. That’s where her life support will be withdrawn and the family can say goodbye.
This donor is in her early 40s. She suffered a stroke three days ago.
"The family has the desire for her to be an organ donor, and really couldn’t think of a better way to end the chapter in her life than to extend her legacy and save the lives of others," says Randall Statzer, an organ recovery coordinator with the Tennessee Donor Services. He tells the team assembled in the operating room: "So to honor her gift of life and her family’s decision to share her gift of life through donation, can we take a moment of silence please. Thank you."
Everyone then waits for Lambert to give the word that life support has been withdrawn.
"The patient has been extubated at 11:50," Lambert finally says, as he starts announcing her vital signs every few minutes.
The team waits again to see if this donor will stop breathing on her own within 90 minutes.
A team member steps to the side to talk about the waiting.
"It's a flood of emotions when this happens," says Deana Clapper, the associate executive director of Tennessee Donor Services. "You never want somebody to die. Yet, when situations occur that someone is not going to be able to survive, we definitely want them to be able to help somebody else."
Finally, there’s news from the team in the donor’s room.
"I have a text message. We are rolling," Lambert says.
The donor has stopped breathing. The nurses are rolling her bed down the hall toward the operating room.
The operating room doors suddenly swing open and the donor’s bed is rushed in. She’s obese so it’s harder than usual to move her to the operating table. Once she's been moved into place, the organ retrieval team gathers around the donor. That includes a surgeon from another state learning how to do NRP.
But everyone has to wait a little longer to make sure her breathing doesn’t spontaneously resume within five minutes.
"We good? We good?" Sellers asks.
"Yeah, so, declared dead at 12:58," a nurse replies.
Sellers saws open the donor’s chest and quickly takes the first key step. He clamps closed the major blood vessels from the heart to the brain.
"Head vessels clamped," he announces.
Then Sellers gets to work attaching the pump to the heart.
"Get ready to bump," he says.
That’s trickier too because of the donor’s size. So Sellers eventually ends up converting to a version of NRP that attaches the pump to an artery in the abdomen instead. Some bioethicists consider that version of NRP to be somewhat less controversial, but others still question this strategy, too.
The pump is finally on, restoring circulation to the abdominal organs. Sellers starts working to remove the liver and kidneys. But he quickly discovers bad news.
"The liver’s no good," he says. It is full of fat and looks diseased, which is a huge disappointment.
Sellers begins working on the kidneys.
"Scissors, please. Scissors," Sellers says.
From outside in the hall, a pounding sound starts as someone breaks up ice to chill the kidneys once they’re out.
Sellers suddenly steps away from the operating table. He nicked his left index finger with a scalpel. After stopping the bleeding and changing into a new gown and gloves, Sellers gets back to it.
Once the kidneys are out, Sellers cleans them up and assesses their condition before they are placed in special boxes that monitor and preserve them.
Sellers takes stock.
"It's disappointing when the liver’s not usable, but that’s not anything related to us," Sellers says "It’s just disappointing when you have a home for the liver, and it winds up not being transplanted. But we got two kidneys out of a donor that only had two kidneys to transplant. So by that standard you’d call it success, especially considering the difficulty that we had having in having to adapt in the middle of the case. So it turned out to be as good as it could have been, I guess."
Sellers turns to a colleague and asks about his next case, even as the debate continues over the ethics of using this controversial new way to retrieve organs for transplants.
"It’s not hyperbolic to say it’s a big deal," Sellers says. "We’re saving a lot of lives that otherwise wouldn’t have a chance. And the data indicate that if NRP was used nationally to the same extent we’re able to do it here in Tennessee we could essentially eliminate liver waiting-list deaths. So anytime you can say that, that’s a big deal."
As for the recovered kidneys, more than 650 attempts were made to locate a recipient for one kidney, which wasn't accepted for reasons ranging from biopsy results to anatomical issues, Tennessee Donor Services says, but the second kidney was successfully transplanted and saved a life.
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