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Ethics of Organ and Tissue Donation – Updated

Situations that offer the opportunity for organ donation include donation after neurologic determination of death, controlled donation after circulatory determination of death, and uncontrolled donation after circulatory determination of death. Controlled donation after circulatory death usually takes place in the hospital after a patient whose advanced directives or surrogate, family, and medical team agree to allow natural death and withdraw life support. Uncontrolled donation usually takes place in an emergency department after exhaustive efforts at resuscitation have failed to achieve ROSC. In 2015, the ILCOR Advanced Life Support Task Force reviewed the evidence that might address the question of whether an organ retrieved from a donor who has had CPR that was initially successful (controlled donation) or unsuccessful (uncontrolled donation) would impact survival or complications compared with an organ from a donor who did not require CPR (controlled donation).

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2015 Evidence Summary

Studies comparing transplanted organ function between those organs from donors who had received successful CPR before donation and those whose donors had not received CPR before donation have found no difference in transplanted organ function. This includes immediate graft function, 1-year graft function, and 5-year graft function. Studies have also shown no evidence of worse outcome in transplanted kidneys and livers from adult donors who have not had restoration of circulation after CPR compared with those from other types of donors.1-4

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2015 Recommendation - Updated

We recommend that all patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death be evaluated for organ donation. (Class I, LOE B-NR)

Patients who do not have ROSC after resuscitation efforts and who would otherwise have termination of efforts may be considered candidates for kidney or liver donation in settings where programs exist. (Class IIb, LOE B-NR)

In making this recommendation, the decisions for termination of resuscitative efforts and the pursuit of organ donation need to be independent processes (see “Part 8: Post–Cardiac Arrest Care”).

In 2010, it was noted that most communities do not optimize the retrieval of organ and tissue donations; this has created protracted waiting time and greater suffering for patients awaiting organ transplantation. The Emergency Cardiovascular Care community of the American Heart Association supports efforts to optimize the ethical acquisition of organ and tissue donations. Studies suggest no difference in functional outcomes of organs transplanted from patients who are determined to be brain dead as a consequence of cardiac arrest when compared with donors who are brain dead from other causes.5-8

Therefore it is reasonable to suggest that all communities should optimize retrieval of tissue and organ donations in brain dead post–cardiac arrest patients (in-hospital) and those pronounced dead in the out-of-hospital setting. (Class IIa, LOE B)

Most important to this process is advance planning and infrastructure support to allow organ donation to occur in a manner sensitive to the needs of the donor’s family and without undue burden on the staff.

Medical directors of EMS agencies, emergency departments (EDs), and critical care units (CCUs) should develop protocols and implementation plans with the regional organ and tissue donation program to optimize donation following a cardiac arrest death (Class I, LOE C), including:

A process by which permission for organ and tissue donations will be obtained
The establishment of clearly defined guidelines for organ and tissue procurement that will be available to all healthcare providers both in and out of the hospital
Information to address the possible differences between applicable laws and societal values in procedures for organ procurement
The emotional support to be offered to providers post event
A system to acquire organ and tissue donations from individuals pronounced dead in the out-of-hospital setting. This discussion should include input from the coroner, EMS, police, and lay people representing the target community

The 2010 Guidelines outlined the debate regarding the ethics of organ donation.9 The debate continues today. Points to consider are outlined in Table 1 below, with opposing viewpoints on the issue.10-17 Although this material was not reviewed as part of the ILCOR review process, this section is intended to highlight some of the ethical issues around organ donation. A full discussion of the merits of each of these viewpoints is beyond the scope of this publication.

Table 1: 2015 - Ethical Questions and Issues Surrounding Organ Donation

 

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References

  1. Orioles A, Morrison WE, Rossano JW, Shore PM, Hasz RD, Martiner AC, Berg RA, Nadkarni VM. An under-recognized benefit of cardiopulmonary resuscitation: organ transplantation. Crit Care Med. 2013;41:2794–2799. doi: 10.1097/CCM.0b013e31829a7202.
  2. Matsumoto CS, Kaufman SS, Girlanda R, Little CM, Rekhtman Y, Raofi V, Laurin JM, Shetty K, Fennelly EM, Johnson LB, Fishbein TM. Utilization of donors who have suffered cardiopulmonary arrest and resuscitation in intestinal transplantation. Transplantation. 2008;86:941–946. doi: 10.1097/TP.0b013e3181852f9a.
  3. Asher J, Navarro A, Watson J, Wilson C, Robson L, Gupta A, Gok M, Balupuri S, Shenton B, Del Rio Martin J, Sen B, Jaques B, Soomro N, Rix D, Manas D, Talbot D. Does donor cardiopulmonary resuscita- tion time affect outcome in uncontrolled non-heart-beating donor renal transplants? Transplant Proc. 2005;37:3264–3265. doi: 10.1016/j. transproceed.2005.09.006.
  4. Reynolds JC, Rittenberger JC, Callaway CW; Post Cardiac Arrest Service. Patterns of organ donation among resuscitated patients at a regional cardiac arrest center. Resuscitation. 2014;85:248–252. doi: 10.1016/j. resuscitation.2013.11.001.
  5. Adrie C, Haouache H, Saleh M, Memain N, Laurent I, Thuong M, Darques L, Guerrini P, Monchi M. An underrecognized source of organ donors: patients with brain death after successfully resuscitated cardiac arrest. Intensive Care Med. 2008;34:132–137.
  6. Ali AA, Lim E, Thanikachalam M, Sudarshan C, White P, Parameshwar J, Dhital K, Large SR. Cardiac arrest in the organ donor does not negatively influence recipient survival after heart transplantation. Eur J Cardiothorac Surg. 2007;31:929–933.
  7. Matsumoto CS, Kaufman SS, Girlanda R, Little CM, Rekhtman Y, Raofi V, Laurin JM, Shetty K, Fennelly EM, Johnson LB, Fishbein TM. Utilization of donors who have suffered cardiopulmonary arrest and resuscitation in intestinal transplantation. Transplantation. 2008;86:941–946.
  8. Mercatello A, Roy P, Ng-Sing K, Choux C, Baude C, Garnier JL, Colpart JJ, Finaz J, Petit P, Moskovtchenko JF, et al. Organ transplants from out-of-hospital cardiac arrest patients. Transplant Proc. 1988;20:749–750.
  9. Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, Vanden Hoek TL, Kronick SL; American Heart Association. Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S768–S786. doi: 10.1161/ CIRCULATIONAHA.110.971002.
  10. Bernat JL. Point: are donors after circulatory death really dead, and does it matter? Yes and yes. Chest. 2010;138:13–16. doi: 10.1378/chest.10-0649.
  11. Bernat JL, Capron AM, Bleck TP, Blosser S, Bratton SL, Childress JF, DeVita MA, Fulda GJ, Gries CJ, Mathur M, Nakagawa TA, Rushton CH, Shemie SD, White DB. The circulatory-respiratory determination of death in organ donation. Crit Care Med. 2010;38:963–970. doi: 10.1097/ CCM.0b013e3181c58916.
  12. Committee on Hospital Care SoS, Section on Critical C. Policy state- ment―pediatric organ donation and transplantation. Pediatrics. 2010;125:822–828.
  13. Gries CJ, White DB, Truog RD, Dubois J, Cosio CC, Dhanani S, Chan KM, Corris P, Dark J, Fulda G, Glazier AK, Higgins R, Love R, Mason DP, Nakagawa TA, Shapiro R, Shemie S, Tracy MF, Travaline JM, Valapour M, West L, Zaas D, Halpern SD; American Thoracic Society Health Policy Committee. An official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/ Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: ethical and policy considerations in organ dona- tion after circulatory determination of death. Am J Respir Crit Care Med. 2013;188:103–109. doi: 10.1164/rccm.201304-0714ST.
  14. Hornby K, Hornby L, Shemie SD. A systematic review of autoresus- citation after cardiac arrest. Crit Care Med. 2010;38:1246–1253. doi: 10.1097/CCM.0b013e3181d8caaa.
  15. Joffe AR, Carcillo J, Anton N, deCaen A, Han YY, Bell MJ, Maffei FA, Sullivan J, Thomas J, Garcia-Guerra G. Donation after cardiocircula- tory death: a call for a moratorium pending full public disclosure and fully informed consent. Philos Ethics Humanit Med. 2011;6:17. doi: 10.1186/1747-5341-6-17.
  16. Nakagawa TA, Rigby MR, Bratton S, Shemie S, Ajizian SJ, Berkowitz I, Bowens CD, Cosio CC, Curley MA, Dhanani S, Dobyns E, Easterling L, Fortenberry JD, Helfaer MA, Kolovos NS, Koogler T, Lebovitz DJ, Michelson K, Morrison W, Naim MY, Needle J, Nelson B, Rotta AT, Rowin ME, Serrao K, Shore PM, Smith S, Thompson AE, Vohra A, Weise K. A call for full public disclosure for donation after circulatory deter- mination of death in children. Pediatr Crit Care Med. 2011;12:375–377; author reply 377. doi: 10.1097/PCC.0b013e31820ac30c.
  17. Truog RD, Miller FG. Counterpoint: are donors after circulatory death really dead, and does it matter? No and not really. Chest. 2010;138:16–18; discussion 18. doi: 10.1378/chest.10-0657.
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Ethics of Organ and Tissue Donation – Updated

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