Uncontrolled donation after circulatory death: ethics of implementation

Molina, María; Domínguez‐Gil, Beatriz; Pérez-Villares, J.M.; Andrés, Amado

doi:10.1097/mot.0000000000000648

Cited by 18 publications

(17 citation statements)

References 36 publications

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“…11,21 Because technologies such as nECMO applied for organ preservation have the potential to circulate oxygenated blood to the brain, some vocal detractors of using regional perfusion for organ preservation are concerned that using these interventions could undermine the permanent cessation of brain circulation rendering the prior determination of death invalid since "once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation." 11 Regional perfusion measures that use balloon catheters inserted after death determination and before nECMO initiation to prevent brain perfusion-an accepted procedure in countries with strong uDCDD programs that exist with opt-out organ donation functioning within universal healthcare systems 22 -may not assuage the ethical concerns of those elsewhere who believe nECMO should not be used after death is declared. For these opponents, the problem is not whether brain perfusion is prevented, but whether doing so makes health providers complicit in the patient's death, and is a technical work-around to avoid the fact that nECMO use would undermine the legal brain death determination.…”

Section: Ta B L E 1 the Modified Maastricht Classification Of Dcdmentioning

confidence: 99%

“…For these opponents, the problem is not whether brain perfusion is prevented, but whether doing so makes health providers complicit in the patient's death, and is a technical work-around to avoid the fact that nECMO use would undermine the legal brain death determination. 11,21 Others do not agree with these analyses-as restoring some circulation to the brain after prolonged, exhaustive resuscitation attempts are unsuccessful, is exceedingly unlikely to restore meaningful neurological function 22 -but the concern is moot in considerations of lung uDCDD.…”

Section: Ta B L E 1 the Modified Maastricht Classification Of Dcdmentioning

confidence: 99%

“…Given that the duration of resuscitation for uDCDD eligibility is at least 30 minutes, the likelihood of auto-resuscitation is nearly negligible; in the unlikely event that auto-resuscitation occurs, continuous monitoring of that event may be applied as is common practice in successful uDCDD programs. 12,22 Previous uDCDD programs in the United States have relied on registered donors to avoid the challenge of obtaining authorization quickly enough for organ preservation, and have largely failed because of insufficient enrollment. 6,8,9 The National Academy of Medicine originally advocated for presumed authorization for organ preservation in uDCDD citing the success of European protocols, but has since backed away from this position, but lungs are unique.…”

Section: Some Experts Fear That Allowing Udcdd Might Create Incentivesmentioning

confidence: 99%

“…Studies have examined the resuscitation duration in context of auto-resuscitation-when a heart stops beating spontaneously and restarts-and have shown cases of auto-resuscitation up to 10 minutes from TOR in adults and 2 minutes in children. 12,22 Previous uDCDD programs in the United States have relied on registered donors to avoid the challenge of obtaining authorization quickly enough for organ preservation, and have largely failed because of insufficient enrollment. 29 Others follow a 5-minute no-touch period.…”

Section: Introductionmentioning

confidence: 99%

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The unique moral permissibility of uncontrolled lung donation after circulatory death

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Caplan

Angel

et al. 2020

American Journal of Transplantation

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Despite the growth in the number of lung transplants performed in the United States, demand far exceeds organ supply. According to 2017 OPTN data, there were 2439 lung transplants; insufficient supply left over 1462 patients waiting for this life-saving procedure resulting in 194 deaths and 141 becoming too sick for transplantation while waiting. These numbers are inclusive of recipients who, as their conditions deteriorate, choose to receive lungs from less than ideal donors (ie, older donors, donors with significant smoking history). To meet the overwhelming demand, one strategy is to expand the donor pool to include lung donation when death occurs unexpectedly in or out-of-hospital settings, what is often termed uncontrolled donation after circulatory determination of death (uDCDD). Widespread dissemination of uDCDD programs could markedly improve supply of donor lungs for patients in need of transplants. The objective of this paper is to propose an ethical framework for transplant programs to facilitate lung uDCDD in the United States. Since 2000, European countries have utilized uDCDD to recover kidneys, livers, and lungs, leading to shorter wait times and thousands more saved lives. 1 Foreign studies suggest uDCDD lung transplant outcomes are within acceptable range with some Abbreviations: BDD, brain death donors; DSMBs, data safety monitoring boards; EVLP, ex-vivo lung perfusion; nECMO, normothermic extracorporeal membrane oxygenation;OPU, organ preservation unit; TOR, termination of resuscitation; uDCDD, uncontrolled donation after circulatory determination of death.

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Section: Ta B L E 1 the Modified Maastricht Classification Of Dcdmentioning

confidence: 99%

Section: Ta B L E 1 the Modified Maastricht Classification Of Dcdmentioning

confidence: 99%

Section: Some Experts Fear That Allowing Udcdd Might Create Incentivesmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

The unique moral permissibility of uncontrolled lung donation after circulatory death

Parent

Caplan

Angel

et al. 2020

American Journal of Transplantation

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“…The wording of the AoMRC Code Of Practice is unclear whether these should be undertaken if available, or whether they can be used in isolation. Given the novelty of the uDCD pilot, we made sure to exceed the routine standards in the declaration of death in the cDCD practice in critical care 30…”

Section: Ethical Considerationsmentioning

confidence: 99%

Lessons from a pilot for uncontrolled donation after circulatory death in the ED in the UK

et al. 2019

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Worldwide there is a shortage of available organs for patients requiring transplants. However, some countries such as France, Italy and Spain have had greater success by allowing donations from patients with unexpected and unrecoverable circulatory arrest who arrive in the ED. Significant advances in the surgical approach to organ recovery from donation after circulatory death (DCD) led to the establishment of a pilot programme for uncontrolled DCD in the ED of the Royal Infirmary of Edinburgh. This paper describes the programme and discusses the lessons learnt.

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US Organ Donation Policy

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Caplan

2020

JAMA

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To the Editor The Viewpoint on organ donation policy maintained that the US opt-in organ donation system performs among the best in the world. 1 Donors per potential eligible donor were used as evidence despite this metric being criticized for potentially overestimating organ procurement organization (OPO) performance. 2 Organ procurement organizations self-regulate and may be incentivized to modify eligibility of missed cases to meet performance requirements. Also, countries with optout programs consider cases when death occurs unexpectedly, often termed uncontrolled donation after circulatory determination of death. Implementing uncontrolled donation after circulatory determination of death increases organ supply but with more attrition. Countries that consider higher-risk candidates have fewer donors per potential eligible donor compared with the United States, which has stricter criteria.To maintain trust, a key component for organ donation, opt-out systems initiate preservation only after judicial approval is obtained, allowing time for families to consider donation. If a family refuses, preservation is discontinued. Families rarely refuse, yielding opt-out rates exceeding 90%. 3 Much of the success of opt-out donation is attributable to functioning within universal health care systems and having physician specialists manage preservation. Unfortunately, empirical data suggest that the US public does not support opt-out donation, given cultural emphasis on autonomy and pervasive mistrust of an inequitable health care system. 4 Unless improvements in trust of the US health care system are achieved, it is unrealistic to expect increases in organ donor registration rates under either the opt-in or the opt-out strategies.We believe it is more important to establish the means for increasing organ donation opportunities through innovative policy, particularly through uncontrolled donation after circulatory determination of death. Current US policy, formulated by ethics panels sponsored by the Health Resources and Services Administration, promotes a rigid interpretation of the dead-donor rule (permanence or irreversibility), deeming it ethical to conduct controlled and live donation over uncontrolled donation after circulatory determination of death. 5 The premise is that any attempt to preserve organ function with oxygenated fluids after death invalidates prior death determination based on circulatory and respiratory criteria. This policy is not universally accepted. 3 In the United States, uncontrolled donors are not eligible, while in Europe they are. Working through this ethical conflict would likely show, using the same metric of donors per potential eligible donor, that the United States underperforms Spain, the best-performing country in the world. We believe mitigating the organ donation crisis in the United States requires modifications of policy to increase organ donation opportunities for those already willing to donate, improving OPO efficiency and accountability, and providing access to health care f...

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Uncontrolled donation after circulatory death: ethics of implementation

Cited by 18 publications

References 36 publications

The unique moral permissibility of uncontrolled lung donation after circulatory death

The unique moral permissibility of uncontrolled lung donation after circulatory death

Lessons from a pilot for uncontrolled donation after circulatory death in the ED in the UK

US Organ Donation Policy

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