In reply

Abstract

We appreciate the dialogue initiated by Mr. Ortega-Deballon and his colleagues in response to our recent contribution on organ donation in emergency medicine. Although we believe that uncontrolled donation after circulatory determination of death may still be possible and ethically justifiable, we agree that it poses significant challenges. Mr. Ortega-Deballon and his colleagues highlight the difficulty in identifying when irreversible circulatory death has occurred. They cite 3 individuals enrolled in a protocol for uncontrolled donation after circulatory determination of death who went on to have return of spontaneous circulation, one of whom has had satisfactory neurologic recovery.1Mateos-Rodríguez A. Pardillos-Ferrer L. Navalpotro-Pascual J.M. et al.Kidney transplant function using organs from non-heart-beating donors maintained by mechanical chest compressions.Resuscitation. 2010; 81: 904-907Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 2Manara A.R. Thomas I. The use of circulatory criteria to diagnose death after unsuccessful cardiopulmonary resuscitation.Resuscitation. 2010; 81: 781-783Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Lest readers think these patients had been declared dead and transitioned to organ preservation efforts when they experienced return of spontaneous circulation, for this particular study, enrollment in the uncontrolled donation after circulatory determination of death protocol took place after 30 minutes of cardiopulmonary resuscitation (CPR) but before the cessation of resuscitative efforts and before any declaration of death. In all 3 patients, return of spontaneous circulation occurred before any declaration of death was made, before confirmation of a 5-minute (or any) period of asystole, and while the patient was still being transported to the hospital, with standard CPR still in progress by the original emergency medical services team. We are not aware of any cases of autoresuscitation occurring after more than 65 seconds of continuously observed asystole nor of any cases of it occurring in the setting of uncontrolled donation after circulatory determination of death after declaration of death, following Institute of Medicine or American Society of Critical Care Medicine guidelines.2Manara A.R. Thomas I. The use of circulatory criteria to diagnose death after unsuccessful cardiopulmonary resuscitation.Resuscitation. 2010; 81: 781-783Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 3Institute of MedicineNon-heart-beating organ transplantation: practice and protocols [Internet].http://www.nap.edu/openbook.php?isbn=0309066417Google Scholar, 4Society of Critical Care MedicineRecommendations for nonheartbeating organ donation.Crit Care Med. 2001; 29: 1826-1831Crossref PubMed Scopus (191) Google Scholar Nevertheless, it seems that there will always be tension between efforts to resuscitate patients and efforts to preserve the organs of the newly dead. In the setting of uncontrolled donation after circulatory determination of death, both resuscitative efforts and organ preservation measures occur within mere minutes of each other, a paradigm shift jarring in how rapidly it must occur to salvage viable organs for donation. As our understanding of the human body grows and technology develops, we will continue to push the limits of who we can save. We expect this trend to continue, and as such any protocol for uncontrolled donation after circulatory determination of death will also have to adjust so that no patient who has a chance of survival may be declared dead prematurely. Given the controversy over initiating organ preservation measures without family consent, we agree that consent ought to be obtained whenever possible. If family members cannot be reached, then how one proceeds may be influenced by societal context. Although transparently informing families that their newly deceased family members were transported to the hospital—organ preservation measures already under way—with the purpose of preserving their organs for donation may be societally acceptable in Spain, there is evidence to suggest that implementing this practice in the United States engenders distrust.5Volk M.L. Warren G.J.W. Anspach R.R. et al.Attitudes of the American public toward organ donation after uncontrolled (sudden) cardiac death.Am J Transplant. 2010; 10: 675-680Crossref PubMed Scopus (41) Google Scholar Given variable societal acceptance of organ preservation measures without previous consent among different nations, it is not surprising that each nation's policies and protocols reflect that variability. It seems that the ultimate goals outlined by Mr. Ortega-Deballon and his colleagues match our own. Even in how we each approach these goals, there is significant overlap. Where we do differ may be explained, in part, by the different societies in which we practice. Uncontrolled Donation After Circulatory Determination of Death Protocols: Ethical Challenges and Suggestions for ImprovementAnnals of Emergency MedicineVol. 61Issue 2PreviewAlthough uncontrolled donation after circulatory determination of death protocols can save and improve the lives of thousands of individuals, they pose ethical, clinical, and logistical challenges.1-3 We raise here 3 concerns about these protocols and propose suggestions for improvement. Full-Text PDF