Many physicians and patients do not realize that it is legally and medically possible to donate organs after euthanasia. The combination of euthanasia and organ donation is not a common practice, often limited by the patient's underlying pathology, but nevertheless has been performed >40 times in Belgium and the Netherlands since 2005. In anticipation of patients' requests for organ donation after euthanasia and contributing to awareness of the possibility of this combination among general practitioners and medical specialists, the Maastricht University Medical Center and the Erasmus University Medical Center Rotterdam have developed a multidisciplinary practical manual in which the organizational steps regarding this combined procedure are described and explained. This practical manual lists the various criteria to fulfill and the rules and regulations the different stakeholders involved need to comply with to meet all due diligence requirements. Although an ethicist was involved in writing this paper, this report is not specifically meant to comprehensively address the ethical issues surrounding the topic. This paper is focused on the operational aspects of the protocol.

SUMMARYThe shortage of organs remains one of the biggest challenges in transplantation. To address this, we are increasingly turning to donation after circulatory death (DCD) donors and now in some countries to uncontrolled DCD donors. We consolidate the knowledge on uncontrolled DCD in Europe and provide recommendations and guidance for the development and optimization of effective uncontrolled DCD programmes.

Background A patient who fulfils the due diligence requirements for euthanasia, and is medically suitable, is able to donate his organs after euthanasia in Belgium, the Netherlands and Canada. Since 2012, more than 70 patients have undergone this combined procedure in the Netherlands. Even though all patients who undergo euthanasia are suffering hopelessly and unbearably, some of these patients are nevertheless willing to help others in need of an organ. Organ donation after euthanasia is a so-called donation after circulatory death (DCD), Maastricht category III procedure, which takes place following cardiac arrest, comparable to donation after withdrawal of life sustaining therapy in critically ill patients. To minimize the period of organ ischemia, the patient is transported to the operating room immediately after the legally mandated no-touch period of 5 min following circulatory arrest. This means that the organ donation procedure following euthanasia must take place in the hospital, which appears to be insurmountable to many patients who are willing to donate, since they already spent a lot of time in the hospital. Case presentation This article describes the procedure of organ donation after euthanasia starting at home (ODAEH) following anesthesia in a former health care professional suffering from multiple system atrophy. This case is unique for at least two reasons. He spent his last conscious hours surrounded by his family at home, after which he underwent general anaesthesia and was intubated, before being transported to the hospital for euthanasia and organ donation. In addition, the patient explicitly requested the euthanasia to be performed in the preparation room, next to the operating room, in order to limit the period of organ ischemia due to transport time from the intensive care unit to the operating room. The medical, legal and ethical considerations related to this illustrative case are subsequently discussed. Conclusions Organ donation after euthanasia is a pure act of altruism. This combined procedure can also be performed after the patient has been anesthetized at home and during transportation to the hospital.

Sinds 2012 kunnen in Nederland organen en weefsels na eu thanasie gedoneerd worden. Huisartsen doen het leeuwen deel van de euthanasiemeldingen; zij zijn ook bij uitstek in de positie om potentiële orgaandonoren te identificeren. Dat stelt hen geregeld voor de keuze of zij dit ingewikkel de traject, waarvan de uitkomst onzeker is, willen ingaan. Euthanasie en orgaandonatie blijven strikt gescheiden pro cedures en een euthanasiewens mag nooit voortkomen uit de wens een orgaan te doneren. Slechts 10% van de eutha nasiepatiënten is geschikt als orgaandonor en de donatie procedure is intensief; toch kan het zinvol zijn het gesprek hierover aan te gaan. In termen van overleving, levensverwachting en kwaliteit van leven heeft orgaantransplantatie grote voordelen boven orgaanfunctievervangende therapieën. [11][12][13] Er is echter een permanent tekort aan geschikte donororganen en men zoekt naar manieren om dit tekort te verminderen. [14][15][16] In 2016 waren er in Nederland 235 postmortale donoren en stonden er bijna 1100 mensen op de wachtlijst voor een donororgaan.17,18 Uit recent onderzoek blijkt dat ongeveer 10% van de patiënten na euthanasie medisch geschikt is voor orgaandonatie; dit kan het donoraanbod dus aanzienlijk vergroten. 19Deze nascholing beschrijft wat orgaandonatie na euthanasie zal betekenen voor huisartsen en biedt handvatten voor de praktijk. Het artikel bevat achtergrondinformatie en een stappenplan voor het initiëren van de procedure en het verstrekken van de juiste informatie. De maatschappelijke, ethische en juridische dilemma's omtrent euthanasie en orgaandonatie, hoe belangrijk ook, blijven buiten beschouwing. Informatie hierover kunt u vinden in de eerdergenoemde richtlijn en in twee recente publicaties. 9,20, 21 WENS TOT EUTHANASIE EN WENS TOT ORGAANDONATIEEen verzoek tot levensbeëindiging of hulp bij zelfdoding wordt alleen gehonoreerd indien voldaan is aan de zorgvuldigheidseisen zoals bepaald in artikel 2 van de Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding.22 Als de patiënt tevens organen wenst te doneren dan kan dat, maar de twee procedures blijven strikt gescheiden. Eén van de kernaanbevelingen van de huidige richtlijn is dat de patiënt in de palliatieve fase zelf de wens tot orgaandonatie moet aangeven. Die wens kan ter tafel komen voor-of nadat de zorgvuldigheidseisen rond euthanasie zijn getoetst. Gebeurt het voordat de zorgvuldigheidseisen zijn getoetst, dan hoort de arts de patiënt te vertellen dat eerst aan die eisen moet zijn voldaan alvorens de donatieprocedure kan worden opgestart. Deel 1 van de richtlijn (p. 13-15) bevat patiënten-informatie over de procedure en de vereisten. 9 De arts, en later ook de SCEN-arts, zal moeten beoordelen of de wens tot euthanasie voortkomt uit de wens tot orgaandonatie. Bij een wens tot orgaandonatie is het zinvol als de arts het Donorregister raadpleegt om een eventuele eerder vastgelegde bezwaarregistratie ongedaan te kunnen maken en te vervan-

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Background. Recently, continuous nonoxygenated hypothermic machine perfusion (HMP) has been implemented as standard preservation method for deceased donor kidneys in the Netherlands. This study was designed to assess the effect of the implementation of HMP on early outcomes after transplantation. Methods. Kidneys donated in the Netherlands in 2016 and 2017 were intended to be preserved by HMP. A historical cohort (2010–2014) preserved by static cold storage was chosen as the control group. Primary outcome was delayed graft function (DGF). Additional analyses were performed on safety, graft function, and survival up until 2 y after transplantation. Results. Data were collected on 2493 kidneys. Analyses showed significantly more donation after circulatory death, preemptive transplantation, and retransplants in the project cohort. Of the 681 kidneys that were transplanted during the project, 81% were preserved by HMP. No kidneys were discarded due to HMP-related complications. DGF occurred in 38.2% of the project cohort versus 43.7% of the historical cohort ( P < 0.001), with a significantly shorter duration within the project cohort (7 versus 9 d, P = 0.003). Multivariate regression analysis showed an odds ratio of 0.69 (95% confidence interval, 0.553-0.855) for the risk of DGF when using HMP compared with cold storage ( P = 0.001). There was no significant difference in kidney function, graft survival, and recipient survival up until 2 y posttransplantation. Conclusions. This study showed that HMP as a standard preservation method for deceased donor kidneys is safe and feasible. HMP was associated with a significant reduction of DGF.

SUMMARY Donation after circulatory death (DCD) donors are becoming an increasingly important population of organ donors in Europe and worldwide. We report the state of the art regarding controlled DCD donation describing the organizational and technical aspects of establishing a controlled DCD programme and provide recommendations regarding the introduction and development of this type of programme.

Euthanasia based on psychiatric suffering, followed by subsequent organ donation, is considered medically and legally permissible in the Netherlands. Although organ donation after euthanasia (ODE) in patients suffering from unbearable psychiatric illness is performed, it is not specifically addressed in the Dutch guideline on organ donation after euthanasia, and national data on ODE in psychiatric patients have not yet been published. In this article, the preliminary results of the 10-year Dutch case series of psychiatric patients who choose ODE are presented and potential factors influencing opportunities for donation in this population are discussed. We conclude that further future in-depth qualitative exploration of ODE in patients suffering from psychiatric illness and its associated ethical and practical dilemmas, including the consequences for the patient and their family and healthcare professionals, will be important to help make sense of potential barriers to donation for people undergoing euthanasia as a result of psychiatric suffering.