Monday, September 21, 2015

Permission for preservation

Wall SP, Plunkett C, Caplan A. A Potential Solution to the Shortage of Solid
Organs for Transplantation. JAMA. 2015 Jun 16;313(23):2321-2.

In the United States, the majority of deaths occur unexpectedly, outside hospitals or in emergency departments. Rarely do these deaths provide opportunities for organ donation. In Europe, unexpected deaths provide substantial numbers of transplantable organs through uncontrolled donation after circulatory determination of death (UDCDD). UDCDD considers decedents candidates for donation even when death is unexpected, regardless of location, as long as preservation begins after all life-sustaining efforts have been exhausted.

United States policy currently promotes organ recovery from 3 sources; neurologic deaths, controlled circulatory deaths, and live donors for kidneys and partial livers.

However, these approaches are incapable of meeting increasing US demand for transplants. During controlled donation after circulatory determination of death (CDCDD), the time from cessation of life support to circulatory arrest often exceeds 60 minutes. Prolonged hypotension leads to irreparable organ damage, thus limiting the effect of CDCDD on organ supply. Live donation primarily affects kidney supply; it is unlikely that altruistic donation will ever meet demand. Although many changes in public policy regarding cadaveric donation are debated (markets and presumed consent), none is likely to become law or make substantial differences in organ supply.

UDCDD requires initiation of organ preservation soon after death. If the warm ischemic time, which represents the time organs receive inadequate circulation to sustain cellular function, exceeds an organ-specific threshold, organs are not viable. European programs initiate organ preservation without requiring explicit consent, a concept the US public will not allow despite supporting UDCDD.  Therefore, some US programs restricted eligibility to deceased persons who had previously registered for organ donation. However, UDCDD programs in the United States experienced recruitment problems by restricting eligibility to previously registered organ donors.

A decision to preserve organs is less complex and consequential than the decision to donate. The capacity required to permit preservation is lower than that required to authorize donation. Grieving persons could be asked to provide permission to preserve when providing authorization for donation would be beyond their current capacity. Immediately following death, family members would be asked only for permission to begin organ preservation, thereby keeping open the option to donate later. The decision to begin organ preservation does not commit the family to a decision to donate, but it does maintain donation as an option.
The second step of the proposed 2-step authorization process is authorization to donate. Family members and loved ones initially need time to process the fact that death has occurred. Later they need the opportunity to weigh the pros and cons of donation against the decedent’s and family’s values.
The proposed schema of “permission for preservation” followed by later consideration of donation serves to protect the decedent’s values and family members’ autonomy when it comes to making a decision to donate. Moreover, this proposed approach also may increase the likelihood that families will authorize organ donation. The importance of “decoupling” pronouncement of death and requests for organ donation is well established. When conversations about organ donation occur several hours after the decedent’s death, in a private setting, with a transplant professional, families are much more likely to authorize donation. If organ preservation is permitted at or close to the time of death, family members can later take the time they need to process death, talk extensively with each other and transplant professionals, and come to a thoughtful decision.

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