Extracorporeal cardiopulmonary resuscitation dissemination and integration with organ preservation in the USA: ethical and logistical considerations

Abstract

Use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary resuscitation, termed eCPR, offers the prospect of improving survival with good neurological function after cardiac arrest. After death, ECMO can also be used for enhanced preservation of abdominal and thoracic organs, designated normothermic regional perfusion (NRP), before organ recovery for transplantation. To optimize resuscitation and transplantation outcomes, healthcare networks in Portugal and Italy have developed cardiac arrest protocols that integrate use of eCPR with NRP. Similar dissemination of eCPR and its integration with NRP in the USA raise novel ethical issues due to a non-nationalized health system and an opt-in framework for organ donation, as well as other legal and cultural factors. Nonetheless, eCPR investigations are ongoing, and both eCPR and NRP are selectively employed in clinical practice. This paper delineates the most pressing relevant ethical considerations and proposes recommendations for implementation of protocols that aim to promote public trust and reduce conflicts of interest. Transparent policies should rely on protocols that separate lifesaving from organ preservation considerations; robust, centralized eCPR data to inform equitable and evidence-based allocations; uniform practices concerning clinical decision-making and resource utilization; and partnership with community stakeholders, allowing patients to make decisions about emergency care that align with their values. Proactively addressing these ethical and logistical challenges could enable eCPR dissemination and integration with NRP protocols in the USA, with the potential to maximize lives saved through both improved resuscitation with good neurological outcomes and increased organ donation opportunities when resuscitation is unsuccessful or not in accordance with individuals’ wishes.

Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under extracorporeal membrane oxygenation (ECMO): a single-center, retrospective observational study

“…However, in some cases, conventional CPR (C-CPR) may not be sufficient in achieving a sustained return of spontaneous circulation (ROSC), and extracorporeal cardiopulmonary resuscitation (ECPR) may be necessary [ 12 , 13 ]. ECPR involves the use of extracorporeal membrane oxygenation (ECMO) to provide circulatory and respiratory support, and it has been shown to improve survival rates and neurological outcomes in patients with refractory CA [ 14 , 15 ]. However, the optimal timing and duration of CPR before transitioning to extracorporeal cardiopulmonary resuscitation (ECPR) are still areas of active research and debate.…”

The decision-making process in out-of-hospital cardiac arrest: from complexity to opportunities

“…To make things more complex, there is a broader dissemination of eCPR programs integrated with uncontrolled donation after circulatory death (uDCD), since extracorporeal membrane oxygenation can also be used to selectively perfuse abdominal and thoracic tissues after circulatory death (normothermic regional perfusion), to improve transplantation outcomes [11,12]. Transparent protocols have been locally implemented consisting of a formal pathway to uDCDD referral in ECPR ineligible patients and including ethical, logistic and organizational factors.…”