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Murphy NB, Slessarev M, Basmaji J, Blackstock L, Blaszak M, Brahmania M, Chandler JA, Dhanani S, Gaulton M, Gross JA, Healey A, Lingard L, Ott M, Shemie SD, Weijer C. Ethical Issues in Normothermic Regional Perfusion in Controlled Organ Donation After Determination of Death by Circulatory Criteria: A Scoping Review. Transplantation 2024:00007890-990000000-00854. [PMID: 39192464 DOI: 10.1097/tp.0000000000005161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
Normothermic regional perfusion (NRP) is a surgical technique that can improve the quality and number of organs recovered for donation after the determination of death by circulatory criteria. Despite its promise, adoption of NRP has been hindered because of unresolved ethical issues. To inform stakeholders, this scoping review provides an impartial overview of the major ethical controversies surrounding NRP. We undertook this review according to a modified 5-step methodology proposed by Arksey and O'Malley. Publications were retrieved through MEDLINE and Embase. Gray literature was sourced from Canadian organ donation organizations, English-language organ donation organization websites, and through our research networks. Three reviewers independently screened all documents for inclusion, extracted data, and participated in content analysis. Disagreements were resolved through consensus meetings. Seventy-one documents substantively engaging with ethical issues in NRP were included for full-text analysis. We identified 6 major themes encompassing a range of overlapping ethical debates: (1) the compatibility of NRP with the dead donor rule, the injunction that organ recovery cannot cause death, (2) the risk of donor harm posed by NRP, (3) uncertainties regarding consent requirements for NRP, (4) risks to stakeholder trust posed by NRP, (5) the implications of NRP for justice, and (6) NRP's potential to benefits of NRP for stakeholders. We found no agreement on the ethical permissibility of NRP. However, some debates may be resolved through additional empirical study. As decision-makers contemplate the adoption of NRP, it is critical to address the ethical issues facing the technique to ensure stakeholder trust in deceased donation and transplantation systems is preserved.
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Affiliation(s)
- Nicholas B Murphy
- Department of Medicine and Philosophy, Western University, London, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Marat Slessarev
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - John Basmaji
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Laurie Blackstock
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Donor family partner, Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Michael Blaszak
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Mayur Brahmania
- Division of Gastroenterology and Hepatology, University of Calgary, Cumming School of Medicine, Calgary, AB, Canada
| | | | - Sonny Dhanani
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Pediatric Intensive Care, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Matthew Gaulton
- University of Western Ontario Faculty of Law, London, ON, Canada
| | - Jed A Gross
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Divisions of Emergency and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lorelei Lingard
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Mary Ott
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Faculty of Education, York University, Toronto, ON, Canada
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
- System Development, Canadian Blood Services, Ottawa, ON, Canada
| | - Charles Weijer
- Department of Medicine and Philosophy, Western University, London, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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Schou A, Mølgaard J, Andersen LW, Holm S, Sørensen M. Ethics in extracorporeal life support: a narrative review. Crit Care 2021; 25:256. [PMID: 34289885 PMCID: PMC8293515 DOI: 10.1186/s13054-021-03689-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022] Open
Abstract
During 50 years of extracorporeal life support (ECLS), this highly invasive technology has left a considerable imprint on modern medicine, and it still confronts researchers, clinicians and policymakers with multifarious ethical challenges. After half a century of academic discussion about the ethics of ECLS, it seems appropriate to review the state of the argument and the trends in it. Through a comprehensive literature search on PubMed, we identified three ethical discourses: (1) trials and evidence accompanying the use of ECLS, (2) ECLS allocation, decision-making and limiting care, and (3) death on ECLS and ECLS in organ donation. All included articles were carefully reviewed, arguments extracted and grouped into the three discourses. This article provides a narrative synthesis of these arguments, evaluates the opportunities for mediation and substantiates the necessity of a shared decision-making approach at the limits of medical care. ![]()
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Affiliation(s)
- Alexandra Schou
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Hobrovej 18-22, 9100, Aalborg, Denmark
| | - Jesper Mølgaard
- Centre for Cancer and Organ Diseases, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Lars Willy Andersen
- Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Søren Holm
- Department of Law, School of Social Sciences, Faculty of Humanities, University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Marc Sørensen
- Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.
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Jochmans I, Hessheimer AJ, Neyrinck AP, Paredes D, Bellini MI, Dark JH, Kimenai HJAN, Pengel LHM, Watson CJE. Consensus statement on normothermic regional perfusion in donation after circulatory death: report from the European Society for Organ Transplantation's Transplant Learning Journey. Transpl Int 2021; 34:2019-2030. [PMID: 34145644 DOI: 10.1111/tri.13951] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/27/2022]
Abstract
Normothermic regional perfusion (NRP) in donation after circulatory death (DCD) is a safe alternative to in situ cooling and rapid procurement. An increasing number of countries and centres are performing NRP, a technically and logistically challenging procedure. This consensus document provides evidence-based recommendations on the use of NRP in uncontrolled and controlled DCDs. It also offers minimal ethical, logistical and technical requirements that form the foundation of a safe and effective NRP programme. The present article is based on evidence and opinions formulated by a panel of European experts of Workstream 04 of the Transplantation Learning Journey project, which is part of the European Society for Organ Transplantation.
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Affiliation(s)
- Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Amelia J Hessheimer
- Department of General & Digestive Surgery, Institut Clínic de Malalties Digestives i Metabòliques (ICMDM), Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Arne P Neyrinck
- Anesthesiology and Algology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - David Paredes
- Donation and Transplant Coordination Unit, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Maria Irene Bellini
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - John H Dark
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Hendrikus J A N Kimenai
- Division of Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Liset H M Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Christopher J E Watson
- University of Cambridge, Department of Surgery, Addenbrooke's Hospital, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
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Gutiérrez Delgado MDP, Sánchez Pérez B, Pérez Daga JA, León Díaz FJ, Santoyo Santoyo J. Controlled Donation After Circulatory Death: A Present in Pancreatic Transplant. Cir Esp 2020; 99:236-238. [PMID: 32560897 DOI: 10.1016/j.ciresp.2020.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/22/2020] [Accepted: 05/03/2020] [Indexed: 11/16/2022]
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Rijkse E, IJzermans JNM, Minnee RC. Machine perfusion in abdominal organ transplantation: Current use in the Netherlands. World J Transplant 2020; 10:15-28. [PMID: 32110511 PMCID: PMC7031624 DOI: 10.5500/wjt.v10.i1.15] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/03/2019] [Accepted: 12/19/2019] [Indexed: 02/05/2023] Open
Abstract
Scarcity of donor organs and the increment in patients awaiting a transplant increased the use of organs from expanded criteria donors or donation after circulatory death. Due to the suboptimal outcomes of these donor organs, there is an increased interest in better preservation methods, such as ex vivo machine perfusion or abdominal regional perfusion to improve outcomes. This state-of-the-art review aims to discuss the available types of perfusion techniques, its potential benefits and the available evidence in kidney, liver and pancreas transplantation. Additionally, translational steps from animal models towards clinical studies will be described, as well as its application to clinical practice, with the focus on the Netherlands. Despite the lack of evidence from randomized controlled trials, currently available data suggest especially beneficial effects of normothermic regional perfusion on biliary complications and ischemic cholangiopathy after liver transplantation. For ex vivo machine perfusion in kidney transplantation, hypothermic machine perfusion has proven to be beneficial over static cold storage in a randomized controlled trial, while normothermic machine perfusion is currently under investigation. For ex vivo machine perfusion in liver transplantation, normothermic machine perfusion has proven to reduce discard rates and early allograft dysfunction. In response to clinical studies, hypothermic machine perfusion for deceased donor kidneys has already been implemented as standard of care in the Netherlands.
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Affiliation(s)
- Elsaline Rijkse
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam 3015 GD, Netherlands
| | - Jan NM IJzermans
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam 3015 GD, Netherlands
| | - Robert C Minnee
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam 3015 GD, Netherlands
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Chonde M, Escajeda J, Elmer J, Callaway CW, Guyette FX, Boujoukos A, Sappington PL, Smith AJ, Schmidhofer M, Sciortino C, Kormos RL. Challenges in the development and implementation of a healthcare system based extracorporeal cardiopulmonary resuscitation (ECPR) program for the treatment of out of hospital cardiac arrest. Resuscitation 2019; 148:259-265. [PMID: 31887368 DOI: 10.1016/j.resuscitation.2019.12.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 12/12/2019] [Accepted: 12/17/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapies. Many institutions are interested in developing their own ECPR program. However, there may be challenges in logistics and implementation. AIMS The aim of our protocol was to demonstrate that an ECPR team was feasible within our healthcare system and that the identification of UPMC Presbyterian as a receiving center allowed for successful treatment within 30 min from EMS dispatch. METHODS We developed out of hospital cardiac arrest (OHCA) ECPR protocols for Emergency Medical Services (EMS), EMS communications, and our in-hospital ECPR team. Inclusion criteria indentified patients with a potentially reversible arrest etiology and high probability of recoverable brain injury using a simple checklist: witnessed collapse, layperson CPR, initial shockable rhythm, and age 18-60 years. We trained local EMS crews to screen patients and reviewed the criteria with a Medic Command Physician prior to transport to our hospital. RESULTS From October 2015 to March 31st 2018, EMS treated 1165 EMS OHCA cases, transported 664 (57%) to a local hospital, and transported 120 (10%) to our institution. Of these, five (4.1%) patients underwent ECPR. Among excluded cases, 64 (53%) had nonshockable rhythms, 48 (40%) were unwitnessed arrests, 50 (42%) were over age 60 and the remaining 20 (17%) had no documented reasons for exclusion. For ECPR cases, median pre-hospital CPR duration was 26 [IQR 25-40] min. Four patients (80%) received mechanical CPR. Interval from arrest to arrival on scene was 5 [IQR 4-6] min and interval from radio call to activation of ECPR was 13 [IQR 7-21] min. Interval from EMS dispatch to departure from scene was 20 [IQR 19-21] min. Time from EMS dispatch to initiation of ECPR was 63 [IQR 59-69] min. CONCLUSIONS ECPR is an infrequent occurrence in EMS practice. Most apparently eligible patients did not get ECPR, highlighting the need for ongoing programmatic development, provider education, and qualitative work exploring barriers to implementation.
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Affiliation(s)
- Meshe Chonde
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States.
| | - Jeremiah Escajeda
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Jonathan Elmer
- University of Pittsburgh, Department of Emergency Medicine, United States; University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Clifton W Callaway
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Frank X Guyette
- University of Pittsburgh, Department of Emergency Medicine, United States
| | - Arthur Boujoukos
- University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Penny L Sappington
- University of Pittsburgh, Department of Critical Care Medicine, United States
| | - Anson J Smith
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States
| | - Mark Schmidhofer
- University of Pittsburgh, Department of Medicine, Divison of Cardiology, United States
| | | | - Robert L Kormos
- University of Pittsburgh, Department of Cardiothoracic Surgery, United States
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