Understanding the Brain-based Determination of Death When Organ Recovery Is Performed With DCDD In Situ Normothermic Regional Perfusion

Bernat, James L.; Domínguez‐Gil, Beatriz; Glazier, Alexandra K.; Gardiner, Dale; Manara, A.R.; Shemie, Sam D.; Porte, Robert J.; Martin, Dominique; Opdam, Helen; McGee, Andrew; Fraga, Marta López; Rayar, Michel; Kerforne, Thomas; Bušić, Mirela; Romagnoli, Renato; Zanierato, Marinella; Tullius, Stefan G.; Miñambres, Eduardo; Royo‐Villanova, Mario; Delmonico, Francis L.

doi:10.1097/tp.0000000000004642

Cited by 23 publications

(10 citation statements)

References 25 publications

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“…If circulatory arrest occurs within 1 to 2 hours, there is a 5‐minute “hands‐off” period to monitor for autoresuscitation of the heart and circulation, after which death is declared and surgeons proceed with organ recovery 9 . This process was designed to ensure death is permanent, meaning circulation will not resume spontaneously (ie, autoresuscitation) nor will interventions (eg, cardiopulmonary resuscitation) be attempted to restore circulation 10,11 . The 5‐minute hands‐off time excludes the possibility of spontaneous autoresuscitation 9 .…”

Section: Organ Donation In Patients Declared Dead By Circulatory Crit...mentioning

confidence: 99%

“…If systemic and cerebral circulations remain arrested, then brain function cannot be restored, and death occurs even if brain death/death by neurologic criteria is not formally assessed. This concept has been referred to as the “unified brain‐based concept of death.” 11,15 …”

Section: Organ Donation In Patients Declared Dead By Circulatory Crit...mentioning

confidence: 99%

“…During DCD‐NRP, the cerebral vessels (carotid and vertebral arteries) are clamped or surgically ligated to avoid antegrade cerebral perfusion and restoration of neuronal activity when cardiac function is resumed. This intervention may be inadequate in preventing cerebral perfusion, because collateral circulation could hypothetically deliver oxygenated blood to the brain via retrograde flow through the anterior spinal and subclavian arteries to the vertebrobasilar system 11,22 . It is unclear how much perfusion the brain receives via this route, and whether that flow is sufficient to support cellular or clinical brain function.…”

Section: Organ Donation In Patients Declared Dead By Circulatory Crit...mentioning

confidence: 99%

“…The DCD‐NRP process may fulfil the autonomous wishes of the donor, benefits the donor's family by allowing them to respect the donor's wishes, increases the supply of available organs for donation, and maximizes outcomes for recipients. By preventing resumption of cerebral blood flow, NRP maintains the permanent absence of brain function and thus the donor's death determination under the permanence standard for circulatory cessation 11,22,27 …”

Section: Organ Donation In Patients Declared Dead By Circulatory Crit...mentioning

confidence: 99%

“…DCD‐NRP opponents argue that by restoring cardiac function in situ, death by circulatory criteria is invalidated, the dead donor principle is violated, and ligation of the cerebral vessels precipitates death by neurologic criteria 28 . The Uniform Determination of Death Act (UDDA), the foundation on which all US states legally define death, indicates that death occurs when there is “irreversible cessation of circulatory and respiratory functions or all functions of the entire brain, including the brainstem.” 29 “Irreversible” means that function cannot be restored, either spontaneously or through intevention 11,30 . DCD‐NRP is intervening to restart the heart, thus the cessation of circulation was not irreversible and the person did not, and does not, meet UDDA criteria for death 28,31,32 .…”

Section: Organ Donation In Patients Declared Dead By Circulatory Crit...mentioning

confidence: 99%

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Beyond the Final Heartbeat: Neurological Perspectives on Normothermic Regional Perfusion for Organ Donation after Circulatory Death

Kirschen,

Lewis,

Rubin

et al. 2024

Annals of Neurology

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Normothermic regional perfusion (NRP) has recently been used to augment organ donation after circulatory death (DCD) to improve the quantity and quality of transplantable organs. In DCD‐NRP, after withdrawal of life‐sustaining therapies and cardiopulmonary arrest, patients are cannulated onto extracorporeal membrane oxygenation to reestablish blood flow to targeted organs including the heart. During this process, aortic arch vessels are ligated to restrict cerebral blood flow. We review ethical challenges including whether the brain is sufficiently reperfused through collateral circulation to allow reemergence of consciousness or pain perception, whether resumption of cardiac activity nullifies the patient's prior death determination, and whether specific authorization for DCD‐NRP is required. ANN NEUROL 2024

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Section: Organ Donation In Patients Declared Dead By Circulatory Crit...mentioning

confidence: 99%

Section: Organ Donation In Patients Declared Dead By Circulatory Crit...mentioning

confidence: 99%

Section: Organ Donation In Patients Declared Dead By Circulatory Crit...mentioning

confidence: 99%

Section: Organ Donation In Patients Declared Dead By Circulatory Crit...mentioning

confidence: 99%

Section: Organ Donation In Patients Declared Dead By Circulatory Crit...mentioning

confidence: 99%

See 3 more Smart Citations

Beyond the Final Heartbeat: Neurological Perspectives on Normothermic Regional Perfusion for Organ Donation after Circulatory Death

Kirschen,

Lewis,

Rubin

et al. 2024

Annals of Neurology

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Neither Ethical nor Prudent: Why Not to Choose Normothermic Regional Perfusion

Omelianchuk,

Capron,

Ross

et al. 2024

Hastings Center Report

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In transplant medicine, the use of normothermic regional perfusion (NRP) in donation after circulatory determination of death raises ethical difficulties. NRP is objectionable because it restores the donor's circulation, thus invalidating a death declaration based on the permanent cessation of circulation. NRP's defenders respond with arguments that are tortuous and factually inaccurate and depend on introducing extraneous concepts into the law. However, results comparable to NRP's—more and higher‐quality organs and more efficient allocation—can be achieved by removing organs from deceased donors and using normothermic machine perfusion (NMP) to support the organs outside the body, without jeopardizing confidence in transplantation's legal and ethical foundations. Given the controversy that NRP generates and the convoluted justifications made for it, we recommend a prudential approach we call “ethical parsimony,” which holds that, in the choice between competing means of achieving a result, the ethically simpler one is to be preferred. This approach makes clear that policy‐makers should favor NMP over NRP.

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In Defense of Normothermic Regional Perfusion

Truog,

Doernberg

2024

Hastings Center Report

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Normothermic regional perfusion (NRP) is a relatively new approach to procuring organs for transplantation. After circulatory death is declared, perfusion is restored to either the thoracoabdominal organs (in TA‐NRP) or abdominal organs alone (in A‐NRP) using extracorporeal membrane oxygenation. Simultaneously, surgeons clamp the cerebral arteries, causing a fatal brain injury. Critics claim that clamping the arteries is the proximate cause of death in violation of the dead donor rule and that the procedure is therefore unethical. We disagree. This account does not consider the myriad other factors that contribute to the death of the donor, including the presence of a fatal medical condition, the decision to withdraw life support, and the physician's actions in withdrawing life support and administering medication that may hasten death. Instead, we claim that physicians play a causative role in many of the events that lead to a patient's death and that these actions are often ethically and legally justified. We advance an “all things considered” view according to which TA‐NRP may be considered ethically acceptable insofar as it avoids suffering and respects the wishes of the patient to improve the lives of others through organ donation. We conclude with a series of critical questions related to the practice of NRP and call for the development of national consensus on this issue in the United States.

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Understanding the Brain-based Determination of Death When Organ Recovery Is Performed With DCDD In Situ Normothermic Regional Perfusion

Cited by 23 publications

References 25 publications

Beyond the Final Heartbeat: Neurological Perspectives on Normothermic Regional Perfusion for Organ Donation after Circulatory Death

Beyond the Final Heartbeat: Neurological Perspectives on Normothermic Regional Perfusion for Organ Donation after Circulatory Death

Neither Ethical nor Prudent: Why Not to Choose Normothermic Regional Perfusion

In Defense of Normothermic Regional Perfusion

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