Donation after uncontrolled cardiac death (uDCD): a review of the debate from a European perspective

The role of healthcare professionals to improve organ donation and transplantation outcome: a national study

BACKGROUND

Improve the quality of donor coordination activities caused by an increased organ donation rate. The aim of this study was to assess the influence of organ donation coordinators' characteristics on rate of donation and family consent rate in Recognition Centers (RCs) and Organ Procurement Units (OPUs) in Iran by analyzing the organ procurement and transplantation data.

MATERIALS AND METHODS

Based on a questionnaire, this retrospective study evaluated the number of confirmed brain deaths, family consent rate, organ recoveries, rate of expired brain death cases before and after family consent in Iran.

RESULTS

According to results, the overall family consent rate in the entire country is equal to 60.63%. The work experience had a significant effect on the number of procured organs (P < 0.004), death rate after family consent (P < 0.04), and eligible donor death before family consent (P < 0.03). The type of unit (RCs or OPUs) had significant difference on death after family consent (P < 0.023), the death before family consent (P < 0.014), the sum of procured organ (P < 0.04).

CONCLUSION

The consent rate and donor management in the cases of brain death are unacceptable. The coordinators need training to increase their efficiency in terms of family approach and maintenance of brain death. Only by improving the level of family consent and increasing the coordinators' maintenance skills for brain death cases can the amount of organ donation in Iran be doubled to the current amount.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

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.

One or two types of death? Attitudes of health professionals towards brain death and donation after circulatory death in three countries

This study examined health professionals' (HPs) experience, beliefs and attitudes towards brain death (BD) and two types of donation after circulatory death (DCD)--controlled and uncontrolled DCD. Five hundred and eighty-seven HPs likely to be involved in the process of organ procurement were interviewed in 14 hospitals with transplant programs in France, Spain and the US. Three potential donation scenarios--BD, uncontrolled DCD and controlled DCD--were presented to study subjects during individual face-to-face interviews. Our study has two main findings: (1) In the context of organ procurement, HPs believe that BD is a more reliable standard for determining death than circulatory death, and (2) While the vast majority of HPs consider it morally acceptable to retrieve organs from brain-dead donors, retrieving organs from DCD patients is much more controversial. We offer the following possible explanations. DCD introduces new conditions that deviate from standard medical practice, allow procurement of organs when donors' loss of circulatory function could be reversed, and raises questions about "death" as a unified concept. Our results suggest that, for many HPs, these concerns seem related in part to the fact that a rigorous brain examination is neither clinically performed nor legally required in DCD. Their discomfort could also come from a belief that irreversible loss of circulatory function has not been adequately demonstrated. If DCD protocols are to achieve their full potential for increasing organ supply, the sources of HPs' discomfort must be further identified and addressed.

Donation after cardiocirculatory death: a call for a moratorium pending full public disclosure and fully informed consent

Many believe that the ethical problems of donation after cardiocirculatory death (DCD) have been "worked out" and that it is unclear why DCD should be resisted. In this paper we will argue that DCD donors may not yet be dead, and therefore that organ donation during DCD may violate the dead donor rule. We first present a description of the process of DCD and the standard ethical rationale for the practice. We then present our concerns with DCD, including the following: irreversibility of absent circulation has not occurred and the many attempts to claim it has have all failed; conflicts of interest at all steps in the DCD process, including the decision to withdraw life support before DCD, are simply unavoidable; potentially harmful premortem interventions to preserve organ utility are not justifiable, even with the help of the principle of double effect; claims that DCD conforms with the intent of the law and current accepted medical standards are misleading and inaccurate; and consensus statements by respected medical groups do not change these arguments due to their low quality including being plagued by conflict of interest. Moreover, some arguments in favor of DCD, while likely true, are "straw-man arguments," such as the great benefit of organ donation. The truth is that honesty and trustworthiness require that we face these problems instead of avoiding them. We believe that DCD is not ethically allowable because it abandons the dead donor rule, has unavoidable conflicts of interests, and implements premortem interventions which can hasten death. These important points have not been, but need to be fully disclosed to the public and incorporated into fully informed consent. These are tall orders, and require open public debate. Until this debate occurs, we call for a moratorium on the practice of DCD.

Organ donation after circulatory determination of death: lessons and unresolved controversies

This article responds to the four pieces in this special symposium of the Journal of Law, Medicine & Ethics on uncontrolled organ donation following circulatory death (uDCD). The response will focus on lessons and debates about the kinds of consent necessary and sufficient for temporary organ preservation in the context of DCD and for organ donation itself; on conflicts of obligation, loyalty, and interest in DCD and ways to address those conflicts; and on benefit, cost, risk assessments of uDCD programs, including measures to achieve a more favorable balance of benefits, costs, and risks.

Introduction: Organ donation and death from unexpected circulatory arrest: engaging the recommendations of the Institute of Medicine

This symposium explores the boldest recommendation of the Institute of Medicine’s (IOM) Committee on Increasing Rates of Organ Donation (hereafter Committee), namely, the recommendation that the U.S. consider a new population of potential donors. In its 2006 report, Organ Donation: Opportunities for Action, the committee recommended pilot programs in socalled “uncontrolled” donation after a circulatory determination of death (uDCD). Potential uDCD donors have died from an unexpected loss of circulation, either due to sudden cardiac arrest or excessive blood loss following traumatic injury. Because circulation is lost before death is determined and long before organ procurement could begin, potentially transplantable organs will die from oxygen starvation (warm ischemia) unless they are quickly preserved by cooling or other means.