Uncontrolled donation after circulatory death: ethics of implementation.

PURPOSE OF REVIEW: Despite its potential to increase the donor pool, uncontrolled donation after circulatory death (uDCD) is available in a limited number of countries. Ethical concerns may preclude the expansion of this program. This article addresses the ethical concerns that arise in the implementation of uDCD. RECENT FINDINGS: The first ethical concern is that associated with the determination of an irreversible cardiac arrest. Professionals must strictly adhere to local protocols and international standards on advanced cardiopulmonary resuscitation, independent of their participation in an uDCD program. Cardiac compression and mechanical ventilation are extended beyond futility during the transportation of potential uDCD donors to the hospital with the sole purpose of preserving organs. Importantly, potential donors remain monitored while being transferred to the hospital, which allows the identification of any return of spontaneous circulation. Moreover, this procedure allows the determination of death to be undertaken in the hospital by an independent health care provider who reassesses that no other therapeutic interventions are indicated and observes a period of the complete absence of circulation and respiration. Extracorporeal-assisted cardiopulmonary resuscitation programs can successfully coexist with uDCD programs. The use of normothermic regional perfusion with ECMO devices for the in-situ preservation of organs is considered appropriate in a setting in which the brain is subject to profound and prolonged ischemic damage. Finally, communication with relatives must be transparent and accurate, and the information should be provided respecting the time imposed by the family's needs and emotions. SUMMARY: uDCD can help increase the availability of organs for transplantation while giving more patients the opportunity to donate organs after death. The procedures should be designed to confront the ethical challenges that this practice poses and respect the values of all those involved.

Summary of Spanish recommendations on intensive care to facilitate organ donation.

With the aim of consolidating recommendations about the practice of initiating or continuing intensive care to facilitate organ donation (ICOD), an ad hoc working group was established, comprising 10 intensivists designated by the Spanish Society of Intensive Care and Coronary Units (SEMICYUC) and the Spanish National Transplant Organization (ONT). Consensus was reached in all recommendations through a deliberative process. After a public consultation, the final recommendations were institutionally adopted by SEMICYUC, ONT, and the Transplant Committee of the National Health-Care System. This article reports on the resulting recommendations on ICOD for patients with a devastating brain injury for whom the decision has been made not to apply any medical or surgical treatment with a curative purpose on the grounds of futility. Emphasis is made on the systematic referral of these patients to donor coordinators, the proper assessment of the likelihood of brain death and medical suitability, and on transparency in communication with the patient's family. The legal and ethical aspects of ICOD are addressed. ICOD is considered a legitimate practice that offers more patients the opportunity of donating their organs upon their death and helps to increase the availability of organs for transplantation.

Intensive Care to Facilitate Organ Donation: A Report on the Experience of 2 Spanish Centers With a Common Protocol.

BACKGROUND: The aim of this study is to report the experience with a program of Intensive Care to facilitate Organ Donation (ICOD) in 2 Spanish centers based on a common protocol. METHODS: Retrospective review of clinical charts of patients with a devastating brain injury whose families were approached to discuss the possibility of ICOD once further treatment was deemed futile by the treating team. Study period is from January 1, 2011, to December 31, 2015. RESULTS: ICOD was discussed with families of 131 patients. Mean age of possible donors was 75 years (SD = 11 years). The main cause of brain injury was an intracranial hemorrhage (72%). Interviews with families were held after the decision had been made not to intubate/ventilate in 50% of cases, and after the decision not to continue with invasive ventilation in the remaining cases. Most interviews (66%) took place in the emergency department. The majority of families (95%) consented to ICOD. Of the 125 consented cases, 101 (81%) developed brain death (BD), most in 72 hours or less. Ninety-nine (98%) patients transitioned to actual donation after BD, with 1.2 organs transplanted per donor. Of patients who did not evolve to BD, 4 died after an unexpected cardiac arrest and 18 after the withdrawal of life-sustaining measures. ICOD contributed to 33% of actual donors registered at both centers. CONCLUSIONS: ICOD is well accepted by families. Most patients evolve to BD within a short period of time. The practice substantially contributes to increasing organ donation and offers more patients the chance of donating their organs after death.

Kidney transplantation from donors after uncontrolled circulatory death: the Spanish experience.

Donation after uncontrolled circulatory death (uDCD) refers to donation from persons who have died following cardiac arrest and unsuccessful attempt at resuscitation. We report the Spanish experience of uDCD kidney transplantation, and identify factors related to short-term post-transplant outcomes. The Spanish CORE system compiles data on all donation and transplant procedures in the country. Between 2012-2015, 517 kidney transplants from 288 uDCD donors were performed. The incidence of primary non-function was 10%, and the incidence of delayed graft function was 76%. One-year death-censored graft survival was 87%. In a Cox-Model, donor age ≥ 60 years (odds ratio [OR] 2.7; 95% confidence interval [CI] 1.2-6.1), in situ cooling of kidneys versus normothermic regional perfusion (OR 5.6; 95% CI 2.7-11.5) or hypothermic regional perfusion based on the use of extracorporeal membrane oxygenation devices (OR 4.3; 95% CI 2.1-8.6), and a recipient history of prior kidney transplant (OR 3.5; 95% CI 1.5-8.3) all significantly increased the risk of graft loss during the first year after transplantation. Kidney transplantation from uDCD donors provides acceptable 1-year outcomes, although there is room for improvement. Hypothermic and normothermic regional perfusion strategies are preferable to in situ cooling of kidneys from uDCD donors.