Ethical Issues in the Use of Extracorporeal Membrane Oxygenation in Controlled Donation After Circulatory Determination of Death

Abstract

The use of donor extracorporeal membrane oxygenation (ECMO) to improve graft outcomes by some controlled donation after circulatory determination of death (cDCDD) programs raises ethical issues. We reviewed cDCDD protocols using ECMO and the relevant ethics literature to analyze these issues. It is not obvious that ECMO in cDCDD improves graft outcomes. In our opinion, ECMO implemented before death can interfere with end-of-life care and damage bodily integrity. By restoring systemic circulation, ECMO risks invalidating the preceding declaration of death if brain and cardiac perfusion is not adequately excluded because of malfunction or misplacement of the supradiaphragmatic aortic occlusion balloon. The use of ECMO is not compatible with the acronym DCDD because circulation is restored after the determination of death. Because of these deficiencies, we concluded that other techniques are preferable, such as rapid recovery or in situ cold infusion. If ECMO is performed, it requires a specific informed consent and transparency.Abbreviations: cDCDD, controlled donation after circulatory determination of death; DBDD, donation after brain determination of death; DBTL, doubleballoon triple-lumen; DCDD, donation after circulatory determination of death; DDR, dead donor rule;

The unique moral permissibility of uncontrolled lung donation after circulatory death

“…The justification of the standard is that circulatory function will not be restored because it will neither return spontaneously, nor return as a result of medical intervention because no resuscitation efforts will be attempted. 11,21 Because technologies such as nECMO applied for organ preservation have the potential to circulate oxygenated blood to the brain, some vocal detractors of using regional perfusion for organ preservation are concerned that using these interventions could undermine the permanent cessation of brain circulation rendering the prior determination of death invalid since "once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation." 11 Regional perfusion measures that use balloon catheters inserted after death determination and before nECMO initiation to prevent brain perfusion-an accepted procedure in countries with strong uDCDD programs that exist with opt-out organ donation functioning within universal healthcare systems 22 -may not assuage the ethical concerns of those elsewhere who believe nECMO should not be used after death is declared.…”

“…For these opponents, the problem is not whether brain perfusion is prevented, but whether doing so makes health providers complicit in the patient's death, and is a technical work-around to avoid the fact that nECMO use would undermine the legal brain death determination. 11,21 Others do not agree with these analyses-as restoring some circulation to the brain after prolonged, exhaustive resuscitation attempts are unsuccessful, is exceedingly unlikely to restore meaningful neurological function 22 -but the concern is moot in considerations of lung uDCDD.…”

“…11,21 Because technologies such as nECMO applied for organ preservation have the potential to circulate oxygenated blood to the brain, some vocal detractors of using regional perfusion for organ preservation are concerned that using these interventions could undermine the permanent cessation of brain circulation rendering the prior determination of death invalid since "once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation." The current evolution of death determination in the United States requires a "permanent" cessation of circulation, which leads to "irreversible" loss of total brain function.…”

“…The current evolution of death determination in the United States requires a "permanent" cessation of circulation, which leads to "irreversible" loss of total brain function. 11,21 Others do not agree with these analyses-as restoring some circulation to the brain after prolonged, exhaustive resuscitation attempts are unsuccessful, is exceedingly unlikely to restore meaningful neurological function 22 -but the concern is moot in considerations of lung uDCDD. 11,21 Because technologies such as nECMO applied for organ preservation have the potential to circulate oxygenated blood to the brain, some vocal detractors of using regional perfusion for organ preservation are concerned that using these interventions could undermine the permanent cessation of brain circulation rendering the prior determination of death invalid since "once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation."…”

“…Further assurance of quality life-saving care and certainty of futility determination is aided in some countries by physicians on the EMS team, which might be considered for implementation in the United States; however, for integrated systems to exist, TOR decisions would need be made in hospitals where a separate team would be called in for transitioning to organ preservation.As additional assurance that separation is in no way breached, medical systems preparing to institute uDCDD should establish independent, educated, and transparent data safety monitoring boards (DSMBs) that are able to quickly convene to review resuscitation and organ preservation case data for compliance with standard resuscitation and TOR guidelines prior to lung preservation consideration 8. Dissemination of nECMO for cardiopulmonary resuscitation in emergency departments and out-of-hospital settings has raised concerns that allowing uDCDD in cases where nECMO is not available does not incentivize future development of eCPR capacity and prioritizes organ preservation for donation over life sustaining efforts 21,25. We disagree.…”