To maintain the support and trust of care providers, families and the general public, it is essential that the decisions, actions, and personnel involved in the withdrawal of life-sustaining treatment and the declaration of death be kept separate from the decisions, actions and personnel involved in the recovery of organs. Trust depends on the knowledge that the best care will be provided to all patients regardless of decisions about organ and tissue donation.

Organ transplantation has gained strong social, medical, and policy support. Public education and public policy measures emphasize the importance of organ donation in providing the life saving benefits of transplantation to organ recipients. The 1997 Institute of Medicine (IOM) report identified the potential for conflict of interest between patient care and organ recovery. One protection against such conflict of interest is the legal mandate of the Uniform Anatomical Gift Act (UAGA) that the person who declares death not be associated in any way with the organ procurement team (IOM, 1997b, pp. 55–57). All organ recovery protocols adhere to this mandate.

However, in an environment of support for donation, the potential for actual or perceived conflicts of interest between patient care and organ recovery is more complex. In non-heart-beating donation, medical treatment is modified in order to allow donation to proceed. These modifications include medications and procedures, and the process of withdrawing life-sustaining treatment and declaring death. The 1997 IOM report’s recommendations in these areas are intended to prevent harm or potential harm to the patient while still making it possible for donation to take place, in conformity with patient and family wishes.

Empirical research should be undertaken to address concerns about the determination of death. The five-minute time interval between cardiopulmonary arrest and the declaration of death recommended in the 1997 IOM report is a considered judgment based on the available data and on expert interpretation of these data. The 1997 report recommended further study in this area that has not been pursued. Although end-of-life research is an ethically sensitive undertaking, simple, noninvasive observations and data collection can contribute to a greater understanding of terminal events, and greater certainty in the declaration of death.

In addition, further research is needed into the psychosocial and ethical impact that non-heart-beating donation may have on families, the community, and health care providers. The level of concern or misunderstanding about the determination of death, or about the possibility that the donor may not expire following the withdrawal of support, are not known. A qualitative study of nurses’ responses to non-heart-beating donation suggests that these concerns need to be better understood (Wolf, 1994).


When death is declared by neurological criteria, the patient commonly is described as “brain dead.” Unfortunately, some confusion persists among the

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