Does Controlled Donation after Circulatory Death Violate the Dead Donor Rule?

Ethical Issues in Normothermic Regional Perfusion in Controlled Organ Donation After Determination of Death by Circulatory Criteria: A Scoping Review

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.

Making organ donation after circulatory death routine: Preserving patienthood and reproducing ways of dying in the intensive care unit

Controlled organ donation after circulatory death (DCD) was re-introduced in the UK in 2008, in efforts to increase rates of organs for transplant. Following reintroduction, there were debates about the ethics of DCD, including whether potential DCD donors receive end-of-life care which is in their best interests. Since this time, DCD has become a routine donor pathway in the NHS. In this article, we present findings from an ethnographic study examining the everyday practices of DCD in two English Trusts. Drawing on the concept of death brokering and Bea's (2020) call to consider organ donation as embedded and routine practice within health care, we look at how DCD is integrated into end-of-life care in intensive care units. We show how DCD is made routine at the end-of-life via the practices of health professionals who create an active separation between discussions about death and donation; reproduce usual ways of doing things in end-of-life care; and respect the distinction between patient/donor, dying and death. In doing so, we argue these function to preserve the patienthood of the potential donor, ensuring DCD operates as an integrated part, and culturally accepted form of, good end-of-life care for potential donors, their relatives, and health professionals alike.

Restoring the Organism as a Whole: Does NRP Resurrect the Dead?

The introduction of normothermic regional perfusion (NRP) in controlled donation after circulatory determination of death (cDCDD) protocols is by some regarded as controversial and ethically troublesome. One of the main concerns that opponents have about introducing NRP in cDCDD protocols is that reestablishing circulation will negate the determination of death by circulatory criteria, potentially resuscitating the donor. In this article, I argue that this is not the case. If we take a closer look at the concept of death underlying the circulatory criterion for determination of death, we find that the purpose of the criterion is to show whether the organism as a whole has died. I argue that this purpose is fulfilled by the circulatory criterion in cDCDD protocols, and that applying NRP does not negate the determination of death or resuscitate the donor.

The Unified Brain-Based Determination of Death Conceptually Justifies Death Determination in DCDD and NRP Protocols

Organ donation after the circulatory determination of death requires the permanent cessation of circulation while organ donation after the brain determination of death requires the irreversible cessation of brain functions. The unified brain-based determination of death connects the brain and circulatory death criteria for circulatory death determination in organ donation as follows: permanent cessation of systemic circulation causes permanent cessation of brain circulation which causes permanent cessation of brain perfusion which causes permanent cessation of brain function. The relevant circulation that must cease in circulatory death determination is that to the brain. Eliminating brain circulation from the donor ECMO organ perfusion circuit in thoracoabdominal NRP protocols satisfies the unified brain-based determination of death but only if the complete cessation of brain circulation can be proved. Despite its medical and physiologic rationale, the unified brain-based determination of death remains inconsistent with the Uniform Determination of Death Act.

Organ Donation by the Imminently Dead: Addressing the Organ Shortage and the Dead Donor Rule

The dead donor rule (DDR) has facilitated the saving of hundreds of thousands of lives. Recent advances in heart donation, however, have exposed how DDR has limited donation of all organs. We propose advancing the moment in the dying process at which death can be determined to increase substantially the supply of organs for transplantation. We justify this approach by identifying certain flaws in the Uniform Determination of Death Act and proposing a modification of that law that permits earlier procurement of healthier organs in greater numbers.

Donor Heart Recovery and Preservation Modalities in 2024

Historically, heart transplantation (HT) has relied on the use of traditional cold storage for donor heart preservation. This organ preservation modality has several limitations, including the risk for ischemic and cold-induced graft injuries that may contribute to primary graft dysfunction and poor post-HT outcomes. In recent years, several novel donor heart preservation modalities have entered clinical practice, including the SherpaPak Cardiac Transport System of controlled hypothermic preservation, and the Transmedics Organ Care System of ex vivo perfusion. Such technologies are altering the landscape of HT by expanding the geographic reach of procurement teams and enabling both donation after cardiac death and the use of expanded criteria donor hearts. This paper will review the emerging evidence on the association of these modalities with improved post-HT outcomes, and will also suggest best practices for selecting between donor heart preservation techniques.

Organ Donation and the Dead Donor Rule: A Synopsis of Pressing Ethical Controversies and Practical Questions

OBJECTIVES

As a result of recent biomedical advancements, organ donation continues to save and enhance countless lives globally.Yet,the gap between the organ supply and demand persists, leading to approximately 17 people dying each day waiting for an organ transplant and another person being added to the transplant waiting list every 9 minutes. This gap persists, in part, because of ethical and practical concerns arising from ambiguities surrounding death determination before donation and the dead donor rule. In this study, we discuss challenges related to defining death in the context of organ donation, critical and tolerant views on the dead donorrule, and possible avenues by which some of the ambiguities and ethicaltensions related to organ donation may be resolved.

MATERIALS AND METHODS

We reviewed literature opinions and data pertaining to cultural and religious influences affecting societal attitudes toward death determination and organ donation and examined the future of deceased organ donation.

RESULTS

Cultural and religious influences affect societal attitudes toward death determination and organ donation. There is a plurality of views on the matter that may be assuaged to an extent by standardized death determination criterion that could be implemented globally or by identifying alternative therapies other than human organ transplant.

CONCLUSIONS

The debate regarding death and the acceptability of dead donor organs fortransplant does not have a straightforward solution, and efforts are needed to overcome social, cultural and religious objections.