Non‐survivors of out‐of‐hospital cardiac arrest should always be␣considered potential non‐heart‐beating organ donors

Abstract

We read with great interest the recent paper by Gratrix et al. [1] in which it was concluded that only a small increase in donor organs could be potentially achieved by considering non-heart-beating (NHB) donation from patients with out-of-hospital cardiac arrest (OHCA). The aim of the study was to identify patients suitable for NHB donation – the main result being that only four of 57 (7%) OHCA patients who died after withdrawal of life support would qualify as NHB donors. Patients were excluded from the study because of age, medical history, but mainly because the length of time between stopping treatment and death exceeded 120 min. We believe that the conclusion that OHCA patients are not commonly suitable for NHB donation cannot be derived from the data as presented. Firstly, the study reports that different modes of withdrawal of treatment were used, suggesting that the stopping of treatment was often performed by successively withdrawing one form of life support, evaluating the effect, followed by withdrawing another. Although this is probably the best way to achieve good end-of-life care, it is unlikely that this is the best way to withdraw treatment in a patient eligible for NHB organ donation. In contrast, it is our practice that, once the decision has been made to withdraw life support because of futility, all life-saving support is withdrawn at once. Secondly, there is no clear definition of the point at which their patients died. For many patients who die in an ICU the process of dying is monitored and it is determined that the patient has died when the electrical activity of the heart has stopped. This is not the same as the definition of death in most NHB protocols, in which the time of death is defined as the moment of circulatory arrest. In the UK protocol to certify death in NHB donors the ‘absence of cardiac output and respiration, the lack of response to supraorbital pressure and absence of the pupillary and corneal reflexes after a minimum of five minutes after cardiorespiratory arrest’ is required [2], but the absence of electrical activity of the heart is not. In many dying patients, electrical activity of the heart is present for up to 10 min after circulatory arrest, and sometimes longer [3]. This may have reduced the number of eligible potential donors in this study. No criteria for predicting death after stopping life support were described by the authors. Both the Wisconsin [4] and unos[2] criteria have been evaluated and provide a reasonable prediction for whether a patient will be suitable for NHB organ donation. Using these or similar criteria will help to identify potential donors and thereby decrease the risk of seeking unnecessary consent from an already distressed and grieving family. We wonder how the decision was made to withdraw or withhold treatment. Although there is very good evidence that we should stop treating patients with persistent coma without pupillary reaction [6] or with absent evoked potentials [7, 8] after 72 h, it is not clear whether these criteria were used. This may have influenced the results, as the neurological condition may be relevant in relation to early death after withdrawal of life-support., Gratrix et al. report a hospital mortality of 95% in patients with OHCA. This, of course, is a selected group of OHCA patients as those in whom a spontaneous circulation did not return were not studied, nor were patients regaining consciousness. This group is not completely comparable therefore with the patients included in the hypothermia studies by Bernard et al. [9] and Holzer et al. [10]. However, the difference in outcome (almost 50% survival in both studies) is striking and brings us to the question whether treatment in these patients included therapeutic hypothermia. In addition, 9% survival was reported in OHCA patients in the Amsterdam area in 1998, including all patients who died during resuscitation (75%) or reaching hospital without spontaneous circulation. In the same study, 82 of 216 patients (38%) admitted to the ICU survived [11]. More recent data from 2005–2006 shows a survival of almost 17% of a cohort of OHCA patients [12]. How do these patients compare with those studied by Gratrix et al.? In conclusion, we consider that the potential for organ donors among non-survivors of OHCA may be greater than suggested by Gratrix et al. We propose that in all ICU patients who have their treatment withdrawn, the possibility of non-heart-beating organ donation is evaluated.