clared dead following the irreversible cessation of respiratory and cardiac function (DeVita et al., 1993; IOM, 1997b). Organs removed after death suffered considerable ischemic damage that compromised transplantation outcomes.

The concept of determining death by neurological criteria was introduced in the late 1960s (Report of the Ad Hoc Committee,1968). These criteria have been incorporated into the Uniform Determination of Death Act (UDDA). According to this act, death can be determined by cardiopulmonary or neurological criteria: the permanent cessation of cardiopulmonary function or the irreversible loss of all brain function. Although challenges and reconsiderations continue to surface, the use of neurological criteria for death has gained wide medical, legal, ethical, and public acceptance in the United States (Bernat, 1998; IOM, 1997b; Olnick, 1991; Veatch, 1993).

Since the establishment and acceptance of neurological criteria for death, the majority of organs for transplantation in the United States have been obtained from patients who are declared dead by these criteria. After death has been declared, cardiopulmonary function is sustained artificially until the organs are removed. Mechanical ventilation and other forms of medical support are continued in order to maintain the circulation of oxygenated blood to the organs and to maintain organ viability for transplantation. Because of improved transplant outcomes, organ procurement after death by neurological criteria has virtually replaced organ procurement after death by cardiopulmonary criteria.

During the past decade, renewed interest in organ donation following death by cardiopulmonary criteria has developed for two main reasons. The first reason is patient and family interest in organ donation in cases where neurological criteria for death cannot be met, but the decision has been made to withdraw life-sustaining treatment (DeVita et al., 1993). The second reason is the potential for increasing the supply of organs for transplantation.

The patient who becomes a non-heart-beating organ donor cannot sustain life without continued medical intervention. When this medical intervention is stopped, cardiac and respiratory functions cease, death is declared, and organs are removed. The process must be carried out rapidly in order to remove organs before they become unsuitable for transplantation.

Non-heart-beating donor organ procurement may be controlled or uncontrolled. In uncontrolled non-heart-beating organ procurement, organs are removed after the patient suffers a sudden cardiopulmonary arrest. The patient may arrive at the hospital in arrest, may suffer an unanticipated arrest (Maastricht categories I and II), or may arrest after neurological criteria for death have been established (Maastricht category IV) (IOM, 1997, pp. 25, 42–43; Koostra, 1995). For the patient who arrives in arrest or for whom arrest is unanticipated, death is declared when resuscitation efforts fail to restore heart function. In these cases, issues of consent arise. The patient’s wishes about donation may not be known, and there may be a delay while the family is located and informed of the patient’s condition. Organ viability can be preserved in situ while efforts are

Front Matter (R1-R16)

Executive Summary (1-5)

1 Non-Heart-Beating Organ Transplantation: Background and Current Practices (6-15)

2 Non-Heart-Beating Donation and End-of-Life Care (16-26)

3 Patient- and Family-Centered Donation (27-37)

4 Non-Heart-Beating Donation Protocols: Content (38-55)

5 Protocol Development and Implementation (56-64)

6 A Research Agenda for Non-Heart-Beating Organ and Tissue Donation (65-86)

References (87-92)

APPENDIX A Statement of Task (93-94)

APPENDIX B Workshop Agenda (95-97)

APPENDIX C Workshop Participants (98-101)

APPENDIX D Bill of Rights for Donor Families National Kidney Foundation (102-106)

APPENDIX E Sample Family Information Brochure (107-111)

APPENDIX F Non-Heart-Beating Donation Protocols (112-156)