WASHINGTON, DC — Christine Frank knew one thing for certain on that horrible day when she was told neither of her teenage sons would survive a car accident.

"I said, 'Listen to me now. They are to be organ donors. That was their wish,"' said Frank, who lost James, 18, and Christopher, 15, in 1998. "When you're hit with tragedy, if you're any kind of survivor, you're going to find something to hold on to, to find it made sense."

In many parts of the country, it would have been impossible to offer Christopher's organs.

Donating James' organs was routine. But in most parts of the country, it would have been unlikely — in many places, impossible — to offer Christopher's organs.

Christopher died when his heart stopped beating. James, like most organ donors, died because his brain stopped functioning, allowing a ventilator to keep his heart working until the moment his organs were removed.

It is a subtle difference that has vast implications when more than 80,000 people are awaiting transplants and more than 6,000 people die each year while waiting.

A heartbeat makes the difference
Across the country, there is a remarkable divide over using organs from people who, like Christopher, die a cardiac death, according to an Associated Press analysis of 2000 and 2001 data. A few of the nation's 59 organ banks are aggressively using these donors. But nearly half have never handled a case; more than a dozen others have handled only one or two.

Last year, more than half of the 168 cardiac donors nationwide were handled by just six organ banks.

Organs must be harvested immediately after the heart stops beating to prevent deterioration.

No regional pattern can explain the national disparity. In Florida, two organ banks handle almost no cardiac donors. The state's other three are among the most aggressive.

Nationally, experts estimate there could be at least 1,000 cardiac donors each year, with each donor providing two to three organs. These donors could provide enough kidneys and livers to cut in half the number who die waiting for the organs.

In Philadelphia, where the local organ bank handles more cardiac donors than any other bank, there have been 151 since 1995. "That's a total of 303 organs that would have been buried if we didn't have this procedure," said Howard Nathan, executive director of Gift of Life Donor Program.

The obstacles
Still, the pursuit of cardiac donors has raised ethical, medical and technical questions, partly because the organs must be harvested almost immediately after the heart stops beating to prevent deterioration. Among them: How long after a heart stops beating before someone is dead? Are these organs good enough to transplant? Will the process make doctors and nurses nervous?

The Institute of Medicine, which advises the government on medical issues, had hoped to put those questions to rest. In 1997 and again in 1999, the institute concluded that using these donors is "important, medically effective and ethically acceptable." A panel of experts urged all organ banks to explore the option.

The family must consent before the patient is declared dead. Then the medical team must watch them die.

Yet there is a lingering sense of discomfort in many parts of the country, even a lack of interest. Often it is hard for doctors and nurses, who are sometimes uncomfortable with removing life support to begin with, said Dr. Christine Cassell, dean of the Oregon Health & Sciences University medical school and head of the institute's 1999 committee.

For cardiac donation to work, a family must consent before the person is declared dead. Then the medical team must watch the patient die. "That's a hard thing psychologically for doctors and nurses to do," Cassell said.

There also have been concerns about the quality of the organs, though recent studies suggest that they work just as well as others. And the logistics are complicated, meaning hospitals must approve protocols and offer special training.

Efforts underway
Hoping to increase the numbers, the United Network for Organ Sharing convened focus groups this year. Most of the more than 200 doctors and nurses who participated knew nothing about cardiac donation, though after learning more, many said they would support it. The network plans an education campaign, plus a medical blueprint addressing procedural issues.

Most of the doctors and nurses who participated knew nothing about cardiac donation.

Organ banks in New York, Cleveland, Houston, Denver and elsewhere are now beginning to take these donors, and others say they are exploring the idea. Some banks say they have not given it much thought.

Christine Frank, of Cincinnati, had talked about organ donation with her sons not six months before they died and knew that is what they wanted.

Retrieving organs from James was relatively straightforward. A ventilator kept his heart pumping and lungs moving while doctors conducted tests that showed he had no brain function, meaning he was brain dead. To preserve James' organs, the ventilator stayed on until surgeons could begin harvesting.

A ventilator also was keeping Christopher's heart pumping. But he had minimal brain function. When a CT scan showed his brain stem was critically injured, indicating no chance for survival, his parents told doctors to end life support.

Doctors turned off the machine, waited for his heart to stop beating, then waited five more minutes to be sure it would not start again. At that point, Christopher was officially dead, and doctors could begin harvesting his kidneys.

In some cases of cardiac death, the liver also can be retrieved, though Christopher's was not usable. Other organs, such as the heart and lungs, deteriorate during the delay and cannot be used from cardiac donors.

When death is death
Thinking of the two women who received kidneys from Christopher, Christine Frank is baffled that cardiac donation is so rare. "I don't understand why it's not being done everywhere," she said.

Part of it is uncertainty about when death is death.

Cleveland hospitals set out to use cardiac donors in 1997, only to have a local prosecutor suggest their effort amounted to homicide. Officials dropped the effort.

Now LifeBanc, the Cleveland organ bank, is trying again with two changes: Hospitals will wait five minutes after the last heartbeat before proceeding, as government advisers recommended, rather than two minutes. Also, doctors will not use Regitine, a drug that helps preserve organs but may block the effects of adrenaline, which could help some patients fight off death.

In 1997 Cleveland hospitals dropped their effort to use cardiac donors after a local prosecutor suggested it amounted to homicide.

There is no national standard, and that is a problem, said Dr. Arthur Caplan, a bioethicist at the University of Pennsylvania. In Pittsburgh, for instance, doctors wait just two minutes at some hospitals. In Madison, Wisconsin, they often use Regitine.

"It's important enough to continue to do it, but I'm warning there is legal liability out there," Caplan said. "One lawsuit could set the whole process back."

Officials with the Lifelink Foundation, which runs organ banks in Atlanta, Puerto Rico and two in Florida, is surveying hospitals to see what their objections might be and reviewing death records to see how many organs his groups might be missing.

"Our concern has always been that the process may be very uncomfortable for the hospital staff," said Jay Campbell, executive vice president of Lifelink. "I'm trying to measure the benefit against the potential risk that may be there."

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