American Journal of Transplantation 2011; 11: 1351–1352 Wiley Periodicals Inc.
Editorial
C 2011 The Authors C 2011 The American Society of Journal compilation Transplantation and the American Society of Transplant Surgeons
doi: 10.1111/j.1600-6143.2011.03583.x
Uncontrolled Donation after Circulatory Determination of Death (UDCDD) and the Definition of Death D. W. Hantoa, * and R. M. Veatchb a
Transplant Institute and the Center for Transplant Outcomes and Quality Improvement, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA b The Kennedy Institute of Ethics, Georgetown University, Washington, DC ∗ Corresponding author: Douglas W. Hanto,
[email protected]
Received 20 March 2011, revised 20 March 2011 and accepted for publication 05 April 2011
In response to the shortage of organs for transplantation, the Institute of Medicine (IOM) report suggesting individuals suffering an out-of-hospital cardiac arrest might be a substantial new source of transplantable organs, and reports of successful uncontrolled donation after circulatory determination of death (UDCDD) in Spain, the New York City UDCDD Study Group has received approval for a UDCDD trial for kidneys only (1). This has been an impressive effort that has involved numerous stakeholders in the community, government agencies and medical specialists. All are to be commended for their thoughtfulness, hard work and cooperation.1 The key features of the protocol include the EMS responders’ decision of termination of resuscitation (TOR) after resuscitative efforts have failed; arrival of organ procurement unit (OPU) staff within 2 min; determination of first person consent for organ donation; brain stem assessment, heparin administration, 1 min of manual chest compressions and transfer to the organ preservation vehicle (OPV); continued preservation using mechanical ventilation and an automated chest compression device; transfer to the hospital where a brain stem assessment will be repeated to be certain that preservation procedures do not prevent ‘. . .natural progression to irreversible brain death’; establishment of normothermic extracorporeal membranous oxygenation (nECMO) with prior placement of a bal-
1
We would encourage the reader to review the supplemental documents that provide more detail of their deliberations.
loon in the abdominal aorta to prevent brain circulation; and initiation of standard New York Organ Donation Network procedures for organ donation including screening, confirming donor’s desire to donate with an authorized party, and procurement with warm ischemia (WIT) times not to exceed 120 min. In spite of their thorough review the authors propose a procedure for circulatory determination of death after attempts to reestablish circulation have failed followed by measures to maintain organ perfusion that reasonable people might view as pronouncing death prematurely. In controlled donation after circulatory determination of death (CDCDD) it has been accepted that death may be pronounced once circulation is deemed permanently lost because spontaneous reversal (autoresuscitation) cannot occur and is irreversibly lost because no attempt will be made to reestablish circulation. Although Marquis (2) and others have disputed that permanent circulation loss counts as irreversible when circulation could be established but will not be because a valid decision has been made not to resuscitate, we, and many others, agree with this premise. In the NY UDCDD protocol efforts to restore circulation are inconsistent with the existing consensus policy because chest compression, mechanical ventilation and nECMO might be seen as restoring circulation, leading to the conclusion that death was pronounced inappropriately. Furthermore, Bernat (3) has expressed concern that ECMO prevents the inevitable progression of brain ischemia leading to brain death because oxygen and blood flow are restored to the brain. The Health Resources and Services Administration (HRSA) required the NY protocol to include brain stem assessments and insertion of a balloon in the aorta to prevent reperfusion of the brain. However, the legal definition of death by circulatory criteria has no requirement for assessing brain function and thus, the only rationale for this requirement would be a concern (probably unfounded) that patients may regain some conscious awareness, not that nECMO prevents progression of brain ischemia leading to brain death. How can these problems be overcome? The most obvious would be to omit chest compressions, mechanical ventilation and nECMO, but this would lead to prolonged WIT that would likely preclude a successful UDCDD program. Alternatively, one could envision a portable operating room that could be used to initiate cold perfusion with preservation solution through femoral cannulas in the 1351
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field after circulatory determination of death. This would require acceptance of preservation based on first person consent through a motor vehicle registry or some other process to assure the donor’s wishes were being adhered to. Other strategies would be to rely on brain death pronouncement, although meeting the criteria for brain death declaration would be nearly impossible in this emergency setting, or developing an acceptable argument that chest compressions and nECMO as proposed do not constitute re-establishing circulation. One could also adopt Truog’s and Miller’s (4) argument that adherence to the dead donor rule in organ donation is not necessary in certain classes of cases including UDCDD. They argue that the requirement of informed consent in the setting of devastating neurologic injury is sufficient for organ donation, and donors will die from withdrawal of support, not organ donation, just as they do in other circumstances not associated with organ donation. However, it is unlikely that there will ever be support for removing organs from individuals who have not been declared dead. Finally, as previously suggested (5) the definition of death could be amended to include those who had permanently and completely lost higher brain function responsible for consciousness, but such a revision is also unlikely to be widely accepted. Although there is much merit to the efforts of the NY UDCDD Study Group, we remain concerned that restoring
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aspects of circulation will be perceived as negating permanent loss of circulation that would justify the declaration of circulatory death as we currently define it and that confusion and controversy around this issue could be a setback for organ donation and UDCDD protocols.
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
References 1. Wall SP, Kaufman BJ, Gilbert AJ et al. Derivation of the uncontrolled donation after circulatory determination of death protocol for New York City. Am J Transplant 2011; 11: 1417–1426. 2. Marquis D. Are DCD donors dead? Hastings Center Report 2010; 40: 24–31. 3. Bernat JL, Capron AM, Bleck TP et al. The circulatory-respiratory determination of death in organ donation. Crit Care Med 2010; 38: 963–970. 4. Truog RD, Miller FG. The dead donor rule and organ transplantation. N Engl J Med 2008; 359: 674–675. 5. Veatch RM. Donating hearts after cardiac death-reversing the irreversible. N Engl J Med 2008; 359: 672–673.
American Journal of Transplantation 2011; 11: 1351–1352
