Ethical and logistical concerns for establishing NRP‐cDCD heart transplantation in the United States. Issue 6 (21st January 2020)

• Record Type: Journal Article
• Authors: Parent, Brendan; Moazami, Nader; Wall, Stephen; Carillo, Julius; Kon, Zachary; Smith, Deane; Walsh, B. Corbett; Caplan, Arthur
• Is Part Of: American journal of transplantation. Volume 20:Issue 6(2020)
• Page Start: 1508
• Page End: 1512
• Publication Date: 2020-01-21
• Subjects: donors and donation: donation after circulatory death (DCD) -- editorial/personal viewpoint -- ethics -- ethics and public policy -- extracorporeal membrane oxygenation (ECMO) -- heart transplantation/cardiology -- organ procurement and allocation -- organ transplantation in general; Transplantation of organs, tissues, etc -- Periodicals; 617.95
• DOI: 10.1111/ajt.15772
• Languages: English
• ISSNs: 1600-6135

Abstract

Abstract : Controlled heart donation after circulatory determination of death (cDCD) is well established internationally with good outcomes and could be adopted in the United States to increase heart supply if ethical and logistical challenges are comprehensively addressed. The most effective and resource‐efficient method for mitigating warm ischemia after circulatory arrest is normothermic regional perfusion (NRP) in situ. This strategy requires restarting circulation after declaration of death according to circulatory criteria, which appears to challenge the legal circulatory death definition requiring irreversible cessation. Permanent cessation for life‐saving efforts must be achieved to assuage this concern and ligating principal vessels maintains no blood flow to the brain, which ensures natural progression to cessation of brain function. This practice—standard in some countries—raises unique concerns about prioritizing life‐saving efforts, informed authorization from decision‐makers, and the clinician's role in the patient's death. To preserve public trust, medical integrity, and respect for the donor, the donation conversation must not take place until after an un‐coerced decision to withdraw life‐sustaining treatment made in accordance with the patient's treatment goals. The decision‐maker(s) must understand cDCD procedure well enough to provide genuine authorization and the preservation/procurement teams must be kept separate from the clinical care team. Abstract : Controlled heart donation after circulatory determination of death using normothermic regional perfusion in situ could be adopted in the United States to increase heart supply if ethical and logistical challenges are comprehensively addressed.