Does new heart transplant method challenge definition of death? MedTwitter
on the issue, is board-certified in both cardiology and critical care, and says he is a supporter of DCD using direct procurement, but he does not believe that NRP is ethical at present. He is not part of the ACP, but says his views align with the organization.
The second ethical problem with NRP is concern about whether, during the process, there would be any circulation to the brain, and if so, would this be enough to restore some brain function? Before NRP is started, the main arch vessel arteries to the head are clamped to prevent flow to the brain, but there are worries that some blood flow may still be possible through small collateral vessels.
"Our position is that death has already been declared based on the lack of circulatory function for over 5 minutes and this has been with the full agreement of the family, knowing that the patient has no chance of a meaningful life. No one is thinking of trying to resuscitate the patient. It has already been established that any future efforts to resuscitate are futile. In this case, we are not resuscitating the patient by restarting the circulation.
He maintains that the clamping of the arch vessels to the head will ensure that when the circulation is restarted"the natural process of circulatory death leading to brain death will continue to progress." "The whole issue revolves around when are we comfortable that death has occurred," he said."Those against NRP are concerned that organs are being taken before the patient is dead. But the key point is that the patient has already been declared dead."
But Peled argues that while NRP may have some possible advantages over direct procurement, that does not justify allowing a process to go ahead that is unethical. The ISHLT conclusion reads:"With appropriate consideration of the ethical principles involved in organ donation, DCD can be undertaken in a morally permissible manner. In all cases, the introduction of DCD programs should be in accordance with local legal regulations. Countries lacking a DCD pathway should be encouraged to develop national ethical, professional, and legal frameworks to address both public and professional concerns.
Jorde adds:"We also have to weigh the wishes of the donor and their family. If family, advocating what are presumed to be the donors wishes, have decided that DCD would be acceptable and they understand the concept and wish to donate the organs after circulatory death, this should be strongly considered under the concept of self-determination, a basic human right.
"We are only doing direct procurement and we are seeing good results that appear to be comparable to DBD. That is good enough for me," he said. He says he thinks it is a"medical shortcoming" that agreement cannot be reached on the ethics of NRP."In an ideal world everyone would be on the same page. It makes me a bit uncomfortable that some people think it's okay and some people don't."
"But the concept of circulatory death itself is accepted after the withdrawal of life support. I think it's the rush to take the organs out that makes it more difficult." However, the question over possible collateral flow to the brain has led the UK to pause the NRP technique as routine practice while this is investigated further. So, at the present time, the vast majority of DCD heart transplants are being conducted using the direct procurement approach.
DCD donors will have had many tests indicating severe brain damage, a neurologist will have declared the prognosis is futile, and relatives will have agreed to withdraw life support, Jorde said."The heart stops beating, and the stand-off time means that blood flow to the brain ceases completely for at least 5 minutes before circulatory death is declared. This is enough on its own to stop brain function.
Large also points out that the fact that the UK requires a neurologic definition for brain-stem death makes the process easier. Jorde says:"It is of critical importance that local guidelines are streamlined, firstly in any one given country and then globally, and these things must be discussed transparently within society with all stakeholders — doctors, patients, citizens."
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