The Professor Merry Lecture: Endings and beginnings.

Organ transplantation has become an established and worthwhile treatment for many otherwise intractable conditions in many countries around the world. For example, over 4000 patients have benefited from heart or lung transplants (or both) since the first heart transplant in Australia or New Zealand was carried out in 1984. However, there is thought to be a worldwide shortage of donors relative to the number of organs needed. Many people, notably many of those involved with situations in which organ donation might be possible, value the opportunity to contribute organs. This has led to interest in expanding the criteria for donation. Standard criteria donation (SCD) involves the formal diagnosis of brain death, and conservative criteria for donor eligibility. Extended criteria donation allows slightly more liberal eligibility criteria, thought acceptable in light of improved results in SCD. In donation after cardiac death (DCD), an alternative approach to increasing the pool of available donors, a formal diagnosis of brain death is not required. The formal diagnosis of brain death is very reliable, but prognosis in less definitive manifestations of severe brain damage is less so, as illustrated by numerous anecdotal reports. There is a tension between providing enough time between withdrawal of treatment and declaration of death for reasonable confidence to be maintained in the process of DCD and the desirability of keeping warm ischemic time to a minimum in the interest of organ survival. In Australia and New Zealand, DCD is undertaken only in the context of planned withdrawal of support in intensive care units (Maastricht category 3). There has been a considered and carefully implemented approach to DCD, and the educational initiatives associated with its introduction may have had incidental benefit to the SCD program as well. It is, nevertheless, important that all involved are cognizant of the practical and ethical issues at stake.