Ethical and Policy Considerations in Organ Donation after Circulatory Determinat

[Clark]

http://www.thoracic.org/media/press-releases/resources/Gries.pdf

An Official American Thoracic Society/International
Society for Heart and Lung Transplantation/Society
of Critical Care Medicine/Association of Organ and
Procurement Organizations/United Network of Organ
Sharing Statement: Ethical and Policy Considerations
in Organ Donation after Circulatory Determination
of Death
Cynthia J. Gries, Douglas B. White, Robert D. Truog, James DuBois, Carmen C. Cosio, Sonny Dhanani,
Kevin M. Chan, Paul Corris, John Dark, Gerald Fulda, Robert Higgins, Robert Love, David P. Mason,
Thomas A. Nakagawa, Ron Shapiro, Sam Shemie, Mary Fran Tracy, John M. Travaline, Maryam Valapour, Lori West,
David Zaas, and Scott D. Halpern; on behalf of the American Thoracic Society Health Policy Committee
THIS OFFICIAL STATEMENT OF THE AMERICAN THORACIC SOCIETY (ATS) WAS APPROVED BY THE ATS BOARD OF DIRECTORS, XXXXXXX

Rationale: Donation after circulatory determination of death (DCDD)
has the potential to increase the number of organs available for transplantation. Because consent and management of potential donors
must occur before death, DCDD raises unique ethical and policyissues.
Objectives: To develop an ethics and health policy statement on adult
and pediatric DCDD relevant to critical care and transplantation
stakeholders.
Methods: A multidisciplinary panel of stakeholders was convened to
develop an ethics and health policy statement. The panel consisted
of representatives from the American Thoracic Society, Society of
Critical Care Medicine, International Society for Heart and Lung
Transplantation, Association of Organ Procurement Organizations,
and the United Network of Organ Sharing. The panel reviewed the
literature, discussed important ethics and health policy considerations, and developed a guiding framework for decision making by
stakeholders.
Results: A framework to guide ethics and health policy statement was
established, which addressed the consent process, pre- and post
mortem interventions, the determination of death, provisions of
end-of-life care, and pediatric DCDD.
Conclusions: The information presented in this Statement is based on
the current evidence, experience, and clinical rationale. New clinical
research and the development and dissemination of new technologies will eventually necessitate an update of this Statement.

EXECUTIVE SUMMARY
This statement is designed to provide a framework to guide ethics
and health policy considerations in adult and pediatric controlled
donation after circulatory determination of death (DCDD) from
the perspective of critical care medicine and the transplant subspecialties. This report addresses controlled DCDD. Although uncontrolled DCDD, or donation after an unexpected circulatory
arrest, also raises many ethical issues, it is beyond the scope of this
statement. We provide ethics and policy considerations on five
aspects of controlled DCDD:
1. Consent
a. When patients themselves have consented to organ
donation, hospital critical care and organ procurement organization (OPO) representatives should respect the patient’s donation decision and provide this
information to surrogate decision makers.
b. After clinicians lead discussions with patients or
surrogates about the decisions to withdraw lifesustaining therapies, discussions about DCDD should
proceed promptly and be coordinated jointly by clinicians and OPO representatives.
c. Consent for DCDD should be obtained by individuals
with appropriate experience and training; these individuals’ organizational affiliations should always
be disclosed clearly.
2. Interventions
a. Use of ante mortem interventions and medications 1
should be disclosed to surrogates at the time of consent
and identified as being administered solely for the purpose of organ donation. Separate consent might be required for some ante mortem interventions consistent
with hospital policies or state/local laws and regulations.
b. Ante mortem interventions are ethically appropriate
if they contribute to good transplant outcomes and
have a low chance of harming the prospective donor.
c. Post mortem donor management interventions such
as extracorporeal membrane oxygenation that may
stimulate physiologic functions (i.e., cardiac or brain
function) require further analysis to determine their
clinical usefulness and ethical merit.
3. Determination of death
a. Death can be declared after the cessation of circulation
and respiratory function for 2 minutes.
b. Information about how death will be determined
should be provided to the patient or the surrogates.
4. End-of-life care
a. Surrogates should be informed during the consent
process regarding: (1) how and where life-sustaining
therapies will be withdrawn, (2) the amount of time
they can spend with their loved one post mortem,
and (3) the possibility that the patient may not die
within the time interval necessary for DCDD to
occur.
b. Hospitals that participate in DCDD should ensure
that experienced personnel with competency in palliative care are available to participate in end-of-life
care if needed.
c. Hospitals that participate in DCDD should have
a clear policy regarding how and where patients will
be cared for if they do not expire within the time
interval acceptable for donation.
5. Pediatric DCDD
a. Although pediatric patients (under the age of 18 yr)
cannot provide consent to their own donation, consent
of the parent or of another legal surrogate can be used.
b. The ethical principles related to consent, intervention,
declaration of death, and end-of-life care in pediatric
DCDD patients is similar to those for adults.