
13 minute read
Organ and tissue donation for transplant purposes
Death as another dimension of life
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While autumn is tinged with ochre, the leaves of the trees cover the ground and creak to accompany our march toward the end of 2022. In jasmine-scented cemeteries, entire families keep company to their dead beloved ones. They adorn the graves with marigold flowers, candles, fruits, sweet-made crafts, and the favorite foods of the deceased to whom this whole party is dedicated. This pagan religious cult is unique in the world, it is illuminated with wax, and it is only possible to live it in Mexico.
There is a place where the mysticism of the day acquires a greater dimension, Tzintzuntzan, Michoacán, a small town that has flourished on the shores of Lake Patzcuaro, the capital of the Purepecha empire. The streets full of bright and polished rocks and houses of red tiles are an invitation to this magical world, where the past comes alive. For the Tarascans, life comes to an end with death. The world of the dead was regarded as a place of delights. On the night of November 1st, canoes depart from the dock to sail to the island of Janitzio, a night that becomes unique in the memory of the spectators.
Wow, this night couldn’t have been more epic! In the Franciscan Convent, a local group premiered the staging of Hamlet.
Yes! Shakespeare’s Hamlet, “a man of infinite human understanding”, is arguably the greatest dramatic character ever created, in the greatest play ever written. But is there really a method to Hamlet’s madness? And what is ‘madness’? Since the sixteenth century, medicine has been given increasing authority to determine the boundaries between sanity and disorder.
The same thing happens between the concepts of life and death. Developments in psychiatry can be influenced by culture and exert significant influence. The same thing is true of the concept of death. It is the culture that gives us a perception about the concept. For example, Drury Lane many decades ago gave us a mourning Hamlet, “this prince [Hamlet] of a reserved and cautious nature, arising from a melancholy stamped by the untimely death of his father and some consequent misfortunes.”¹
Hamlet transcended me many years ago, I was an inexperienced young doctor facing the miracle of the birth of a human being, and I was at the exact point where magic comes to life. In the general hospital where I consolidated my medical training, my hands had already received the cry of cellular precision, as well as had already closed the eyelids of whoever lived their last breath. There I was, reflecting on death as another dimension of life. A few years have passed since then and I have taken up this idea again.
A few days ago, at the morning visit round, a patient that we will call “Maria” was recovering from a successful liver transplant. Emotionally she showed immense gratitude to her entire medical team, but especially to her donor. Maria inspired this article when she said, “I will give this liver all the love and care it deserves because it has given me a second chance to continue.”

In multicellular organisms, there is a constant effort to maintain a balance between the number of new cells that are generated through mitosis and the number of damaged or unrequired cells that are eliminated from the body. This constant renewal of cells is necessary for the development of life².
In the human being, what is the exact moment in which life is declared? Dr. José Alberto Villarreal-Rodriguez explains: “From the first perceived heartbeat of an embryo in utero, it is clear that a new life has been formed. Life is the force that creates and sustains this universe, we are part of it, and we move with it always. Human life is valuable for the simple fact that the human person himself is.”
There are two types of modes of cell death. One is the one that occurs as a result of a massive cellular injury known as necrosis, while many cells of the organism die through a more refined mechanism, called apoptosis. Cell death and neurodegenerative conditions have been linked to oxidative stress and the imbalance between free radical generation and antioxidant defenses. Multiple sclerosis, strokes, and neurodegenerative diseases have been associated with reactive oxygen and nitric oxide species⁴. The uncontrolled production of free radicals and the lack of antioxidants to neutralize them, damage molecules and alter cellular processes favoring cell death in a positive feedback mode. Martin Heidegger is right to define that “Death is the essential event in the human adventure.”
Clinical death corresponds to prolonged cardiac arrest that prevents oxygenation of the organism. Until 1950, any cardiac arrest meant death. But the invention of the ventilator in 1952, by Danish anesthesiologist Björn Ibsen, revolutionized this definition of death by allowing the implementation of resuscitation and intensive care. A few years later, in 1959, the neurologist Maurice Goulon and the infectologist Pierre Mollaret of the Claude-Bernard hospital in Paris, proposed the concept of “exceeded coma”, corresponding to the state of brain death. ³
This concept was resumed again in the Anglo-Saxon world in 1968, under the impulse of the committee of Harvard Medical School (HMS) in Boston, United States. In their opening statement, they wrote: “Our main goal is to define irreversible coma as a new criterion for death. There are 2 reasons why a definition is necessary, 1: the improvement in resuscitation and support measures has led to increased efforts to save those who are seriously injured. Sometimes these efforts are only partially successful, so the result is an individual whose heart is still beating but whose brain suffers irreversible damage. The burden is great for patients suffering a permanent loss of intellect, for their families, and for hospitals. 2: outdated criteria for the definition of death may lead to controversy in obtaining organs for transplantation.’’
The concept of brain death was developed, in part, to allow patients with devastating neurological injuries to be pronounced dead before cardiopulmonary arrest occurred. Brain death is essential to current practices of organ and tissue recovery for transplant purposes because it legitimizes the removal of organs from bodies that continue to have circulation and respiration, thus preventing ischemic organ injury. The Conference of Royal Medical Colleges and their Faculties in the United Kingdom published a statement on the diagnosis of brain death in 1976 where brain death was defined as the irreversible and complete loss of brain stem function.4,5 This statement provided guidelines that included a refinement of apnea testing and pointed to the brainstem as the center of brain function: without it, there is no life.
Understand that the story of a human being is over when we still hear that “Tum lub! Tum lub!” that once declared us that the beginning of life is complex.
The difficulties in determining brain death and making it understood by family members not only increase the costs of medical care but also hinder the process of organ and tissue transplantation, that is where this text makes sense. The “dead donor rule” requires that patients be pronounced dead prior to the removal of organs vital for transplantation6.
Brain injury from hemorrhage, trauma or other causes of anoxia is the common diagnosis in potential organ donors. It has been shown to be associated with significant hemodynamic, metabolic, and hormonal changes. These result in a progressive and profound systemic inflammatory response, which affects the function and viability of donor organs prior to recovery and transplantation8.
Time is a non-renewable resource, and it is in this context that the phrase makes sense. Once a patient is diagnosed with brain death, a potential organ and tissue donor can be identified for transplant purposes. The period of donor management, after confirmation of death by neurological criteria and before organ recovery takes place, may offer an important opportunity to reduce organ injury and potentially initiate cell repair and regeneration.
In Mexico, three decades have passed since the first heart transplant and the scenario, as in the rest of the world, is characterized by a shortage of donations and transplants. Mortality remains high for patients on the organ transplant waiting list. A marked imbalance persists between the number of organs available and the recipients that need to be transplanted.
Today, thanks to the efforts of the National Transplant Center (CENATRA), in order to professionalize and standardize donation and transplantation activities, there are Hospital Coordinators for Organ and Tissue Donation for Transplant purposes. Highly trained health professionals who perform precision clinical work, adequately inform family members if the patient diagnosed with brain death is a potential organ and tissue donor for transplant purposes, and also participate in the proper management of donors, this offers the opportunity to reduce organ damage to maximize the number of organs that can be offered, to respect the donor’s altruistic gift. It is not an easy task, the pillars of donor treatment include: correction of hypovolemia; maintenance of organ perfusion; timely treatment of diabetes insipidus; corticosteroid therapy, and pulmonary protective ventilation. But above all, the accompaniment and management of the grieving processes of the donor’s family7.
Death, like the birth of a human being, is an event with significance within society and culture. It is important to respect and attend to the loss of a family member or loved one with its psycho-affective consequences, its external manifestations, rituals, and the evolutionary psychological process following the loss. Grief is a common event after the death of a close person, but it is necessary to maintain vigilance over the people who live it in order to prevent pathological mourning. This moment of suffering can be transformed into an altruistic manifestation through the donation of organs and tissues for transplant purposes.
Two decades ago, a 7-year-old boy named Nicholas Green was fatally shot while on vacation with his family in Italy. In an astonishing act of humanity, his parents immediately agreed to donate his organs to other adults and children awaiting a transplant. His altruistic decision received numerous praises from the media and contributed to a spectacular and sustained tripling of deceased organ donation rates throughout Italy, which continues to this day.
Nicholas Green is among the most famous deceased organ donors in history and is credited with rising organ donation rates in other European countries. In the U.S., however, rates of organ and tissue donation for transplantation by deceased people have increased only marginally. Current major campaigns target community members to become organ donor card holders.
In Mexico, there is a section in the driver’s license where we can express our consent to be organ donors. A signed organ donor card is neither necessary nor sufficient for donation. U.S. and Mexican law only allows the removal of organs from patients when consent has been documented, but organ retrieval usually does not take place if the family objects. Therefore, an organ donor card in practice only provides an opportunity to start a conversation: the final authorization is based on the consent of the family. Deceased organ donors are recognized heroes, but only if their family manages to make a decision despite the tragedy.
Definitions of death have evolved from the intuitive to the pathophysiological and medico-legal. A poor understanding of the physiological nature of death and the methods for determining death has resulted in a bifurcated concept of death as cardiorespiratory arrest and brain death. It is necessary to promote a culture of donation prior to any tragic situation, starting with human dignity and respect for life and death.

In deceased donor organ and tissue transplantation, the interests of the donor as a person are paramount, and no interest of organ recipients or society at large can justify the denial of the rights and bodily integrity of the person who is a donor.
Events praising vital contributions from organ donors are widespread both locally and nationally, and public honors for surviving families are relatively rare. Donor families remain invisible to the public. Large general hospitals could recognize surviving families of deceased organ donors, but they don’t. The mismatch in hospital recognition of organ donation versus time donation seems to indicate that large general hospitals are reluctant to prioritize the recognition of deceased donors.
Organ donor families are hardly mentioned in traditional organ and tissue donation campaigns for transplant purposes, perhaps because of society’s natural reluctance to talk about death. The culture of donation focuses primarily on grateful transplant recipients and how lives can be transformed. However, some community members may relate better to bereaved families who donate rather than receive.
These lines have been written in memory of our dear Elsa Maria MG and her beautiful family. And in gratitude to all the donors and their families who with this act of immense generosity have made possible the dream of many people to continue living, loving, and smiling.
Dr. Ana Villaseñor-Todd

Mexican scientist and entrepreneur noted for her studies on minimal hepatic encephalopathy, oxidative stress, quality of life and social cognition. A physician by profession, she completed her postgraduate studies at Texas A&M University. Certified by the Pan American Health Organization (PAHO) as a facilitator of MhGap (Action Program to bridge the gaps that exist in mental health care), she is currently a candidate to receive the degree of Doctor of Medicine from the UANL. CEO VICOMMA group.
Technical committee: Dr. Med. Homero Arturo Zapata Chavarría
Sources:
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Woodfine JD, Redelmeier DA. New thinking about honor and deceased organ donation. Am J Med. 2014 Sep;127(9):802-3. doi: 10.1016/j.amjmed.2014.05.021. Epub 2014 May 22. PMID: 24858064.
Radi E, Formichi P, Battisti C, Federico A. Apoptosis and oxidative stress in neurodegenerative diseases. J Alzheimers Dis. 2014;42 Suppl 3:S125-52. doi: 10.3233/JAD-132738. PMID: 25056458.
Spinello IM. Brain Death Determination. J Intensive Care Med. 2015 Sep;30(6):326-37. doi: 10.1177/0885066613511053. Epub 2013 Nov 12. PMID: 24227449.
Truog RD, Robinson WM. Role of brain death and the dead-donor rule in the ethics of organ transplantation. Crit Care Med. 2003 Sep;31(9):2391-6. doi: 10.1097/01.CCM.0000090869.19410.3C. PMID: 14501972.
Bera KD, Shah A, English MR, Harvey D, Ploeg RJ. Optimisation of the organ donor and effects on transplanted organs: a narrative review on current practice and future directions. Anaesthesia. 2020 Sep;75(9):1191-1204. doi: 10.1111/anae.15037. Epub 2020 May 19. PMID: 32430910.
Bera KD, Shah A, English MR, Harvey D, Ploeg RJ. Optimisation of the organ donor and effects on transplanted organs: a narrative review on current practice and future directions. Anaesthesia. 2020 Sep;75(9):1191-1204. doi: 10.1111/anae.15037. Epub 2020 May 19. PMID: 32430910.