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Then SN, Martin DE, McGee A, Gardiner D, El Moslemani N. Decision-making About Premortem Interventions for Donation: Navigating Legal and Ethical Complexities. Transplantation 2023; 107:1655-1663. [PMID: 37069655 DOI: 10.1097/tp.0000000000004591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Premortem interventions (PMIs) for organ donation play a vital role in preserving opportunities for deceased donation or increasing the chances of successful transplantation of donor organs. Although ethical considerations relating to use of particular PMIs have been well explored, the ethical and legal aspects of decision-making about the use of PMIs have received comparatively little attention. In many countries, there is significant uncertainty regarding whether PMIs are lawful or, if they are, who can authorize them. Furthermore, emphasis on consideration of therapeutic goals in substitute decision-making frameworks may discourage consideration of donation goals. In this article, we examine the fundamental questions of who should have the authority to make decisions about the use of PMIs on behalf of a potential donor and how such decisions should be made. We draw on international examples of legal reform that have sought to clarify the legal position in relation to administering PMIs and identify potential elements of an effective regulatory model for PMIs. In doing so, we argue that reforms are needed in many countries to provide legal certainty for clinicians who are responsible for supporting decision-making about PMIs and to ensure that the goals and preferences of potential donors are accorded due consideration in the decision-making process.
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Affiliation(s)
- Shih-Ning Then
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane City, Australia
| | | | - Andrew McGee
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane City, Australia
| | - Dale Gardiner
- Adult Intensive Care, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Best foot forward: now is the time for Canadian ethical guidance on prospective interventional trials of antemortem interventions in organ donation. Can J Anaesth 2022; 69:1196-1202. [PMID: 35831739 DOI: 10.1007/s12630-022-02288-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 01/12/2023] Open
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Then SN, Martin DE. Transitions in decision-making authority at the end of life: a problem of law, ethics and practice in deceased donation. JOURNAL OF MEDICAL ETHICS 2022; 48:112-117. [PMID: 33246994 DOI: 10.1136/medethics-2020-106572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 06/12/2023]
Abstract
Where a person is unable to make medical decisions for themselves, law and practice allows others to make decisions on their behalf. This is common at the end of a person's life where decision-making capacity is often lost. A further, and separate, decision that is often considered at the time of death (and often preceding death) is whether the person wanted to act as an organ or tissue donor. However, in some jurisdictions, the lawful decision-maker for the donation decision (the 'donation decision-maker') is different from the person who was granted decision-making authority for medical decisions during the person's life. To date, little attention has been given in the literature to the ethical concerns and practical problems that arise where this shift in legal authority occurs. Such a change in decision-making authority is particularly problematic where premortem measures are suggested to maximise the chances of a successful organ donation. This paper examines this shift in decision-making authority and discusses the legal, ethical and practical implications of such frameworks.
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Affiliation(s)
- Shih-Ning Then
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
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Honarmand K, Alshamsi F, Foroutan F, Rochwerg B, Belley-Cote E, Mclure G, D'Aragon F, Ball IM, Sener A, Selzner M, Guyatt G, Meade MO. Antemortem Heparin in Organ Donation After Circulatory Death Determination: A Systematic Review of the Literature. Transplantation 2021; 105:e337-e346. [PMID: 33901108 DOI: 10.1097/tp.0000000000003793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Donation after circulatory death determination frequently involves antemortem heparin administration to mitigate peri-arrest microvascular thrombosis. We systematically reviewed the literature to: (1) describe heparin administration practices and (2) explore the effects on transplant outcomes. We searched MEDLINE and EMBASE for studies reporting donation after circulatory death determination heparin practices including use, dosage, and timing (objective 1). To explore associations between antemortem heparin and transplant outcomes (objective 2), we (1) summarized within-study comparisons and (2) used meta-regression analyses to examine associations between proportions of donors that received heparin and transplant outcomes. We assessed risk of bias using the Newcastle Ottawa Scale and applied the GRADE methodology to determine certainty in the evidence. For objective 1, among 55 eligible studies, 48 reported heparin administration to at least some donors (range: 15.8%-100%) at variable doses (up to 1000 units/kg) and times relative to withdrawal of life-sustaining therapy. For objective 2, 7 studies that directly compared liver transplants with and without antemortem heparin reported lower rates of primary nonfunction, hepatic artery thrombosis, graft failure at 5 y, or recipient mortality (low certainty of evidence). In contrast, meta-regression analysis of 32 liver transplant studies detected no associations between the proportion of donors that received heparin and rates of early allograft dysfunction, primary nonfunction, hepatic artery thrombosis, biliary ischemia, graft failure, retransplantation, or patient survival (very low certainty of evidence). In conclusion, antemortem heparin practices vary substantially with an uncertain effect on transplant outcomes. Given the controversies surrounding antemortem heparin, clinical trials may be warranted.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Farid Foroutan
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Cote
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Graham Mclure
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Frederick D'Aragon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ian M Ball
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Alp Sener
- Department of Surgery and Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Markus Selzner
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Maureen O Meade
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
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Weiss MJ, van Beinum A, Harvey D, Chandler JA. Ethical considerations in the use of pre-mortem interventions to support deceased organ donation: A scoping review. Transplant Rev (Orlando) 2021; 35:100635. [PMID: 34174656 DOI: 10.1016/j.trre.2021.100635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 10/21/2022]
Abstract
AIM Pre-mortem interventions (PMIs) are performed on patients before the determination of death in order to preserve or enhance the possibility of organ donation. These interventions can be ethically controversial, and we thus undertook a scoping review of the ethical issues surrounding diverse PMIs. METHODS Using modified scoping review methods, we executed a search strategy created by an information specialist. Screening and iterative coding of each article was done by two researchers using qualitative thematic analysis, and narrative summaries of coded themes were presented. RESULTS We identified and screened 5365 references and coded 196 peer-reviewed publications. The most frequently cited issues were related to possible harms to the patient who is a potential donor, and legitimacy of consent. The most controversial issue was that PMIs may place patients at risk for physical harm, yet benefit is accrued mainly to recipients. Some authors argued that lack of direct medical benefit to the still living patient precluded valid consent from surrogate decision makers (SDMs), while many stated that some medical risk could be approved by SDMs if it aligns with non-medical benefits valued by the patient. CONCLUSION PMIs require consensus that benefit includes concepts beyond medical benefit to the patient who is a potential donor. Informed consent must be confirmed for each PMI and not assumed to be part of general consent for donation. Risk must be proportionate to the potential benefit and newly proposed interventions should be reviewed carefully for medical efficacy and potential risks.
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Affiliation(s)
- Matthew J Weiss
- Transplant Québec, 4100 Rue Molson #200, Montréal, QC H1Y 3N1, Canada; Canadian Donation and Transplantation Research Program (CDTRP), Room 6002, Li Ka Shing Centre for Health Research Innovation, University of Alberta, Edmonton, AB T6G 2E1, Canada; Division of Pediatric Intensive Care, Centre Mère-Enfant Soleil du CHU de Québec, 2705 boul Laurier, Québec, Québec, Canada.
| | - Amanda van Beinum
- Canadian Donation and Transplantation Research Program (CDTRP), Room 6002, Li Ka Shing Centre for Health Research Innovation, University of Alberta, Edmonton, AB T6G 2E1, Canada; Department of Sociology and Anthropology, B750 Loeb Building, Carleton University, 1125 Colonel By Drive, Ottawa, ON K1S 5B6, Canada
| | - Dan Harvey
- Nottingham University Hospital NHS Trust, Derby Road, Nottingham NG72UH, UK; University of Nottingham, University Park, Nottingham NG72RD, UK; National Health Services Blood & Transplant, Fox Den Road, Stoke Gifford, Avon, Bristol BS348RR, UK
| | - Jennifer A Chandler
- Canadian Donation and Transplantation Research Program (CDTRP), Room 6002, Li Ka Shing Centre for Health Research Innovation, University of Alberta, Edmonton, AB T6G 2E1, Canada; Bertram Loeb Research Chair, University of Ottawa, 57 Louis Pasteur St., Ottawa, Ontario K1N 6N5, Canada; Centre for Health Law, Policy and Ethics, Faculty of Law, University of Ottawa, 57 Louis Pasteur St., Ottawa, Ontario K1N 6N5, Canada.
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Murphy N, Weijer C, Smith M, Chandler J, Chamberlain E, Gofton T, Slessarev M. Controlled Donation After Circulatory Determination of Death: A Scoping Review of Ethical Issues, Key Concepts, and Arguments. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2021; 49:418-440. [PMID: 34665091 DOI: 10.1017/jme.2021.63] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Controlled donation after circulatory determination of death (cDCDD) is an important strategy for increasing the pool of eligible organ donors.
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Parent B, Moazami N, Wall S, Carillo J, Kon Z, Smith D, Walsh BC, Caplan A. Ethical and logistical concerns for establishing NRP-cDCD heart transplantation in the United States. Am J Transplant 2020; 20:1508-1512. [PMID: 31913567 DOI: 10.1111/ajt.15772] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/12/2019] [Accepted: 12/31/2019] [Indexed: 01/25/2023]
Abstract
Controlled heart donation after circulatory determination of death (cDCD) is well established internationally with good outcomes and could be adopted in the United States to increase heart supply if ethical and logistical challenges are comprehensively addressed. The most effective and resource-efficient method for mitigating warm ischemia after circulatory arrest is normothermic regional perfusion (NRP) in situ. This strategy requires restarting circulation after declaration of death according to circulatory criteria, which appears to challenge the legal circulatory death definition requiring irreversible cessation. Permanent cessation for life-saving efforts must be achieved to assuage this concern and ligating principal vessels maintains no blood flow to the brain, which ensures natural progression to cessation of brain function. This practice-standard in some countries-raises unique concerns about prioritizing life-saving efforts, informed authorization from decision-makers, and the clinician's role in the patient's death. To preserve public trust, medical integrity, and respect for the donor, the donation conversation must not take place until after an un-coerced decision to withdraw life-sustaining treatment made in accordance with the patient's treatment goals. The decision-maker(s) must understand cDCD procedure well enough to provide genuine authorization and the preservation/procurement teams must be kept separate from the clinical care team.
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Affiliation(s)
- Brendan Parent
- Department of Population Health, Division of Medical Ethics, NYU Langone Health, New York, New York
| | - Nader Moazami
- NYU Langone Transplant Institute, New York, New York
| | - Stephen Wall
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, New York.,Department of Population Health, Division of Health and Behavior, NYU Langone Health, New York, New York
| | - Julius Carillo
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Zachary Kon
- NYU Langone Transplant Institute, New York, New York
| | - Deane Smith
- NYU Langone Transplant Institute, New York, New York.,Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - B Corbett Walsh
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Langone Health, New York, New York
| | - Arthur Caplan
- Department of Population Health, Division of Medical Ethics, NYU Langone Health, New York, New York
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Ethische Relevanz und faktische Mängel in der Kommunikation von Spezifika der Organspende nach Kreislaufstillstand. Ethik Med 2018. [DOI: 10.1007/s00481-018-0501-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Hardart GE, Labriola MK, Prager K, Morris MC. Consent for organ donation after circulatory death at U.S. transplant centers. AJOB Empir Bioeth 2017; 8:205-210. [DOI: 10.1080/23294515.2017.1363319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Affiliation(s)
- George E. Hardart
- Department of Pediatrics, Columbia University College of Physicians and Surgeons
| | | | - Kenneth Prager
- Department of Medicine, Columbia University College of Physicians and Surgeons
| | - Marilyn C. Morris
- Department of Pediatrics, Columbia University College of Physicians and Surgeons
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Organ donation after assisted suicide: a potential solution to the organ scarcity problem. Transplantation 2014; 98:247-51. [PMID: 24825514 DOI: 10.1097/tp.0000000000000099] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Switzerland has low deceased organ donation rates. It is also one of the few countries where assisted suicide is decriminalized in some circumstances. If organs donated by Swiss and foreign citizens assisted in committing suicide in Switzerland were used for transplantation, the country could achieve a surplus of organs. There are several practical problems and ethical and legal objections to this proposal, all of which can be overcome. Organ donation after planned death is a potential solution to the organ scarcity problem in any country that permits assisted dying.
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de Lora P. What does "presumed consent" might presume? Preservation measures and uncontrolled donation after circulatory determination of death. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2014; 17:403-411. [PMID: 24481849 DOI: 10.1007/s11019-014-9548-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
One of the most controversial aspects in uncontrolled (out-of-hospital) donation of organs after circulatory death (uDCD) is the initiation of preservation measures before death. I argue that in so-called opting-out systems only under very stringent conditions we might presume consent to the instauration of those measures. Given its current legal framework, I claim that this is not the case of Spain, a well-known country in which consent is presumed-albeit only formally-and where uDCD is currently practiced.
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Affiliation(s)
- Pablo de Lora
- Department of Legal Philosophy, Law School, Universidad Autónoma de Madrid, 28049, Madrid, Spain,
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