Uncontrolled donation after circulatory determination of death (uDCDD) refers to organ donation after a refractory cardiac arrest. We analyzed ethical issues raised by the uDCDD protocols of France, Madrid, and New York City. We recommend: (1) Termination of resuscitation (TOR) guidelines need refinement, particularly the minimal duration of resuscitation efforts before considering TOR; (2) Before enrolling in an uDCDD protocol, physicians must ascertain that additional resuscitation efforts would be ineffective; (3) Inclusion in an uDCDD protocol should not be made in the outpatient setting to avoid error and conflicts of interest; (4) The patient’s condition should be reassessed at the hospital and reversible causes treated; (5) A no-touch period of at least 10 minutes should be respected to avoid the risk of autoresuscitation; (6) Once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation; (7) Specific consent is required prior to entry into an uDCDD protocol; (8) Family members should be informed about the goals, risks, and benefits of planned uDCDD procedures; and (9) Public information on uDCDD is desirable because it promotes public trust and confidence in the organ donation system.
Le GuenMNicolas-RobinACarreiraS. Extracorporeal life support following out-of-hospital refractory cardiac arrest. Crit Care. 2011;15(1):R29. doi:10.1186/cc9976.
2.
LamhautLJouffroyRSoldanM. Safety and feasibility of prehospital extra corporeal life support implementation by non-surgeons for out-of-hospital refractory cardiac arrest. Resuscitation. 2013;84(11):1525–1529.
3.
BurnodAAntoineC. Resuscitation of non-heart-beating donors in the prehospital setting. Réanimation. 2007;16:687–694. doi:1016/j.reaurg.2007.09.027.
4.
AntoineCTenaillonA. Conditions à respecter pour réaliser des prélèvements de reins sur des donneurs à Coeur arrêté dans un établissement de santé autorisé aux prélèvements d’organes. Agence de la biomédecine. 2007. http://www.urgences-serveur.fr/IMG/pdf/DVprotocole_V12_avril_2007.pdf.
5.
Mateos-RodriguezAPardillos-FerrerL. Kidney transplant function using organs from non-heart-beating donors maintained by mechanical chest compressions. Resuscitation. 2010;81(7):904–907.
6.
Pérez-VillaresJMLara-RosalesRPino-SanchezF. Alpha code. The start of a new non-heart beating donor program. Med Intensiva. 2013;37(4):224–231.
7.
Mateos-RodriguezAANavalpotro-PascualJMDel Rio GallegosF. Out-hospital donors after cardiac death in Madrid, Spain: a 5-year review. Australas Emerg Nurs J. 2012;15(3):164–169.
8.
DupriezFDe PauwLDariusT. Fourteen years of experience in uncontrolled organ donation after cardio-circulatory death. Transplant Proc. 2014;46(9):3134–3137.
9.
HooglanERSnoeijsMGWinkensBChristaansMHvan HeurnLW. Kidney transplantation from donors after cardiac death: uncontrolled versus controlled donation. Am J Transplant. 2011;11(7):1427–1434.
10.
Dominguez-GilBHaase-KromwijkBVan LeidenH. Current situation of donation after circulatory death in European countries. Transpl Int. 2011;24(7):676–686.
11.
Gonzalez-AguirreDJarmillo-GanteMAMuruato-AraizaSSánchez-AguilarJMMontes de Oca-ArceJL. Trasplante renal en asistolia Maastricht II. Reporte del primer caso en Mexico. Gac Med Mex. 2014;150(4):345–347.
12.
ReznikONSkvortsovAEReznikAO. Uncontrolled donors with controlled reperfusion after sixty minutes of asystole: a novel reliable resource for kidney transplantation. PLoS One. 2013;8(5):e64209. doi:10.1371/journal.pone.0064209.
13.
GeraciPMAzzomiGAbelliM. The Italian ‘Programma Alba’ for organ donation after circulatory death. Organs Tissues Cells. 2010;13:107–118.
14.
LeeJHHongSYOhCKHongYSYimH. Kidney transplantation form a donor following cardiac death supported with extracorporeal membrane oxygenation. J Korean Med Sci. 2012;27(2):115–119.
15.
LeeCYTsaiMKKoWJ. Expanding the donor pool: use of renal transplants form non-heart-beating donors supported with extracorporeal membrane oxygenation. Clin Transplant. 2005;19(3):383–390.
16.
DeVitaMACallawayCWPacellaCBrooksMMLutzJStuartS. Experience with a new process—condition T—for uncontrolled donation after circulatory determination of death in a University Emergency Department. Prog Transplant. 2016;26(1):21–27.
17.
LightJA.The Washington, D. C. experience with uncontrolled donation after circulatory determination of death: promises and pitfalls. J Law Med Ethics. 2008;36(4):735–740. doi:10.1111/j.1748-720X.2008.00332.x.
18.
WallSPMunjalKGDublerNNGoldfrankLR; NYC uDCDD Study Group. Uncontrolled organ donation after circulatory determination of death: US policy failures and call to action. Ann Emerg Med. 2014;63(4):392–400.
19.
WallSPKaufmanBJGilbertAJ. Derivation of the uncontrolled donation after circulatory determination of death protocol for New York City. Am J Transplant. 2011;11(7):1417–1426.
20.
WallSPPlunkettCCaplanA. A potential solution to the shortage of solid organs for transplantation. JAMA. 2015;313(23):2321–2322. doi:10.1001/jama.2015.5328.
21.
MunjalKGWallSPGoldfrankLRGilbertAKaufmanBJDublerNN; New York City uDCDD study group. A rationale in support of uncontrolled donation after circulatory determination of death. Hastings Cent Rep. 2013;43(1):19–26.
22.
BernatJL. Controversies in defining and determining death in critical care. Nat Rev Neurol. 2013;9(3):164–173.
23.
BernatJLCapronAMBleckTP. The circulatory-respiratory determination of death in organ donation. Crit Care Med. 2010;38(3):963–970.
24.
Dalle AveALShawDMBernatJL. Ethical issues in the use of extracorporeal membrane oxygenation in controlled donation after circulatory determination of death. Am J Transplant. 2016;16(8):2293–2299.
25.
Dalle AveALBernatJL. Using the brain criterion in organ donation after the circulatory determination of death. J Crit Care. 2016;33:114–118.
26.
Dalle AveALShawDBernatJL. An analysis of heart donation after circulatory determination of death. J Med Ethics. 2016;42(5):312–317. doi:10.1136/medethics-2015-103224.
27.
Dalle AveALShawDM. Controlled donation after circulatory determination of death: ethical issues in withdrawing life-sustaining therapy [published online February 22, 2016]. J Intensive Care Med. 2016. pii: 0885066615625628.
28.
RabbatCGThorpeKERussellJD. Comparison of mortality risk for dialysis patients and cadaveric first renal transplant recipients in Ontario, Canada. J Am Soc Nephrol. 2000;11(5):917–922.
29.
British Transplantation Society: UK guidelines: transplantation from donors after deceased circulatory death. 2013. www.bts.org.uk. Accessed July 2016.
30.
BernatJL. Determining death in uncontrolled DCDD organ donors. Hastings Cent Rep. 2013;43(1):30–33.
31.
Rodriguez-AriasDOrtega-DeballonISmithMYoungnerSJ. Casting light and doubt on uncontrolled DCDD protocols. Hastings Cent Rep. 2013;43(1):27–23.
32.
Dalle AveALShawDMGardinerD. Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation or uncontrolled donation after the circulatory determination of death following out-of-hospital refractory cardiac arrest—an ethical analysis of an unresolved clinical dilemma. Resuscitation. 2016;108:87–94.
33.
BernatJLBleckTPBlosserSA. Circulatory death determination in uncontrolled organ donors: a panel viewpoint. Ann Emerg Med. 2014;63(4):384–390. doi.org/10.1016/j.annemergmed.2013.05.018.
34.
DoigCJZygunDA. (Uncontrolled) donation after cardiac determination of death: a note of caution. J Law Med Ethics. 2008;36(4):760–765.
35.
HantoDWVeatchRM. Uncontrolled donation after circulatory determination of death (UDCDD) and the definition of death. Am J Transplant. 2011;11(7):1351–1352.
36.
Rodriguez-AriasDOrtega DeballonI. Protocols for uncontrolled donation after circulatory death. Lancet. 2012;379(9823):1275–1276.
37.
MegarbaneBDeyeNAoutM. Usefulness of routine laboratory parameters in the decision to treat refractory cardiac arrest with extracorporeal life support. Resuscitation. 2011;82(9):1154–1161.
38.
NagaoKKikushimaKWatanabeK. Early induction of hypothermia during cardiac arrest improves neurological outcomes in patients with out-of-hospital cardiac arrest who undergo emergency cardiopulmonary bypass and percutaneous coronary intervention. Circ J. 2010;74(1):77–85.
39.
ChenYSLinJWYuHY. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet. 2008;372(9638):554–561.
40.
SakamotoTMorimuraNNagaoK. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study. Resuscitation. 2014;85(6):762–768.
41.
Uniform Determination of Death Act, 12 uniform laws annotated 589 (West 1993 and West Suppl 1997).
42.
Gomez-de-AntonioDVarelaA. Non-heart-beating donation in Spain. Gen Thorac Cardiovasc Surg. 2011;59(1):1–5.
43.
FieuxFLosserMRBourgeoisE. Kidney retrieval after sudden out of hospital refractory cardiac arrest: a cohort of uncontrolled non heart beating donors. Crit Care. 2009;13(4):R141. doi:10.1186/cc8022.
44.
FernandezECalatayudJJaraboJR. Profitability of our lung retrieval program from non heart beating donors. Eur J Cardiothorac Surg. 2009;35(2):287–292.
45.
FondevilaCHessheimerAJFloresE. Applicability and results of Maastricht type 2 donation after cardiac death liver transplantation. Am J Transplant. 2012;12(1):162–170.
46.
BarrettCSBrattonSLSalvinJWLaussenPCRycusPTThiagarajanRR. Neurological injury after extracorporeal membrane oxygenation use to aid pediatric cardiopulmonary resuscitation. Pediatr Crit Care Med. 2009;10(4):445–451.
47.
Dalle AveALGardinerDShawDM. The ethics of extracorporeal membrane oxygenation in brain-dead potential organ donors. Transpl Int. 2016;29(5):612–618. doi:10.1111/tri.12772.
48.
Dalle AveALGardinerDShawDM. Cardio-pulmonary resuscitation of brain-dead organ donors: a literature review and suggestions for practice. Transpl Int. 2016;29(1):12–19. doi:10.1111/tri.12623.
49.
DrennanIRLinSSidalakDEMorrisonLJ. Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: an observational cohort study. Resuscitation. 2014;85(11):1488–1493. doi:10.1016/j.resuscitation.2014.07.011.
50.
SoarJCallawayCWAibikiM. Part 4: advanced life support 2015 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation. 2015;95:e71–e120.
51.
KleinmanMEBrennanEEGoldbergerZD. Part 5: adult life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 suppl 2):S414–S435.
52.
ReynoldsJCFrischARittenbergerJCCallawayC. Duration of resuscitation efforts and functional outcome after out-of-hospital cardiac arrest: when should we change to novel therapies?Circulation. 2013;128(23):2488–2494. doi:10.1161/CIRCULATIONAHA.113.002408.
53.
MarshallW.Termination of resuscitation for futility physician guideline. NYC REMAC (Regional Emergency Medical Services Council of NYC). Issued date: January 21, 2009.
54.
KämäräinenAVirkkunenIHolopainenLErkkiläEYli-HankalaATenhunenJ. Spontaneous defibrillation after cessation of resuscitation in out-of-hospital cardiac arrest: a case of Lazarus phenomenon. Resuscitation. 2007;75(3):543–546.
55.
FabrePBougouinWDumasF. Early identification of patients with out-of-hospital cardiac arrest with no chance of survival and consideration for organ donation[published online September 13, 2016]. Ann Intern Med. 2016. doi:10.7326/M16-0402 (epub).
56.
ShinTGChoiJHJoIJ. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: a comparison with conventional cardiopulmonary resuscitation. Crit Care Med. 2011;39(1):1–7. doi:10.1097/CCM.0b013e3181feb339.
57.
JohnsonNJAckerMHsuCH. Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest. Resuscitation. 2014;85(11):1527–1532.
58.
DuboisJM. Increasing rates of organ donation: exploring the Institute of Medicine’s boldest recommendation. J Clin Ethics. 2009;20(1):13–22.
Ortega-DeballonI. Programmes for uncontrolled donation after circulatory death: clinical, ethical and legal benchmarks. Health Care Curr Rev. 2015;3(1):1–4.
63.
Code de la santé publique. Article R1232-1 et R 1232-2.
64.
Swiss Federal Act on Transplantation of Organs, Tissues and Cells. 8th October 2004 (SR 810.21).
65.
DhananiSHornbyLWardR. Vital signs after cardiac arrest following withdrawal of life-sustaining therapy: a multicenter prospective observational study. Crit Care Med. 2014;42(11):2358–2369.
66.
ShemieSDBakerAJKnollG. National recommendations for donation after cardiocirculatory death in Canada. CMAJ. 2006;175(8):S1.
67.
BernatJL. How the distinction between “irreversible” and “permanent” illuminates circulatory-respiratory death determination. J Med Philos. 2010;35(3):242–255. doi:10.1093/jmp/jhq018.
68.
BernatJL. How auto-resuscitation impacts death determinations in organ donor. Crit Care Med. 2010;38(5):1377–1378.
69.
HornbyKHornbyLShemieSD. A systematic review of autoresuscitation after cardiac arrest. Crit Care Med. 2010;38(5):1246–1253.
70.
SprungCLLedouxDBulowHH. Relieving suffering or intentionally hastening death: where do you draw the line?Crit Care Med. 2008;36(1):8–13.
71.
Committee on increasing rates of organ donation, ChildressJFLivermanCT. Organ donation: opportunities for action. 2006. www.nap.edu/catalog/11643.html. Accessed 2015.
72.
HawardMFMurphyROLorenzJM. Default options and neonatal resuscitation decisions. J Med Ethics. 2012;38(12):713–718.
73.
Ethical commission of the Reanimation Society of French Language (SRLF). Statement of the SRLF on non-heart beating donor transplantation (Position de la société de réanimation de langue française (SRLF) concernant les prélèvements d’organes chez les donneurs à cœur arrêté). Réanimation. 2007;16:428–435.
74.
Dalle AveALShawD. Donation after circulatory determination of death: What information to whom. Bioethica Forum. 2016;9(1):32–38.
75.
OverbyKJWeinsteinMSFeisterA. Addressing consent issues in donation after circulatory determination of death. Am J Bioeth. 2015;15(8):3–9.
Guibet LafayeCPuybassetL. Décider la mort et prélever les organs: la question de l’extension des conditions du prélèvement d’organes. Ethique publique. 2011;13(1):235–259.
78.
BellD. Emergency medicine and organ donation—a core responsibility at a time of need or threat to professional integrity. Resuscitation. 2010;81(9):1061–1062.
79.
AbboudIVigliettiDAntoineC. Preliminary results of transplantation with kidneys donated after cardiocirculatory determination of death: a French single-center experience. Nephrol Dial Transplant. 2012;27(6):2583–2587.
80.
Sanchez-FructuosoAIMarquesMPratsD. Victims of cardiac arrest occurring outside the hospital: a source of transplantable kidneys. Ann Intern Med. 2006;145(3):157–164.
81.
Garcia-ValdecasasJCFondevillaC. In-vivo normothermic recirculation: an update. Curr Opin Organ Transplant. 2010;15(2):173–176.
