Lung donation after medical assistance in dying at home

The Extent to Which the Wish to Donate One's Organs After Death Contributes to Life-Extension Arguments in Favour of Voluntary Active Euthanasia in the Terminally Ill: An Ethical Analysis

In terminally ill individuals who would otherwise end their own lives, active voluntary euthanasia (AVE) can be seen as life-extending rather than life-shortening. Accordingly, AVE supports key pro-euthanasia arguments (appeals to autonomy and beneficence) and meets certain sanctity of life objections. This paper examines the extent to which a terminally ill individual's wish to donate organs after death contributes to those life-extension arguments. It finds that, in a terminally ill individual who wishes to avoid experiencing life he considers to be not worth living, and who also wishes to donate organs after death, AVE maximizes the likelihood that such donations will occur. The paper finds that the wish to donate organs strengthens the appeals to autonomy and beneficence, and fortifies the meeting of certain sanctity of life objections, achieved by life-extension arguments, and also generates appeals to justice that form novel life-extension arguments in favour of AVE in this context.

Organ donation following medical assistance in dying, Part II: a scoping review of existing processes and procedures

OBJECTIVE

The objective of this review was to collate and summarize the current literature on what is known about organ donation following medical assistance in dying (MAiD). For this second part of a 2-part scoping review, the focus is on the existing procedures and processes for organ donation following MAiD.

INTRODUCTION

Organ donation following MAiD is a novel and contentious issue worldwide. To give direction for future research and initiatives, a comprehensive understanding of the available evidence of existing procedures and processes for organ donation following MAiD is needed.

INCLUSION CRITERIA

For this review, the population of interest included all individuals who underwent organ donation following MAiD; the concept was defined as procedures and processes involved in organ donation after MAiD; and the context was reports of organ donation following MAiD at home or in any health care setting worldwide. We considered quantitative and qualitative studies, text and opinion papers, gray literature, and unpublished material provided by stakeholders.

METHODS

This scoping review was conducted in line with JBI methodology. Published studies were retrieved from MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), Web of Science Core Collection, and Academic Search Complete (EBSCOhost). Gray and unpublished literature included reports from websites and organ donation organizations in Canada, Belgium, and The Netherlands. Two independent reviewers screened all reports (both title and abstract, and full text) against the predetermined inclusion criteria, extracted data, and completed a content analysis. Any disagreements between the 2 reviewers were resolved through discussion or with another reviewer.

RESULTS

We included 121 documents across parts I and II, and we report on 107 documents in this second part. The majority of the 107 documents were discussion papers, published in English, and in Canada from 2019 to 2021. In the content analysis, we identified 5 major categories regarding existing procedures and processes of organ donation following MAiD: i) clinical pathways for organ donation following MAiD; ii) organ donation following MAiD and the donor; iii) clinical practice tools for organ donation following MAiD; iv) education and support for health care providers involved in organ donation following MAiD; and v) health care providers' roles and perceptions during organ donation following MAiD.

CONCLUSIONS

Findings from this review can be used to provide support and guidance for improvements in procedures and processes, as well as a rich resource for countries currently planning to establish programs for organ donation after MAiD.

Organ donation after euthanasia starting with anesthesia at home is legal in The Netherlands, Belgium, Canada and Spain

We would like to respond to the article "Organ donation after euthanasia starting at home in a patient with multiple system atrophy Tajaâte et al., [2021] 22:120" on organ donation after euthanasia from home [ODEH]. Although we welcome the performance of ODEH, we would like to make some critical comments regarding the article, both in relation to factual inaccuracies and in terms of the vision expressed on this subject. In this letter we stress the protection of autonomy of vulnerable euthanasia patients, we contradict the assumption of illegality, we question if the anesthesia method utilized is optimal and correct a mistake in regard to an article to which is referred of ourselves.

Missed opportunities: saving lives through organ donation following voluntary assisted dying

Organ donation after voluntary assisted dying (VAD) in Australia may potentially increase organ transplant rates. Despite significant international experience with donation after VAD, there has been little discussion of this in Australia. We review potential ethical and practical concerns relating to donation after VAD and advocate action to establish programmes in Australia that ensure safe, ethical and effective donation after VAD.

Outcomes from organ donation following medical assistance in dying: A scoping review

AIM

To collate and summarize the current international literature on the transplant recipient outcomes of organs from Medical Assistance in Dying (MAiD) donors, as well as the actual and potential impact of organ donation following MAiD on the donation and transplantation system.

BACKGROUND

The provision of organ donation following MAiD can impact the donation and transplantation system, as well as potential recipients of organs from the MAiD donor, therefore a comprehensive understanding of the potential and actual impact of organ donation after MAiD on the donation and transplantation systems is needed.

DESIGN

Scoping review using the JBI framework.

METHODS

We searched for published (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Academic Search Complete), and unpublished literature (organ donation organization websites worldwide). Included references discussed the actual and potential impact of organ donation following MAiD on the donation and transplantation system. All references were screened, extracted and analysed by two independent reviewers.

RESULTS

We included 78 references in this review and our finding were summarized across three categories: (1) Impact in the donor pool: (2) statistics on organ donation following MAiD; and (3) potential and actual impact of MAiD on the donation and transplant system.

CONCLUSIONS

The potential impact of the MAiD donor on the transplant waiting list is relatively small as this process is still rare, however, due to the current organ shortage worldwide the contribution of this procedure should not be disregarded. Additionally, despite being limited, the existing research provided scanty evidence that organs retrieved from MAiD donors are associated with satisfactory graft function and survival rates and that outcomes from transplant recipients are comparable to those of organs from donation following brain death and may be better than those of organs from other types of donation after circulatory determined death. Still, further studies are required for comprehensive and reliable evidence.

Practice and challenges for organ donation after medical assistance in dying: A scoping review including the results of the first international roundtable in 2021

The procedure combining medical assistance in dying (MAiD) with donations after circulatory determination of death (DCDD) is known as organ donation after euthanasia (ODE). The first international roundtable on ODE was held during the 2021 WONCA family medicine conference as part of a scoping review. It aimed to document practice and related issues to advise patients, professionals, and policymakers, aiding the development of responsible guidelines and helping to navigate the issues. This was achieved through literature searches and national and international stakeholder meetings. Up to 2021, ODE was performed 286 times in Canada, the Netherlands, Spain, and Belgium, including eight cases of ODE from home (ODEH). MAiD was provided 17,217 times (2020) in the eight countries where ODE is permitted. As of 2021, 837 patients (up to 14% of recipients of DCDD donors) had received organs from ODE. ODE raises some important ethical concerns involving patient autonomy, the link between the request for MAiD and the request to donate organs and the increased burden placed on seriously ill MAiD patients.

Outcomes of lung transplantation from organ donation after medical assistance in dying: First North American experience

Over 2.5% of deaths in Canada occur as a result from medical assisting in dying (MAID), and a subset of these deaths result in organ donation. However, detailed outcomes of lung transplant recipients using these donors is lacking. This is a retrospective single center cohort study comparing lung transplantation outcomes after donation using MAID donors compared to neurologically determined death and controlled donation after circulatory death (NDD/cDCD) donors from February 2018 to July 2021. Thirty-three patients received lungs from MAID donors, and 560 patients received lungs from NDD/cDCD donors. The donor diagnoses leading to MAID provision were degenerative neurological diseases (n = 33) and end stage organ failure (n = 5). MAID donors were significantly older than NDD/cDCD donors (56 [IQR 49-64] years vs. 48 [32-59]; p = .0009). Median ventilation period and 30 day mortality were not significantly different between MAID and NDD/cDCD lungs recipients (ventilation: 1 day [1-3] vs 2 days [1-3]; p = .37, deaths 0% [0/33] vs. 2% [11/560], p = .99 respectively). Intermediate-term outcomes were also similar. In summary, for lung transplantation using donors after MAID, recipient outcomes were excellent. Therefore, where this practice is permitted, donation after MAID should be strongly considered for lung transplantation as a way to respect donor wishes while substantially improving outcomes for recipients with end-stage lung disease.

Utility of Islet Cell Preparations From Donor Pancreases After Euthanasia

Patients fulfilling criteria for euthanasia can choose to donate their organs after circulatory death [donors after euthanasia (DCD V)]. This study assesses the outcome of islet cell isolation from DCD V pancreases. A procedure for DCD V procurement provided 13 pancreases preserved in Institut Georges Lopez-1 preservation solution and following acirculatory warm ischemia time under 10 minutes. Islet cell isolation outcomes are compared with those from reference donors after brain death (DBD, n = 234) and a cohort of donors after controlled circulatory death (DCD III, n = 29) procured under the same conditions. Islet cell isolation from DCD V organs resulted in better in vitro outcome than for selected DCD III or reference DBD organs. A 50% higher average beta cell number before and after culture and a higher average beta cell purity (35% vs 24% and 25%) was observed, which led to more frequent selection for our clinical protocol (77% of isolates vs 50%). The functional capacity of a DCD V islet cell preparation was illustrated by its in vivo effect following intraportal transplantation in a type 1 diabetes patient: injection of 2 million beta cells/kg body weight (1,900 IEQ/kg body weight) at 39% insulin purity resulted in an implant with functional beta cell mass that represented 30% of that in non-diabetic controls. In conclusion, this study describes procurement and preservation conditions for donor organs after euthanasia, which allow preparation of cultured islet cells, that more frequently meet criteria for clinical use than those from DBD or DCD III organs.

Pushing the Envelope for Donor Lungs

The shortage of organ donors remains the major limiting factor in lung transplant, with the number of patients on the waiting list largely exceeding the number of available organ donors. Another issue is the low utilization rate seen in some types of donors. Therefore, novel strategies are continuously being explored to increase the donor pool. Advanced age, smoking history, positive serologies, and size mismatch are common criteria that decrease the rate of use when it comes to organ utilization. Questioning these limitations is one of the purposes of this review. Challenging these limitations by adapting novel donor management strategies could help to increase the rate of suitable lungs for transplantation while still maintaining good outcomes. A second goal is to present the latest advances in organ donation after controlled and uncontrolled cardiac death, and also on how to improve these lungs on ex vivo platforms for assessment and future specific therapies. Finally, pushing the limit of the donor envelope also means reviewing some of the recent improvements made in lung preservation itself, as well as upcoming experimental research fields. In summary, donor lung optimization refers to a global care strategy to increase the total numbers of available allografts, and preserve or improve organ quality without paying the price of early-, mid-, or long-term negative outcomes after transplantation.