Does uncontrolled cardiac death for organ donation raise ethical questions? An opinion survey

A scoping review of the perceptions of death in the context of organ donation and transplantation

BACKGROUND

Socio-cultural perceptions surrounding death have profoundly changed since the 1950s with development of modern intensive care and progress in solid organ transplantation. Despite broad support for organ transplantation, many fundamental concepts and practices including brain death, organ donation after circulatory death, and some antemortem interventions to prepare for transplantation continue to be challenged. Attitudes toward the ethical issues surrounding death and organ donation may influence support for and participation in organ donation but differences between and among diverse populations have not been studied.

OBJECTIVES

In order to clarify attitudes toward brain death, organ donation after circulatory death and antemortem interventions in the context of organ donation, we conducted a scoping review of international English-language quantitative surveys in various populations.

STUDY APPRAISAL

A search of literature up to October 2020 was performed, using multiple databases. After screening, 45 studies were found to meet pre-specified inclusion criteria.

RESULTS

32 studies examined attitudes to brain death, predominantly in healthcare professionals. In most, around 75% of respondents accepted brain death as equivalent to death of the person. Less common perspectives included equating death with irreversible coma and willingness to undertake organ donation even if it caused death. 14 studies examined attitudes to organ donation following circulatory death. Around half of respondents in most studies accepted that death could be confidently diagnosed after only 5 min of cardiorespiratory arrest. The predominant reason was lack of confidence in doctors or diagnostic procedures. Only 6 studies examined attitudes towards antemortem interventions in prospective organ donors. Most respondents supported minimally invasive procedures and only where specific consent was obtained.

CONCLUSIONS

Our review suggests a considerable proportion of people, including healthcare professionals, have doubts about the medical and ethical validity of modern determinations of death. The prognosis of brain injury was a more common concern in the context of organ donation decision-making than certainty of death.

Death determination, organ donation and the importance of the Dead Donor Rule following withdrawal of life-sustaining treatment: A survey of community opinions

Organ donation (OD) following circulatory determination of death (DCDD) is an increasing source of transplant organs but little is known about community opinions on treatment withdrawal, death determination death and acceptance of OD in DCDD. To determine attitudes on death determination, the importance of patient choice in treatment withdrawal and OD agreement, and the importance of the 'Dead Donor Rule', we undertook a scenario-based online survey of 1017 members of the Australian general public. Mean levels of agreement across respondent's responses to statements were compared by repeated measures ANOVA. 54% (548) of respondents agreed that a DCDD scenario patient could be declared dead 2 minutes after circulatory standstill, however over 80% nonetheless agreed OD would be appropriate, including 77% (136/176) of those disagreeing with 2-minute death declaration. 48% (484) supported OD even if it caused the patient's death. 75% (766) accepted relatively benign ante-mortem treatments administered to improve transplant outcomes. Over 70% supported a high quadriplegic patient's request to be allowed to die, with 61% (622) agreeing that he should be allowed to donate his organs under anaesthesia, but 60% (610) also agreed that he should first be declared dead. In conclusion, we found high levels of support for treatment withdrawal in severe brain injury and when requested by a quadriplegic patient. While there was variable agreement with the timing of death determination and with OD under anaesthesia, support for OD was high in both scenarios. For many people death determination prior to OD may not be of paramount importance. This article is protected by copyright. All rights reserved.

A Comparison of Request Process and Outcomes in Donation After Cardiac Death and Donation After Brain Death: Results From a National Study

Available literature points to healthcare providers' discomfort with donation after cardiac death (DCD) and their perception of public reluctance toward the procedure. Using a national sample, we report on the communication content of actual DCD and donation after brain death (DBD) approaches by organ procurement organization (OPO) requesters and compare family decision makers' (FDMs') experiences of both modalities. We recruited 1601 FDMs using a validated protocol; 347 (21.7%) were of potential DCD donors. Semistructured telephone interviews yielded FDMs' sociodemographic data, donation attitudes, assessment of approach, final outcomes, and substantiating reasons. Initial analysis consisted of bivariate analyses. Multilevel mixture models compared groups representing authorization outcome and DCD/DBD status. No significant differences in family authorization were found between DCD and DBD cases. Statistically significant associations were found between sociodemographic characteristics and authorization, with white FDMs more likely to authorize DCD or DBD than black FDMs. FDMs of both modalities had similar evaluations of requester skills, topics discussed, satisfaction, and refusal reasons. The findings suggest that the DCD/DBD distinction may not be notable to families. We recommend the use of similar approach strategies and communication skills and the development of education campaigns about the public's acceptance of DCD.

Analysis of knowledge of the general population and health professionals on organ donation after cardiac death

Objective

To evaluate the knowledge and acceptance of the public and professionals working in intensive care units regarding organ donation after cardiac death.

Methods

The three hospitals with the most brain death notifications in Curitiba were selected, and two groups of respondents were established for application of the same questionnaire: the general public (i.e., visitors of patients in intensive care units) and health professionals working in the same intensive care unit. The questionnaire contained questions concerning demographics, intention to donate organs and knowledge of current legislation regarding brain death and donation after cardiac death.

Results

In total, 543 questionnaires were collected, including 442 from family members and 101 from health professionals. There was a predominance of women and Catholics in both groups. More females intended to donate. Health professionals performed better in the knowledge comparison. The intention to donate organs was significantly higher in the health professionals group (p = 0.01). There was no significant difference in the intention to donate in terms of education level or income. There was a greater acceptance of donation after uncontrolled cardiac death among Catholics than among evangelicals (p < 0.001).

Conclusion

Most of the general population intended to donate, with greater intentions expressed by females. Education and income did not affect the decision. The type of transplant that used a donation after uncontrolled cardiac death was not well accepted in the study population, indicating the need for more clarification for its use in our setting.

Protocols for uncontrolled donation after circulatory death: a systematic review of international guidelines, practices and transplant outcomes

INTRODUCTION

A chronic shortage of organs remains the main factor limiting organ transplantation. Many countries have explored the option of uncontrolled donation after circulatory death (uDCD) in order to expand the donor pool. Little is known regarding the variability of practices and outcomes between existing protocols. This systematic review addresses this knowledge gap informing policy makers, researchers, and clinicians for future protocol implementation.

METHODS

We searched MEDLINE, EMBASE, and Google Scholar electronic databases from 2005 to March 2015 as well as the reference lists of selected studies, abstracts, unpublished reports, personal libraries, professional organization reports, and government agency statements on uDCD. We contacted leading authors and organizations to request their protocols and guidelines. Two reviewers extracted main variables. In studies reporting transplant outcomes, we added type, quantity, quality of organs procured, and complications reported. Internal validity and the quality of the studies reporting outcomes were assessed, as were the methodological rigour and transparency in which a guideline was developed. The review was included in the international prospective register of systematic reviews (Prospero, CRD42014015258).

RESULTS

Six guidelines and 18 outcome studies were analysed. The six guidelines are based on limited evidence and major differences exist between them at each step of the uDCD process. The outcome studies report good results for kidney, liver, and lung transplantation with high discard rates for livers.

CONCLUSIONS

Despite procedural, medical, economic, legal, and ethical challenges, the uDCD strategy is a viable option for increasing the organ donation pool. Variations in practice and heterogeneity of outcomes preclude a meta-analysis and prevented the linking of outcomes to specific uDCD protocols. Further standardization of protocols and outcomes is required, as is further research into the role of extracorporeal resuscitation and other novel therapies for treatment of some refractory cardiac arrest. It is essential to ensure the maintenance of trust in uDCD programs by health professionals and the public.