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Bernat JL, Khush KK, Shemie SD, Hartwig MG, Reese PP, Dalle Ave A, Parent B, Glazier AK, Capron AM, Craig M, Gofton T, Gordon EJ, Healey A, Homan ME, Ladin K, Messer S, Murphy N, Nakagawa TA, Parker WF, Pentz RD, Rodríguez-Arias D, Schwartz B, Sulmasy DP, Truog RD, Wall AE, Wall SP, Wolpe PR, Fenton KN. Knowledge gaps in heart and lung donation after the circulatory determination of death: Report of a workshop of the National Heart, Lung, and Blood Institute. J Heart Lung Transplant 2024; 43:1021-1029. [PMID: 38432523 PMCID: PMC11132427 DOI: 10.1016/j.healun.2024.02.1455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/07/2024] [Accepted: 02/16/2024] [Indexed: 03/05/2024] Open
Abstract
In a workshop sponsored by the U.S. National Heart, Lung, and Blood Institute, experts identified current knowledge gaps and research opportunities in the scientific, conceptual, and ethical understanding of organ donation after the circulatory determination of death and its technologies. To minimize organ injury from warm ischemia and produce better recipient outcomes, innovative techniques to perfuse and oxygenate organs postmortem in situ, such as thoracoabdominal normothermic regional perfusion, are being implemented in several medical centers in the US and elsewhere. These technologies have improved organ outcomes but have raised ethical and legal questions. Re-establishing donor circulation postmortem can be viewed as invalidating the condition of permanent cessation of circulation on which the earlier death determination was made and clamping arch vessels to exclude brain circulation can be viewed as inducing brain death. Alternatively, TA-NRP can be viewed as localized in-situ organ perfusion, not whole-body resuscitation, that does not invalidate death determination. Further scientific, conceptual, and ethical studies, such as those identified in this workshop, can inform and help resolve controversies raised by this practice.
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Affiliation(s)
- James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, New Hampshire.
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, PQ, Canada
| | - Matthew G Hartwig
- Division of Thoracic Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Peter P Reese
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Dalle Ave
- Kennedy Institute of Ethics, Georgetown University, Washington, District of Columbia
| | - Brendan Parent
- Division of Medical Ethics and Department of Surgery, NYU Grossman School of Medicine, New York, New York
| | - Alexandra K Glazier
- Brown University, School of Public Health, Providence, Rhode Island; New England Donor Services, Waltham, Massachusetts
| | - Alexander M Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Matt Craig
- Lung Biology and Disease Branch, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Elisa J Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Healey
- Department of Medicine McMaster University and William Osler Health System, Hamilton, Ontario, Canada
| | | | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab); Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Simon Messer
- Department of Transplant, Golden Jubilee National Hospital, Clydebank, Scotland UK
| | - Nick Murphy
- Departments of Medicine and Philosophy, Western University, London, Ontario, Canada
| | - Thomas A Nakagawa
- University of Florida College of Medicine-Jacksonville, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Jacksonville, Florida
| | - William F Parker
- Department of Medicine and Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Rebecca D Pentz
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | | | - Bryanna Schwartz
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, Maryland; Department of Cardiology, Children's National Medical Center, Washington, District of Columbia
| | - Daniel P Sulmasy
- The Kennedy Institute of Ethics and the Departments of Medicine and Philosophy, Georgetown University, Washington, District of Columbia
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital; Center for Bioethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine; NYU Grossman School of Medicine and Department of Population Health, NYU, New York, New York
| | - Paul R Wolpe
- Center for Ethics, Department of Medicine, Emory University, Atlanta, Georgia
| | - Kathleen N Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, and Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland
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da Graca B, Borries T, Polk H, Ramakrishnan S, Testa G, Wall A. Ethical Issues in Donation following Circulatory Death: A Scoping Review Examining Changes over Time from 1993 to 2022. AJOB Empir Bioeth 2023; 14:237-277. [PMID: 37343208 DOI: 10.1080/23294515.2023.2224590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Background: Ethical frameworks for organ donation following circulatory death (DCD) were established >20 years ago. However, considerable variation exists among these, indicating consensus has not been reached on all issues. Additionally, advances such as cardiac DCD transplants and normothermic regional perfusion (NRP) may have reignited old debates.Methods: We reviewed the English-language literature addressing ethical issues in DCD from 1993 to 2022, examining changes in frequency with which ethical principles and their sub-themes identified within each, were addressed.Results: Non-maleficence was the most frequently addressed principle (192 of 199 articles), as well as the most varied, with 9 subthemes (versus 2-4 within each of the other bioethical principles).Conclusions: There were several changes in the terminology used to refer to DCD over time, and substantial interest in cardiac DCD and NRP in recent publications, arising in 11 and 19 of the 30 publications from 2018 to 2022.
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Affiliation(s)
| | - Trevor Borries
- Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Heather Polk
- Baylor Scott & White Research Institute, Dallas, TX, USA
| | | | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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Lalgudi Ganesan S, Hornby L, Weiss M, Dawe K, Lanos C, Wollny K, Dhanani S, Gofton T. Brain-based arterial pulse pressure threshold for death determination: a systematic review. Can J Anaesth 2023; 70:685-698. [PMID: 37138154 PMCID: PMC10202984 DOI: 10.1007/s12630-023-02425-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 05/05/2023] Open
Abstract
PURPOSE There is lack of consensus regarding the minimum arterial pulse pressure required for confirming permanent cessation of circulation for death determination by circulatory criteria in organ donors. We assessed direct and indirect evidence supporting whether one should use an arterial pulse pressure of 0 mm Hg vs more than 0 (5, 10, 20, 40) mm Hg to confirm permanent cessation of circulation. SOURCE We conducted this systematic review as part of a larger project to develop a clinical practice guideline for death determination by circulatory or neurologic criteria. We systematically searched Ovid MEDLINE, Ovid Embase, Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library, and Web of Science for articles published from inception until August 2021. We included all types of peer-reviewed original research publications related to arterial pulse pressure as monitored by an indwelling arterial pressure transducer around circulatory arrest or determination of death with either direct context-specific (organ donation) or indirect (outside of organ donation context) data. PRINCIPAL FINDINGS A total of 3,289 abstracts were identified and screened for eligibility. Fourteen studies were included; three from personal libraries. Five studies were of sufficient quality for inclusion in the evidence profile for the clinical practice guideline. One study measured cessation of cortical scalp electroencephalogram (EEG) activity after withdrawal of life-sustaining measures and showed that EEG activity fell below 2 μV when the pulse pressure reached 8 mm Hg. This indirect evidence suggests there is a possibility of persistent cerebral activity at arterial pulse pressures > 5 mm Hg. CONCLUSION Indirect evidence suggests that clinicians may incorrectly diagnose death by circulatory criteria if they apply any arterial pulse pressure threshold of greater than 5 mm Hg. Moreover, there is insufficient evidence to determine that any pulse pressure threshold greater than 0 and less than 5 can safely determine circulatory death. STUDY REGISTRATION PROSPERO (CRD42021275763); first submitted 28 August 2021.
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Affiliation(s)
- Saptharishi Lalgudi Ganesan
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
- Paediatric Critical Care Medicine, Children's Hospital - London Health Sciences Center, London, ON, Canada.
| | | | - Matthew Weiss
- Transplant Québec, Montreal, QC, Canada
- CHU de Québec, Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Kirk Dawe
- Discipline of Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
- Critical Care Program, Eastern Health, St. John's, NL, Canada
| | - Chelsea Lanos
- County of Renfrew Paramedic Service, Pembroke, ON, Canada
| | - Krista Wollny
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Sonny Dhanani
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Wall A, Polk H, Bedros N, Casanova M, Trahan C, Clay M, Adams BL, Niles P, Testa G, Fine R. Organ Donation and End-of-Life Discussions: A Scripting Template for Supportive Palliative Care. J Pain Symptom Manage 2022; 64:e300-e304. [PMID: 35961430 DOI: 10.1016/j.jpainsymman.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/27/2022] [Accepted: 08/03/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Anji Wall
- Baylor University Medical Center (A.J., G.T.), Division of Abdominal Transplantation, Dallas, Texas.
| | - Heather Polk
- Baylor University Medical Center (H.P.), Department of Internal Medicine, Dallas, Texas
| | - Nicole Bedros
- Baylor University Medical Center (N.B.), Division of Trauma and Acute Care Surgery, Dallas, Texas
| | - Mark Casanova
- Baylor University Medical Center (M.C., R.F.), Supportive Palliative Care, Dallas, Texas
| | - Chad Trahan
- Southwest Transplant Alliance (C.T., B.L.A., P.N.), Dallas, Texas
| | - Michael Clay
- Southwest Transplant Alliance (C.T., B.L.A., P.N.), Dallas, Texas
| | - Bradley L Adams
- Southwest Transplant Alliance (C.T., B.L.A., P.N.), Dallas, Texas
| | - Patricia Niles
- Southwest Transplant Alliance (C.T., B.L.A., P.N.), Dallas, Texas
| | - Giuliano Testa
- Baylor University Medical Center (A.J., G.T.), Division of Abdominal Transplantation, Dallas, Texas
| | - Robert Fine
- Baylor University Medical Center (M.C., R.F.), Supportive Palliative Care, Dallas, Texas
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