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Protocols for uncontrolled donation after circulatory death: a comprehensive approach to refractory cardiac arrest.

In their special contribution, Simon et al. identify ethical issues of donation after cardiac death (DCD) procedures. We propose a cause-based approach to refractory cardiac arrest for increasing survival in selected patients, making a rational use of resources while retaining the possibility of increasing the pool of organs. As the authors conclude, both emergency medical services (EMS) and in-hospital emergency department (ED) professionals are essential in DCD procedures. While Spain pioneered the most active international program for uncontrolled (after unexpected cardiac arrest) DCD, a recent internal cost-effectiveness analysis revealed a high cost and low specificity in terms of the number of organs actually used. Simon et al. report similar outcomes in other protocols for uncontrolled DCD procedures. Another identified concern is terminologic ambiguity describing individuals who suffers refractory cardiac arrest, when eligible for uncontrolled DCD: when does he or she cease to be a patient and become a potential donor? When should the goal change from saving the patient’s brain and heart, for life, to preserving organs for transplantation? Our proposal would not only improve cost-effectiveness results, but also would clarify the status of patient-donors: by exploring all of the possibilities of high-quality cardiopulmonary and cerebral resuscitation, it minimizes the conflict of interest identified in EMS and ED professionals and the risk of compromising the treatment of these patients. The proposal consists of implementing a comprehensive approach to refractory cardiac arrest and to subordinate the option of organ donation until after the failure of such an approach. According to the proposal, EMS and ED professionals, based on a validated predictive model and aligned with updated resuscitation guidelines, select patients in refractory cardiac arrest who may benefit from available resuscitation techniques, seeking to restore their life with intact quality of life using extracorporeal resuscitation (ECPR) and/ or percutaneous coronary intervention (PCI) followed by hypothermia. The results of those centers that have implemented such an approach show an encouraging improvement in survival rates. The option of organ donation remains if these attempts fail and irreversible cardiac arrest is declared, as when a bad neurologic prognosis follows despite of return of spontaneous circulation. In fact, the patient’s organs have received outstanding management in terms of preservation during resuscitation attempts, which minimizes warm ischemia time. Eligibility criteria for patients in refractory cardiac arrest benefiting from early ECPR and PCI match with potential donors. By implementing such a strategy, we avoid the identified conflicts of interest, because we are really still treating a patient, rather than only preserving his or her organs. Additionally, consent is required and public confidence in the system remains, and the health care community avoids the misunderstanding impression of hastening death. Does a more efficient way to treat patients with refractory cardiac arrest exist, according to best evidence? Is there any fairer possible use of the treatments we have? By trying to save no longer hopeless patients’ lives (and when this is not possible, increasing organ availability for transplantation) we mitigate most clinical, ethical, legal, and economic conflicts identified in uncontrolled DCD. doi: 10.1111/acem.12383