Non-heart-beating organ donation

Abstract

The transplantation community endorses controlled and uncontrolled non-heart-beating organ donation (NHBD) to increase the supply of transplantable organs at end of life. Cardiac arrest must occur within 1–2 hours after the withdrawal of life-support in controlled NHBD. Uncontrolled NHBD is performed after failed cardiopulmonary resuscitation in an unexpected witnessed cardiac arrest. Donor management aims to protect transplantable organs against warm ischaemic injury through the optimization of haemodynamics and mechanical ventilation. This also requires antemortem instrumentation and systemic anticoagulation for organ perseveration in controlled NHBD. Interval support with extracorporeal membrane oxygenation or cardiopulmonary bypass is generally required for optimal organ perfusion and oxygenation in uncontrolled NHBD, which remains a controversial medical practice. There are several unresolved ethical challenges. The circulatory criterion of 2–10 minutes of absent arterial pulse does not comply with the uniform determination of death criterion of the irreversible cessation of functions of the cardiovascular or central nervous systems. There are no robust safeguards in clinical practice that can prevent faulty prognostication, and premature withdrawal of treatment or termination of cardiopulmonary resuscitation. Unmanaged conflicting interests of increasing the supply of transplantable organs can have serious consequences on the medical care of potentially salvageable patients. Perimortem interventions can interfere with the delivery of an optimal quality of end-of-life care. The lack of disclosure of these NHBD ethical controversies does not uphold the moral obligation for an informed consent.