Pro/con debate: in patients who are potential candidates for organ donation after cardiac death, starting medications and/or interventions for the sole purpose of making the organs more viable is an acceptable practice

Heads, Bodies, Brains, and Selves: Personal Identity and the Ethics of Whole-Body Transplantation

Plans to attempt what has been called a head transplant, a body transplant, and a head-to-body transplant in human beings raise numerous ethical, social, and legal questions, including the circumstances, if any, under which it would be ethically permissible to attempt whole-body transplantation (WBT) in human beings, the possible effect of WBT on family relationships, and how families should shape WBT decisions. Our assessment of many of these questions depends partially on how we respond to sometimes centuries-old philosophical thought experiments about personal identity. As with so much in bioethics, it is impossible to escape, or at least inadvisable to try to bypass, the relevant foundational philosophical concerns.

Ethical considerations in the use of pre-mortem interventions to support deceased organ donation: A scoping review

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.

ICU Management of the Potential Organ Donor: State of the Art

End-organ failure is associated with high mortality and morbidity, in addition to increased health care costs. Organ transplantation is the only definitive treatment that can improve survival and quality of life in such patients; however, due to the persistent mismatch between organ supply and demand, waiting lists continue to grow across the world. Careful intensive care management of the potential organ donor with goal-directed therapy has the potential to optimize organ function and improve donation yield.

Organ donation protocols

Organ transplantation improves survival and quality of life in patients with end-organ failure. Waiting lists continue to grow across the world despite remarkable advances in the transplantation process, from the creation of public engagement campaigns to the development of critical pathways for the timely identification, referral, approach, and treatment of the potential organ donor. The pathophysiology of dying triggers systemic changes that are intimately related to organ viability. The intensive care management of the potential organ donor optimizes organ function and improves the donation yield, representing a significant step in reducing the mismatch between organ supply and demand. Different beliefs and cultures reflect diverse legislations and donation practices amongst different countries, creating a challenge to standardized practices. Maintaining public trust is necessary for continued progress in organ donation and transplantation, hence the urge for a joint effort in creating uniform protocols that ensure transparent practices within the medical community.

Premortem interventions in dying children to optimise organ donation: an ethical analysis

A range of interventions in dying patients can improve both the possibility of successful organ donation and the likely long-term success of transplantation. The ethical and legal issues surrounding such interventions, which most frequently occur in the context of donation after circulatory determination of death, are complex, controversial and many remain unresolved. This is true with adults, but even more so with children, where the issue of organ donation and premortem interventions to facilitate it, are highly sensitive. Essentially, such interventions are being undertaken in dying children who cannot medically benefit from them, though arguments have been advanced that becoming a donor might be in a child's extended best interest. However, certain interventions carry a potential risk, although small, of direct harm and of course overall objections to child donation after circulatory determination of death per se are still expressed in the literature. But, unlike the case in critically ill adults, those giving permission for such interventions are normally able to fully participate in decision-making, and indeed to consent, to both donation and premortem interventions. We review the issue of the use of premortem interventions in dying children to facilitate organ donation, including decision-making and ethical justification. Individual interventions are then considered, including an ethical analyse of their use. Finally, we recommend an approach using a combination of welfare checklist strategy, coupled with the establishment of an agreed zone of parental discretion about individual interventions which might be used in dying children to increase the possibility of successful organ donation.

Donation after circulatory death: a national survey of current practice in England in 2012

OBJECTIVE

In recent years, England has seen renewed interest in donation after circulatory death. Many national and local initiatives have been implemented to encourage and support donation after circulatory death. To assess whether practice is in line with published guidance, we conducted a national survey with regard to current donation after circulatory death practices, local guidelines, and views on the need to further develop a national standardized protocol for donation after circulatory death.

DESIGN

Online survey.

SUBJECTS

Lead physicians for intensive care or organ donation for every acute National Health Service trust in England delivering adult care between April and June 2012.

INTERVENTIONS

Physicians were e-mailed a link to a structured online questionnaire regarding their experience and practice of donation after circulatory death, including local protocols, use of organ optimization, and the need for a national protocol.

MEASUREMENTS AND MAIN RESULTS

We received replies from 119 of 156 eligible trusts (76.3%) in England. Of these, 112 trusts (94%) have performed donation after circulatory death. Ninety-three trusts (78.1%) have a local donation after circulatory death protocol, and 89 trusts (74.7%) felt there should be a national donation after circulatory death protocol. All responding transplant centers had performed donation after circulatory death, 14 of 17 (82.3%) had a donation after circulatory death protocol with 14 of 17 respondents (82.3%) supporting a national protocol. Regarding organ optimization, 92 institutions (77.3%) used vasoactive drugs to achieve a target mean arterial blood pressure with 82 centers (68.9%) employing positive end-expiratory pressure and FIO2 to optimize oxygenation. Eight centers (6.7%) used heparin premortem compared with two of 17 transplant centers (11.8%). Two centers have used phentolamine to facilitate organ retrieval, with another five centers (4.2%) cannulating vessels premortem.

CONCLUSIONS

Our survey revealed varying approaches and views toward donation after circulatory death across England. A greater than expected percentage use premortem cannulation, heparinization, and phentolamine despite current guidance in England to the contrary. The majority of institutions practicing donation after circulatory death with protocols in place favor the development of national guidelines, particularly with respect to organ optimization. We believe that such a protocol would help to address potential barriers to donation after circulatory death, which may lead to increased donation rates and improved outcomes.

The potential for neonatal organ donation in a children's hospital

OBJECTIVE

Neonatal organ donation does not occur in the UK. Unlike in other European countries, Australasia and the USA death verification/certification standards effectively prohibit use of neurological criteria for diagnosing death in infants between 37 weeks' gestation and 2 months of age and therefore donation after neurological determination of death. Neonatal donation after circulatory definition of death is also possible but is not currently undertaken. There is currently no specific information about the potential neonatal organ donation in the UK; this study provides this in one tertiary children's hospital.

DESIGN

Retrospective mortality database, clinical document database and patient notes review.

SETTING

Neonatal and Paediatric Intensive Care in a tertiary children's hospital.

PATIENTS

Infants dying between 37 weeks' gestation and 2 months of age between 1 January 2006 and 31 October 2012. Potential assessed using current UK guidelines for older children and neonatal criteria elsewhere.

RESULTS

84 infants died with 45 (54%) identified as potential donors. 34 (40%) were identified as potential donors after circulatory definition of death and 11 (13%) were identified as being theoretical potential donors after neurological determination of death. 10 (12%) were identified as unlikely donors due to relative contraindications and 39 (46%) were definitely not potential donors.

CONCLUSIONS

With around 60 paediatric organ donors in the UK annually, there does appear significant potential for donation within the neonatal population. Reconsideration of current infant brain stem death guidelines is required to allow parents the opportunity of donation after neurological determination of death, together with mandatory training in organ donation for neonatal teams, which will also facilitate donation after circulatory definition of death.

Donation after cardiac death and the emergency department: ethical issues

Organ donation after cardiac death (DCD) is increasingly considered as an option to address the shortage of organs available for transplantation, both in the United States and worldwide. The procedures for DCD differ from procedures for donation after brain death and are likely less familiar to emergency physicians (EPs), even as this process is increasingly involving emergency departments (EDs). This article explores the ED operational and ethical issues surrounding this procedure.

The M3 from the international point of view

Deciding to cease treatment in intensive care unit patients whose prognosis is hopeless allows programming the moment of death, and hence, post mortem transplantable organ donation. Such organ donations are more frequent in Anglo-Saxon countries. In the context of growing organ needs, they have significantly increased the number of organs that are available for transplant. Progressive experience has shown that crystal-clear procedures must be set up in order to avoid lack of understanding, opposition, or even conflict between involved medical teams and immediate relatives of potential donors. The decision of organ transplantation must totally be separated from the decision of treatment cessation. Supportive treatment cessation must be done according to previously established procedures. Medications that are compatible with organ transplantation must be listed. Finally, the needs of patient relatives must be met.

Donation after cardiac death: ethical dilemmas and implications for advanced practice nurses

Donation after cardiac death has always presented ethical concerns among health care providers. As advanced practice nurses and critical care nurses, it is our responsibility to ensure that health care providers and families are educated about the process and that we remain advocates for the potential donors. This article reviews the donation after cardiac death process, provides a donation after cardiac death hypothetical case report and its outcome, and addresses the ethical concerns associated with donation after cardiac death from both opponents' and proponents' points of view. It will also discuss the benefits of obtaining a palliative care consult and the roles of the advanced practice nurse in the care of the potential donor.

Incremental Increases in Organ Retrieval after Protocol Driven Change in an Organ Procurement Organization: A 15-Year Assessment

The need for transplantable organs exceeds the available supply. Organ procurement organizations (OPOs) have undergone both voluntary and mandated changes to optimize available organs. The data from a single statewide OPO was reviewed from 1993 to 2008 and tracked with implementation of new protocols. During the study, 5548 organs were recovered with 4875 transplanted from 1441 donors (3.38 organs transplanted/donor (OTPD)). The conversion rate (CR) for consent rose from 42 to 72 per cent whereas the average age of donors increased from 33 to 45 years. After implementation of a family support liaison program, a higher performing hospital in the OPO realized an increase in CR from 57 to 97 per cent over 8 years. Implementation of an intensivist program improved OTPD. The number of standard criteria donors and extended criteria donors (ECD) increased. The increase in standard criteria donors yielded a large number of thoracic organs. ECD increased as did the organ discard rate from 8 to 16 per cent. Increases in organ retrieval were noted after incremental changes in OPO protocol. Family support and intensivist programs enhanced CR and OTPD. Increases in the number of ECD were noted with increasing age after the introduction of the intensivist program and an increase in transplant center use of these organs.

Organ Procurement After Cardiocirculatory Death: A Critical Analysis

To shorten the transplantation waiting time in the United States, federal regulations have been introduced requiring hospitals to develop policies for organ donation after cardiac (or circulatory) death (DCD). The practice of DCD is invoked based on the validity of the University of Pittsburgh Medical Center (UPMC) protocol and relies on the accuracy of the University of Wisconsin (UW) evaluation tool to appropriately identify organ donors. There is little evidence to support the position that the criteria for organ procurement adopted from the UPMC protocol complies with the dead donor rule. A high false-positive rate of the UW evaluation tool can expose many dying patients to unnecessary perimortem interventions because of donation failure. The medications and/or interventions for the sole purpose of maintaining organ viability can have unintended negative consequences on the timing and quality of end-of-life care offered to organ donors. It is essential to address and manage the evolving conflict between optimal end-of-life care and the necessary sacrifices for the procurement of transplantable organs from the terminally ill. The recipients of marginal organs recovered from DCD can also suffer higher mortality and morbidity than recipients of other types of donated organs. Finally, transparent disclosure to the public of the risks involved to both organ donors and recipients may contribute to open societal debate on the ethical acceptability of DCD.