This case has now been blown wide open with police investigating the heavily disputed cause of death of the eight-year-old boy and looking into allegations that he died from a fatal dose of fentanyl, the painkiller.
Cole Hartman’s questionable cause of death
Cole was born with a genetic abnormality, fragile X syndrome, causing him to have physical and intellectual disabilities. On that fateful day in July 2013, his father found Cole headfirst in a running washing machine—by his parents’ estimation—Cole’s head could have been submerged underwater for up to 25 minutes.
Upon being brought to the UCLA Medical Centre, Dr Judith Brill, professor emeritus of clinical anaesthesiology and perioperative medicine, assessed Cole. According to notes Brill made in Cole’s chart, the team informed the Hartmans that a brain scan was “markedly abnormal” and suggested extensive damage from lack of oxygen.
She also wrote that the family “unanimously stated that they would prefer to withdraw support” and decided to donate his organs. As Cole was not brain-dead, the procedure had to be done as a donation after cardiac death (DCD). This means once the ventilator is removed and his heart stops beating.
Brill administered fentanyl when ventilator was removed which she claims was to ease his suffering. Denise Bertone - a county coroner who later examined the boy’s body — alleges the 500 microgrammes dose of fentanyl was what killed him. It raises the question about whether a fatal dose was to speed up his death and keep his organs more viable for donation.
Bertone filed a case alleging retaliation from her bosses after expressing her doubts.
The controversy behind DCD
Donation after brain death (DBD) is more commonly carried out and, in some ways, considered a logical standard for organ donation. This is because it resolves the paradox of: The donor must be dead, but the organ itself alive. It was first thought up in 1968; however, less than 1% of patients who die in hospitals are brain dead.
Thus, scientists were advocating for the expansion of the potential donor pool in the 1990s to curb the long transplant wait list problems. Hence, DCD was popularised once again since the early 1970s prior to the acceptance of DBD.As DCD involves removing a ventilator and then waiting for the patient to cease breathing on their own, time is of the essence.
DCD donors can rarely donate viable hearts and lungs but more resilient organs like livers and kidneys can last 30 to 60 minutes. In this case, the whole donation is cancelled if the patient does not cease to breathe within the acceptable time period. Time pressure associated with DCD has led critics to cite ethical concerns as reasons against this method compared to brain death.
In 2007, a doctor in San Luis Obispo stood trial as he used morphine in attempts to quicken a potential organ donor’s death. The patient did not die for seven hours. Despite the fact that the clinician was acquitted, the case served as a warning for transplant surgeons.
Unclear questions and vague protocols
DCD protocols in hospitals have since been refined and detailed to avoid conflict. However, some questions are still left unanswered.
One such example is how far can doctors go to preserve organs before the DCD donor dies? Are they allowed to administer heparin that enables preservation but is not beneficial to the patient? Can they insert a catheter into the patient to continue oxygenation of blood immediately after the heart stops beating?
Jeremy Simon, an emergency doctor and bioethicist at Columbia University said, “As long as a patient’s heart is beating they’re considered our patient.” He suggests a way to tackle this matter would be to obtain consent for these procedures from the patient or a representative beforehand.
In Cole’s case, Brill administered fentanyl as form of “comfort care”. It was noted that UCLA's policy allows the use of opioids “in doses that are clinically appropriate to prevent discomfort”. The policy also adds “interventions intended to preserve organ function, but which may hasten death, are prohibited”. MIMS
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