Uncontrolled Organ Donation After Circulatory Determination of Death: US Policy Failures and Call to Action

Abstract

In the United States, more than 115,000 patients are wait-listed for organ transplants despite that there are 12,000 patients each year who die or become too ill for transplantation. One reason for the organ shortage is that candidates fordonation must die in the hospital, not the emergency department (ED), either from neurologic or circulatory-respiratory death under controlled circumstances. Evidence from Spain and France suggests that a substantial number of deaths from cardiac arrest may qualify for organ donation using uncontrolled donation after circulatory determination of death (uDCDD) protocols that rapidly initiate organ preservation in out-of-hospital and ED settings. Despite its potential, uDCDD has beencriticized by panels of experts that included neurologists, intensivists, attorneys, and ethicists who suggest that organpreservation strategies that reestablish oxygenated circulation to the brain retroactively negate previous death determination based on circulatory-respiratory criteria and hence violate the dead donor rule. In this article, we assert thatin uDCDD, all efforts at saving lives are exhausted before organ donation is considered, and death is determined according to "irreversible cessation of circulatory and respiratory functions" evidenced by "persistent cessation of functionsduring an appropriate period of observation and/or trial of therapy." Therefore, postmortem invivo organ preservation with chest compressions, mechanical ventilation, and extracorporeal membrane oxygenation is legally andethically appropriate. As frontline providers for patients presenting with unexpected cardiac arrest, emergency medicinepractitioners need be included in the uDCDD debate to advocate for patients and honor the wishes of the deceased.