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Sam D. Shemie, Andrew J. Baker, Greg Knoll, William Wall, Graeme Rocker, Daniel Howes, Janet Davidson, Joe Pagliarello, Jane Chambers-Evans, Sandra Cockfield, Catherine Farrell, Walter Glannon, William Gourlay, David Grant, Stéphan Langevin, Brian Wheelock, Kimberly Young, and John Dossetor
Donation after cardiocirculatory death in Canada
CMAJ 2006; 175: S1 [Abstract] [Full text] [PDF]
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[Read eLetter] Organ Donation after Cardiocirculatory Death and the Dead Donor Rule: what is the evidence?
Mohamed Y Rady   (30 October 2006)

Organ Donation after Cardiocirculatory Death and the Dead Donor Rule: what is the evidence? 30 October 2006
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Mohamed Y Rady
Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Arizona

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Re: Organ Donation after Cardiocirculatory Death and the Dead Donor Rule: what is the evidence?

rady.mohamed{at}mayo.edu Mohamed Y Rady

Mohamed Y. Rady (1) MD, PhD, FCCM;Joseph L. Verheijde(2), PhD, MBA;Joan McGregor (3), Ph.D.

From the Departments of (1)Critical Care Medicine, (2) Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Mayo Clinic Arizona, Phoenix, Arizona; (3) Bioethics, Policy, and Law Program, School of Life Sciences and Department of Philosophy, Arizona State University, Tempe, Arizona.

The national recommendations for donation after cardiocirculatory death (DCD) advocated a 5-minute period of continuous absence of palpable pulses, blood pressure and respiration to confirm the irreversibility of cardiocirculatory arrest (1). Similar criteria are applied for the purpose of recovery of transplantable organs in the United States (2). The above criteria do not fulfill the prerequisite requirement of irreversibility for the determination of death (3). First, auto-resuscitation (spontaneous return of circulatory and neurological function) also known as the Lazarus Phenomenon has been reported after more than 10 minutes of cardiac electric asystole in humans (4, 5). Second, the presence of electrocardiographic activity without blood pressure (i.e. pulseless electric activity or ventricular fibrillation) does not indicate irreversible cessation of mechanical cardiac activity (6). Third, the applicability of DCD criteria to permit organ procurement becomes questionable when artificial circulatory and ventilatory support is resumed after death to maintain abdominal and thoracic organs’ viability in potential donors (7-9). Extracorporeal circulatory support can lead to return of neurological function in individuals who are neurologically intact before cardiac death (10, 11). Mechanical occlusion of cardiac and cerebral circulation has been employed in an attempt to prevent re- animation during the procurement process without substantial evidence for its effectiveness (8). The arbitrary timing of cardiocirculatory criteria alone and without simultaneous total cessation of neurological activity in the donor during postmortem circulatory support will not universally fulfill the dead donor rule (12-14). The abandonment of dead donor rule may be necessary to permit the recovery of transplantable organs in DCD.

Reference:

1. Shemie SD, Baker AJ, Knoll G, et al. Donation after cardiocirculatory death in Canada. Canadian Medical Association Journal. 2006;175:S1.

2. Committee on Increasing Rates of Organ Donation-Board on Health Sciences Policy-Institute of Medicine. Organ Donation: Opportunities for Action. . Washington, D.C.: The National Academies Press; 2006.

3. National Conference of Commissioners on Uniform State Laws. The Uniform Determination of Death Act. . http://www.law.upenn.edu/bll/ulc/fnact99/1980s/udda80.htm. Accessed October 29, 2006.

4. Maleck WH, Piper SN, Triem J, Boldt J, Zittel FU. Unexpected return of spontaneous circulation after cessation of resuscitation (Lazarus phenomenon). Resuscitation. 1998;39:125-128.

5. Adhiyaman V, Sundaram R. The Lazarus Phenomenon. J R Coll Physicians Edinb 2002;32:9-13.

6. American Heart Association. Management of Cardiac Arrest. Circulation. 2005;112:IV-58-IV-66.

7. The Institute of Medicine. Executive Summary, Committee on Non- Heart-Beating Transplantation II. The Scientific and Ethical Basis for Practice and Protocols. Washington, DC: National Academy Press; 2000.

8. Magliocca JF, Magee JC, Rowe SA, et al. Extracorporeal support for organ donation after cardiac death effectively expands the donor pool. J Trauma-Injury Infect & Crit Care. 2005;58:1095-1101; discussion 1101 -1092.

9. Sanchez-Fructuoso AI, Marques M, Prats D, et al. Victims of Cardiac Arrest Occurring Outside the Hospital: A Source of Transplantable Kidneys. Ann Intern Med. 2006;145:157-164.

10. Martin GB, Rivers EP, Paradis NA, Goetting MG, Morris DC, Nowak RM. Emergency department cardiopulmonary bypass in the treatment of human cardiac arrest. Chest. 1998;113:743-751.

11. Younger JG, Schreiner RJ, Swaniker F, Hirschl RB, Chapman RA, Bartlett RH. Extracorporeal Resuscitation of Cardiac Arrest. Acad Emerg Med. 1999;6:700-707.

12. Ethics Committee, American College of Critical Care Medicine; Society of Critical Care Medicine. Recommendations for nonheartbeating organ donation: a position paper by the Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med. 2001;29:1826-1831.

13. Rady MY, Verheijde JL, McGregor J. Organ donation after circulatory death: the forgotten donor. Crit Care. 2006; 10:166-169. Available at: http://ccforum.com/content/10/5/166.

14. Menikoff J. The importance of being dead: non-heart-beating organ donation. Issues Law Med. 2002;18:3-20.

Conflict of Interest:

None declared