Expanding controlled donation after the circulatory determination of death: statement from an international collaborative

Abstract

A decision to withdraw life-sustaining treatment (WLST) is derived by a conclusion that further treatment will not enable a patient to survive or will not produce a functional outcome with acceptable quality of life that the patient and the treating team regard as beneficial. Although many hospitalized patients die under such circumstances, controlled donation after the circulatory determination of death (cDCDD) programs have been developed only in a reduced number of countries. This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation. The Statement addresses three fundamental aspects of the cDCDD pathway. First, it describes the process of determining a prognosis that justifies the WLST, a decision that should be prior to and independent of any consideration of organ donation and in which transplant professionals must not participate. Second, the Statement establishes the permanent cessation of circulation to the brain as the standard to determine death by circulatory criteria. Death may be declared after an elapsed observation period of 5 min without circulation to the brain, which confirms that the absence of circulation to the brain is permanent. Finally, the Statement highlights the value of perfusion repair for increasing the success of cDCDD organ transplantation. cDCDD protocols may utilize either in situ or ex situ perfusion consistent with the practice of each country. Methods to accomplish the in situ normothermic reperfusion of organs must preclude the restoration of brain perfusion to not invalidate the determination of death.

Current status and further potential of lung donation after circulatory death

“…54 The main barrier here is the lack of recognition that DCD is a platform to donation, due to legal and ethical concerns. To overcome this issue, a guideline statement from an international collaborative was recently published, 58 identifying three fundamental aspects. First, the fatal prognoses that justify the Withdrawal of Life Supporting Therapy (WLTS) need to be determined and assured to be declared for each individual by an interdisciplinary team, independent of the transplant team, to avoid mistrust.…”

“…For the establishment of these fundaments, a clear and transparent public discussion is crucial, involving next to medical and ethical experts also all stakeholders, including patients, cultural and religious representatives, and political decision makers. 58 Among countries legalizing DCD, several ethical differences exist. While some legislations allow heparin, steroids, or even ECMO placement prior of declaration of death, this is not allowed in many countries.…”

Expanding controlled donation after the circulatory determination of death: stronger emphasis on different cultural, religious and legal backgrounds is needed

“…Dominguez-Gil and colleagues have presented a very important statement with the intent to expand controlled donation of organs after the circulatory determination of death (cDCDD) [ 1 ]. It summarizes the necessary preconditions and the process of withdrawing life-sustaining treatment exceptionally well.…”

“…Therefore, for thoraco-abdominal normothermic regional perfusion (TA-NRP), a rapid sternotomy is performed and the supra-aortic vessels are clamped to immediately stop cerebral perfusion. Yet, the procedure is not well established, as recently “a refinement to current protocols has been proposed to ensure that circulation to the brain through collateral circulation does not occur” [ 1 , 3 ]. With only “eight heart transplant procedures… in the world with the use of TA-NRP without ex situ machine perfusion” [ 1 ], the experience with this specific procedure is insufficient, and many questions remain unresolved.…”

“…Yet, the procedure is not well established, as recently “a refinement to current protocols has been proposed to ensure that circulation to the brain through collateral circulation does not occur” [ 1 , 3 ]. With only “eight heart transplant procedures… in the world with the use of TA-NRP without ex situ machine perfusion” [ 1 ], the experience with this specific procedure is insufficient, and many questions remain unresolved. We do not support the proposal that TA-NRP without ex situ machine perfusion should be adopted by countries to make heart transplantation economically feasible.…”