Article, Emergency Medicine

When health care priorities are unclear: do we obtain organs or try to save lives?

Correspondence

References

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When health care priorities are unclear: do we obtain organs or try to save lives?B,BB

To the Editor,

In the comment entitled “When health care priorities are unclear: do we obtain organs or try to save lives?,” the authors (curiously none of them is a medical doctor) review a set of ethical principles, which should be guiding the practice of donation after death has been determined by circulatory criteria in persons whose death has occurred after an unexpected out-of-hospital cardiac arrest [1].

Currently also implemented in France, Italy, and the Netherlands among others, Spain was one of the countries first developing protocols allowing Organ donation to occur from persons whose death had resulted from an unexpected cardiac arrest, this taking place either in the out-of-hospital setting or within the hospital [2]. Starting in the 90s, these protocols have allowed the transplantation of 1361 kidneys, 133 livers, and 52 lungs in our country, with excellent results in the case of kidney transplants and promising outcomes in liver and lung transplantation [3-7]. Over the years, the programs have been extending throughout the country with an excellent acceptance by the entire professional network and an adequate public perception, as made evident by the high consent rate in this type of donation [8]. Its practice has been based on a specific legislation in place since 1999 and on national consensus documents released in 1996 and recently in 2012 and developed with the active participation of all relevant national professional societies in the field of emergency and intensive care [9-11].

Contrary to what is stated, uncontrolled donation after circulatory death (DCD) is only activated when all appropriate therapeutic possibilities have been applied and resulted unsuccessful, strictly following local protocols according to

? No grants or financial support.

?? Uncontrolled donation after circulatory death: in the donor’s best interest.

411

the National Cardiopulmonary Resuscitation Plan, aligned with international professional standards–those mentioned by the authors [12,13]. Such protocols are applied by highly qualified and trained emergency medical teams and are exactly the same, regardless of the engagement of the team in a DCD program and regardless the patient is to be potentially considered a donor should the measures fail. Protocols in place always include the treatment of the known or suspected cause of the cardiac arrest. It is only after further treatment is deemed futile under the light of the mentioned standards– termination of resuscitation rules–when uncontrolled DCD protocols are considered. Should the treatment of out-of- hospital cardiac arrest not be optimal, the corresponding health care quality indicators of the Spanish emergency services would not place our country in a position of excellence [14,15]. The authors propose the option of nonconventional Resuscitation procedures (NCRPs) to be incorporated to the standards of care in cases of unexpected cardiac arrest. Of note, not all procedures referred in the article as such are considered NCRP: some of them are conventional resusci- tative measures, others are specific measures applicable in special situations, and some are only applicable in patients with spontaneous recovery of circulation (ie, hypothermia). Contrary to what is suggested, pure NCRPs are not recommended in current international guidelines because the effectiveness of these emerging protocols is still to be proven and their proportionality evaluated. Moreover, far from being effective, some of the proposed measures have proven to be harmful in international multicentric randomized clinical trials, references curiously obviated in the article [16]. If the limited and contradictory available evidence is enough for the authors to call countries with uncontrolled DCD programs in place to implement such therapeutic strategies, this call should be extended to the rest of the developed countries as well because all of them would be overlooking strategies proven so effective in saving life with quality–in the authors’ view. Far from being considered an obstacle, existing uncontrolled DCD programs would not be but facilitators of the implementation of NCRP. In fact, they have been applied in selected patients in our country, with the option of DCD being further activated in case of failure–just

as the authors propose.

Of course, Ethical concerns and dilemmas are still to be overcome in DCD, as in other fields of donation and transplantation medicine, but the approach to these dilemmas should start with a detailed study of the facts, based on evidence and not on personal interests or opinions. Uncon- trolled DCD is the result of the coordinated efforts of a huge number of professionals who have made possible to comprise both the interests of the potential organ recipients and those of organ donors, by placing the opportunity of donation as part of end of life care when death occurs–after optimizing all available and appropriate therapeutic options [17]. Under- mining and defaming these important achievements with articles as this one is what threatens the professional and the public perception of organ donation, and this is not precisely

412 Correspondence

what is needed in the progress towards self-sufficiency in transplantation.

R. Matesanz1

http://dx.doi.org/10.1016/j.ajem.2012.08.022

Appendix. Spanish Group for Donation after Circulatory Death

M. Abradelo (12 de Octubre University Hospital, Madrid),

M. Alba (San Juan de Alicante University Hospital, San Juan Alicante), T. Aldabo (Representative of the Spanish Society of Intensive Medicine, Critics and Coronary Units, SEMICYUC. Virgn del Rocio University Hospital, Sevilla), M. Alonso (Regional Transplant Coordinator Andalucia), A. Andres (12 de Octubre University Hospital, Madrid), A. Barrientos (Clinico San Carlos University Hospital, Madrid), D. Cala- tayud-Mizrahi (Clinic University Hospital, Barcelona), JM. Campos (Clinico San Carlos University Hospital, Madrid), C. Carriedo (Direction of Urgencies, Emergencies and Health Transport. Castilla La Mancha Health Service), C. Chamorro (Regional Transplant Coordinator Madrid), E. Coll (Organiza- cion Nacional de Trasplantes, Madrid), E. Corral-Lozano (Santiago University Hospital, Vitoria), E. Corral-Torres (General Vice-director SAMUR-Proteccion Civil, Madrid),

B. de la Calle (Gregorio Maranon University Hospital, Madrid), F. del Rio (Clinico San Carlos University Hospital, Madrid), M. Delicado (Representative of the Spanish Intensive and Coronary Units Nurse Society, SEEIUC. Basurto University Hospital, Bilbao), R. Deulofeu (Former Regional Transplant Coordinator, Cataluna), B. Dominguez-Gil (Orga- nizacion Nacional de Trasplantes, Madrid), M. Duque (Organizacion Nacional de Trasplantes, Madrid), JL. Escalante (Gregorio Maranon University Hospital, Madrid), A. Fernan- dez-Garcia (A Coruna University Hospital, A Coruna), C. Fondevila (Clinic University Hospital, Barcelona), P. Gamez (12 de Octubre University Hospital, Madrid), F. Garcia- Alfranca (Medical EmergencyService, Cataluna), JC. Garcia- Valdecasas (Clinic University Hospital, Barcelona), E. Gil- Pinero (Representative of Health Emergencies, Andalucia), M. Gomez-Gutierrez (A Coruna University Hospital, A Coruna),

J. Gonzalez-Cotorruelo (Former Regional Transplant Coordi- nator, Cantabria), M. Gonzalez-Romero (Clinico San Carlos University Hospital, Madrid), JA. Iglesias (Spanish Society of Urgency and Emergency Medicine, SEMES. Galicia), C. Jimenez-Romero (12 de Octubre University Hospital, Madrid), JL. Lopez del Moral (President of the Provincial Court, Cantabria), A. Manzano (Santiago University Hospital, Vitoria), F. Martinez- Soba (Regional Transplant Coordinator, La Rioja), K. Martinez-Urionabarrenetxea (President of the Fundamental and Clinical Bioethics Association. Navarra

1 On behalf of the Spanish Group for Donation after Circulatory Death. See Appendix section for full details.

University Hospital, Pamplona), N. Masnou (Representative of the Spanish Society of Intensive Medicine, Critics and Coronary Units, SEMICYUC. Vall d’Hebron University Hospital, Barcelona), A. Mateos (Representative of the Medical Urgencies Service, SUMMA 112 Madrid), J. Maynar (Santiago University Hospital, Vitoria), B. Miranda (Former Head of Transplant Service Foundation, Clinic University Hospital, Barcelona), E. Moreno (12 de Octubre University Hospital, Madrid), JR. Nunez (Clinico San Carlos University Hospital, Madrid), F. Oppenheimer (Clinic University Hospi- tal, Barcelona), A. Otero (A Coruna University Hospital, A Coruna), LZ. Peiro (San Juan de Alicante University Hospital, San Juan Alicante), I. Perez-Flores (Clinico San Carlos University Hospital, Madrid), JM. Perez-Villares (Virgen de las Nieves University Hospital, Granada), L. Peri (Clinic University Hospital, Barcelona), A. Ruiz- Arranz (Clinic University Hospital, Barcelona). E. Sagredo (Organizacion Nacional de Trasplantes, Madrid), MJ. Sanchez-Carretero (Regional Transplant CoordinatorCastilla La Mancha), A. Sanchez-Fructuoso (Clinico San Carlos University Hospital, Madrid), J. Sanchez-Ibanez (Regional Transplant Coordinator, Galicia), M. Sanroma (Regional Transplant Coordination, Cataluna), I. Saralegui (Representative of the Spanish Society of Intensive Medicine, Critics and Coronary Units, SEMI- CYUC. Santiago University Hospital, Vitoria), C. Segovia (Organizacion Nacional de Trasplantes, Madrid), P. Ussetti (Puerta de Hierro University Hospital, Madrid), A. Varela (Puerta de Hierro University Hospital, Madrid), R. Vega (Organizacion Nacional de Trasplantes, Madrid), M. Velasco (Representative of the Medical Urgencies Service, SUMMA 112 Madrid), P. Villarroel (Representative of the Spanish Society of Urgency and Emergency Medicine, SEMES. Clinico San Carlos University Hospital, Madrid).

With the Support of: National Transplant Committee, Inter-Regional Council of Health, Ministry of Health, Social Policy and Equity Spain: PA. Monserrat (Cataluna),

J. Sanchez-Ibanez (Galicia), M. Alonso (Andalucia), JI. Sanchez-Miret (Aragon), E. Minambres (Cantabria), JL. Rey (CA Valenciana), G. Guerrero (Extremadura), A. Gaya (Baleares), C. Chamorro (Madrid), C Fernandez Renedo (Castilla y Leon), MJ. Sanchez Carretero (Castilla La Mancha), J. Aldave (Navarra), AP. Rodriguez Hernandez (Canarias), JL. Aranzabal (Pais Vasco), J Otero (Asturias), P. Ramirez Romero (Murcia), F. Martinez Soba (La Rioja)

Spanish Society of Urgency and Emergency Medicine (SEMES). President: T. Toranzo.

Spanish Society of Intensive Medicine, Critics and Coronary Units (SEMICYUC). President: J. Cunyat.

Spanish Society of Nephrology (SEN). President: A. Martinez-Castelao.

Spanish Transplantation Society (SET). President: M. Arias.

Spanish Society of liver transplantation (SETH).

President: M. de la Mata.

Spanish Society of Neumology and Thoracic Surgery (SEPAR). President: J. Ruiz-Manzano.

Correspondence 413

Spanish Society of Dialysis and Transplantation . President: J. Ocharan-Corcuera.

Andalusian Organ and Tissue Transplantation Soci- ety (SATOT). President: D. Burgos.

Spanish Urology Association . Kidney Trans- plant Group. Coordinator: E. Lledo.

Catalonian Transplantation Society . President: JM. Campistol.

Madrid Transplantation Society . President: JM. Morales.

Valencia Transplantation Society . President:

J. Mir.

References

  1. Deballon IO, Rodriguez-Arias Vailhen D, de la Plaza Horche E. When health care priorities are unclear: Do we obtain organs or try to save lives. Am J Emerg Med 2012;30:1001-3.
  2. Dominguez-Gil B, Haase-Kromwijk B, Van Leiden H, Neuberger J, Coene L, Morel P, et al. Current situation of donation after circulatory death in European countries. Transpl Int 2011;24(7):676-86.
  3. Sanchez-Fructuoso AI, Marques M, Prats D, Conesa J, Calvo N, Perez- Contin MJ, et al. Victims of cardiac arrest occurring outside the hospital: a source of transplantable kidneys. Ann Intern Med 2006; 145(3):157-64.
  4. Suarez F, Otero A, Solla M, Arnal F, Lorenzo MJ, Marini M, et al. biliary complications after liver transplantation from maastricht category-2 Non-heart-beating donors. Transplantation 2008;85(1):9-14.
  5. Jimenez-Galanes Marchan S, Meneu-Diaz JC, Moreno Elola-Olaso A, Perez-Saborido B, Fundora-Suarez Y, Gimeno Calvo A, et al. Liver transplantation using uncontrolled non-heart-beating donors under normothermic extracorporeal membrane oxygenation. Liver Trans- plant 2009;15:1110-8.
  6. Fondevila C, Hessheimer AJ, Flores E, Ruiz A, Mestres N, Calatayud D, et al. Applicability and results of maastricht type 2 donation after cardiac death liver transplantation. Am J Transplant 2012;12(1):162-70.
  7. De Antonio DG, Marcos R, Laporta R, Mora G, Garcia-Gallo C, Gamez P, et al. Results of clinical lung transplant from uncontrolled non-heart-beating donors. J Heart Lung Transplant 2007;26:529-34.
  8. Andres A, Morales E, Vazquez S, Cebrian MP, Nuno E, Ortuno T, et al. Lower rate of family refusal for organ donation in non-heart- beating versus brain-dead donors. Transplant Proc 2009;41(6):2304-5.
  9. Real Decreto 2070/1999, de 30 de diciembre, por el que se regulan las actividades de obtencion y utilizacion clinica de organos humanos y la coordinacion territorial en materia de donacion y trasplante de organos y tejidos. ONT website. http://www.ont.es/infesp/Legislacin/ REAL_DECRETO_DONACION_Y_TRASPLANTE.pdf. Last access: May 2012.
  10. Matesanz R. Documento de consenso espanol sobre extraccion de organos de donantes en asistolia. Nefrologia 1996;16(Suppl 2):48-53.
  11. 2012 National Consensus Document on Donation after Circulatory Death. ONT website. http://www.ont.es/infesp/Documentos DeConsenso/DONACION%20EN%20ASISTOLIA%20EN% 20 ES PANA.%2 0SI T UACION%20 ACTUAL%2 0Y%

20RECOMENDACIONES.pdf. Last access: May 2012.

  1. Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, et al. European Resuscitation Council Guidelines for Resuscitation 2010. Section 1. Executive summary. Resuscitation 2010;81:1219-76.
  2. Field J, Hazinski MF, Sayre M, Chameides L, Stephen M. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S640-56.
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resuscitation during extrahospital assistance. Emergencias 2007;19: 300-5.

  1. Moreno Martin JL, Esquilas Sanchez O, Corral Torres E, Suarez Bustamante RM, Vargas Roman MI. Efectividad de la implementacion de la desfibrilacion semiautomatica en las Unidades de Soporte Vital Basico. Emergencias 2009;21:12-6.
  2. Bottiger BW, Arntz HR, Chamberlain DA, Bluhmki E, Belmans A, Danays T, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 2008;359(25):2651-62.
  3. Bernat JL, Capron AM, Bleck TP, Blosser S, Bratton SL, Childress JF, et al. The circulatory-respiratory determination of death in organ donation. Crit Care Med 2010;38(3):963-70.

The authors reply: Following the patient’s best interest Uncontrolled donation after circulatory determination of death

To the Editor,

We appreciate the publication of divergent opinions on a topic as controversial as donation after circulatory determi- nation of death (DCDD).

Addressing not only the merely descriptive disagreements on how protocols for uncontrolled DCDD (uDCDD) are being put in practice, but also the discrepancies based on conceptual issues, we hope to agree with the respondents that health care providers should pursue the same goal: increasing organ donation rates in an ethical manner to reduce the gap between decreasing available organs and the growing waiting lists [1]. The author states that “[protocolos for uDCDD] have made possible to comprise […] the interest […] of organ donors by placing the opportunity of donation as part of end of life care when death occurs, after optimizing all available

and appropriate therapeutic options.”

Such a claim involves a number of inaccuracies. First, organ donation cannot be considered part of end-of-life care in uDCDD. After failed CPR, interventions are not intended to reverse the cause of their circulatory arrest, or to manage individuals potential discomfort, but to preserve their organs. Second, it is odd to describe organ preservation without explicit consent by the patient or his or her family (Spain has an opt-out system and refusal registries are inexistent) as offering an opportunity to organ donors. We agree with those who state that “the opportunity to donate does not serve the patient, unless the patient’s consent to donation is

genuinely and freely expressed” [2].

Third, organ preservation is not started when death occurs, or after optimizing all available therapeutic options, but earlier. Whether or not all available therapeutic options are appropriate depends on the meaning of appropriate, which is controversial. The therapeutic options available for patients suffering an unexpected out-of-hospital cardiac arrest (OHCA) are increasing as a result of the development of nonstandard cardiopulmonary resuscitation (NS-CPR) procedures [3-10].

International guidelines insist on the need to carry out a minimally interrupted resuscitation and endorse high

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