PERSPECTIVE LIFE OR DEATH FOR THE DEAD-DONOR RULE in a dead person. In non-dona- the concepts of death and crite- ing donation consent rates by en tion circumstances, the precise ria for determining it in both hancing family education and moment separating alive from DBDD and DCDD, reviews of communication, optimizing end dead is usually inconsequential, professional and public opinion of-life care for donors while sup- because physicians declaring death from several studies reveal strong porting grieving families, and have the luxury of time. In the support for the DDr. Indeed, developing state donor registries circumstances of donation, tim- the DDR is so clearly regarded as to authorize first-person donor ing is critical to minimize warm an axiom that survey questions consent. Recognizing that the ischemic exposure of the organs assume its essential role and in- harms of abandoning the DDR being transplanted. Thus, a rea- quire whether the protocols for exceeded the benefits, John Rob- soned judgment must be made DCDd or DBDD violate it. 4 ertson proposed a two-part pru- about the moment of death that I believe that the DDR is an dential test for assessing pro is conceptually coherent, physio- indispensable ethical protection posed changes to the rule, asking logically plausible, and socially for dying patients who plan to what effect they would have on acceptable donate organs and one that the protection of vulnerable per- Physicians should apply the strengthens public trust and con- sons and on preserving the pub- circulatory criterion for death fidence in our voluntary system lic trust. 2 These essential questions similarly whether or not organs of organ donation. Public sup- need to be answered conclusively are intended to be donated. port for organ donation is broad before our society considers aban When a dying patient with a but shallow. It remains precari- doning the DDr. do-not-resuscitate (dnr order ous and can be shaken dramati inclosure forms provided by the author is not an organ donor, death is cally by highly publicized dona- are available with the full text of this arti. usually declared at the moment tion scares such as those following cle at NEJM or of asystole, a time when it still a BBC Panorama expose in 1980, might be possible to resuscitate CBS's 1997 report on 60 Minutes he Departments of Neurology and ne. Geisel School of Medicine at the patient if cardiopulmonary about the Cleveland Clinics con- uth. Hanover NH resuscitation(CPR) were attempt- sideration of a DCDD protocol ed. Thus, physicians require only and the story of the California 1. Morrissey PE. The case for kidney dona. the permanent cessation of circu- transplant surgeon who allegedly 2012: 12: 1-8 lation in order to declare death. wrote terminal care orders for an 2. Robertson JA. The dead donor rule. Hast clared when circulation has per- ple harbor a fear that physicians dono r frep1999:29(): 6 In DCDD donors, too, death is de- organ donor in 2006. Many peo- ings cent rug RD, Brock DW. The dead manently ceased. Permanence is have a greater interest in procur- Med Philos 2010,35: 299-3 4. Bastami S. Matthes o Krones T. Biller. that sufficient time has elapsed welfare. They need the reassur- toward donation after cardiac death amon after the occurrence of asystole ance provided by the DDR. In healthcare providers and the general public to assure that circulation will not 2006. the Institute of Medicine Crit Care Med 2013: 41: 897-905 restart spontaneously(autoresus- supported the DDR as a protec- determining death in critical care. nat re citation)and that CPR will not be tive standard necessary to instill Neurol 2013: 9:164-73 Do:10.1056/NEMp1308078 Although public-survey data I favor strategies to increase Copyrighto2013Massachusetts Medical Society. consistently reveal confusion over the organ supply such as improv- What Would you do if it Were your kid? David n. krones md know we're not supposed to though her curly brown hair had tumor recurred, her parents and have favorites, but Lizzy was long since fallen out because of I knew she would ultimately die one of mine. She was 8 years old. radiation and chemotherapy for a of her disease. But she felt fine, Her eyes still sparkled, even malignant brain tumor. When the and it was impossible not to give ENGLJMED 369: 14 NEJM.ORG OCTOBER 3, 2013n engl j med 369;14 nejm.org october 3, 2013 PERSPECTIVE 1291 Life or Death for the Dead-Donor Rule? in a dead person. In non-dona￾tion circumstances, the precise moment separating alive from dead is usually inconsequential, because physicians declaring death have the luxury of time. In the circumstances of donation, tim￾ing is critical to minimize warm ischemic exposure of the organs being transplanted. Thus, a rea￾soned judgment must be made about the moment of death that is conceptually coherent, physio￾logically plausible, and socially acceptable. Physicians should apply the circulatory criterion for death similarly whether or not organs are intended to be donated. When a dying patient with a do-not-resuscitate (DNR) order is not an organ donor, death is usually declared at the moment of asystole, a time when it still might be possible to resuscitate the patient if cardiopulmonary resuscitation (CPR) were attempt￾ed. Thus, physicians require only the permanent cessation of circu￾lation in order to declare death. In DCDD donors, too, death is de￾clared when circulation has per￾manently ceased. Permanence is established by two conditions: that sufficient time has elapsed after the occurrence of asystole to assure that circulation will not restart spontaneously (autoresus￾citation) and that CPR will not be administered.5 Although public-survey data consistently reveal confusion over the concepts of death and crite￾ria for determining it in both DBDD and DCDD, reviews of professional and public opinion from several studies reveal strong support for the DDR.4 Indeed, the DDR is so clearly regarded as an axiom that survey questions assume its essential role and in￾quire whether the protocols for DCDD or DBDD violate it.4 I believe that the DDR is an indispensable ethical protection for dying patients who plan to donate organs and one that strengthens public trust and con￾fidence in our voluntary system of organ donation. Public sup￾port for organ donation is broad but shallow. It remains precari￾ous and can be shaken dramati￾cally by highly publicized dona￾tion scares such as those following a BBC Panorama exposé in 1980, CBS’s 1997 report on 60 Minutes about the Cleveland Clinic’s con￾sideration of a DCDD protocol, and the story of the California transplant surgeon who allegedly wrote terminal care orders for an organ donor in 2006. Many peo￾ple harbor a fear that physicians have a greater interest in procur￾ing their organs than in their welfare. They need the reassur￾ance provided by the DDR. In 2006, the Institute of Medicine supported the DDR as a protec￾tive standard necessary to instill public confidence. I favor strategies to increase the organ supply such as improv￾ing donation consent rates by en￾hancing family education and communication, optimizing end￾of-life care for donors while sup￾porting grieving families, and developing state donor registries to authorize first-person donor consent. Recognizing that the harms of abandoning the DDR exceeded the benefits, John Rob￾ertson proposed a two-part pru￾dential test for assessing pro￾posed changes to the rule, asking what effect they would have on the protection of vulnerable per￾sons and on preserving the pub￾lic trust.2 These essential questions need to be answered conclusively before our society considers aban￾doning the DDR. Disclosure forms provided by the author are available with the full text of this arti￾cle at NEJM.org. From the Departments of Neurology and Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH. 1. Morrissey PE. The case for kidney dona￾tion before end-of-life care. Am J Bioeth 2012;12:1-8. 2. Robertson JA. The dead donor rule. Hast￾ings Cent Rep 1999;29(6):6-14. 3. Miller FG, Truog RD, Brock DW. The dead donor rule: can it withstand critical scrutiny? J Med Philos 2010;35:299-312. 4. Bastami S, Matthes O, Krones T, Biller￾Andorno N. Systematic review of attitudes toward donation after cardiac death among healthcare providers and the general public. Crit Care Med 2013;41:897-905. 5. Bernat JL. Controversies in defining and determining death in critical care. Nat Rev Neurol 2013;9:164-73. DOI: 10.1056/NEJMp1308078 Copyright © 2013 Massachusetts Medical Society. What Would You Do if It Were Your Kid? David N. Korones, M.D. I know we’re not supposed to have favorites, but Lizzy was one of mine. She was 8 years old. Her eyes still sparkled, even though her curly brown hair had long since fallen out because of radiation and chemotherapy for a malignant brain tumor. When the tumor recurred, her parents and I knew she would ultimately die of her disease. But she felt fine, and it was impossible not to give