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Castro PP, Salas SP. Ethical issues of organ donation after circulatory death: Considerations for a successful implementation in Chile. Dev World Bioeth 2022; 22:259-266. [PMID: 34773430 PMCID: PMC9886168 DOI: 10.1111/dewb.12338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 02/01/2023]
Abstract
Organ transplantation is a lifesaving procedure for end-organ damage and remains up to today as the most cost-effective alternative to treat these conditions. However, the main limitation to performing organ transplants is the availability of donor organs suitable for transplantation. To increase the donor pool, expanding organ donation from the conventional neurologic determination of death (NDD) to include circulatory determination of death (DCD) has been a well-established method of increasing donors in other countries. In this article, we discuss the clinical and ethical considerations for introducing DCD in Chile. The concepts we have used could very well be translatable to other similar countries which have not implemented this donation system yet. The most relevant issue to date is that DCD needs to alter the care of dying patients to obtain quality donor organs. In some countries, including Chile, there are some cultural barriers regarding withdrawal-of-care. These barriers include confusing withdrawal of care with acceleration of death, which leads to many practitioners refusing to remove artificial life support, and in turn only minimize ventilatory support or switch to a T-tube (without extubation). This cultural barrier could be overcome with careful consideration of the opinions of healthcare workers, family members, community and policy-based stakeholders. We also identified ethical issues related to informed consent of both donor and recipients, among other relevant ethical considerations. In conclusion, DCD donation in Chile can increase organ donation numbers in one of Latin America's countries with the lowest effective donor rate. However, this opportunity must be taken with caution to avoid the opposite effect if this policy is not well implemented, respecting the sound ethical principles mentioned in this paper.
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Affiliation(s)
- Pablo Pérez Castro
- Transplant Center, Clinica Alemana de Santiago-Universidad del Desarrollo, Santiago, Chile,Department of Surgery, Universidad de Chile, Santiago, Chile,Master of Public Health Program, Johns Hopkins University, Baltimore, Maryland, United States
| | - Sofía P. Salas
- Department of Bioethics, Universidad del Desarrollo, Santiago, Chile
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Le Dorze M, Gaillard Le Roux B, Audibert G, Quéré R, Muller L, Lavoué S, Venhard JC, Perrigault PF, Lesieur O. Transferring an ICU Patient at the End of His Life for the Purpose of Organ Donation: Could It Be Considered? Transpl Int 2022; 35:10549. [PMID: 35812161 PMCID: PMC9257584 DOI: 10.3389/ti.2022.10549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/23/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Matthieu Le Dorze
- Ethics Committee of the French Society of Anesthesia and Critical Care Medicine (SFAR), Paris, France
- Department of Anesthesia and Critical Care Medicine, Hôpital Lariboisière AP-HP, Paris, France
- Université Paris-Saclay, UVSQ, INSERM, CESP, U1018, Villejuif, France
- *Correspondence: Matthieu Le Dorze, , orcid.org/0000-0001-9307-1913
| | - Bénédicte Gaillard Le Roux
- Ethics Commission of the French Intensive Care Society (SRLF), Paris, France
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Gérard Audibert
- Ethics Committee of the French Society of Anesthesia and Critical Care Medicine (SFAR), Paris, France
- Department of Anesthesia and Critical Care Medicine, Nancy University Hospital, University of Lorraine, Nancy, France
| | - Régis Quéré
- Ethics Commission of the French Intensive Care Society (SRLF), Paris, France
- Organ Procurement Organization, Necker University Hospital, Paris, France
| | - Laurent Muller
- Ethics Committee of the French Society of Anesthesia and Critical Care Medicine (SFAR), Paris, France
- Department of Anesthesia and Critical Care Medicine, University Hospital, Nîmes, France
| | - Sylvain Lavoué
- Ethics Commission of the French Intensive Care Society (SRLF), Paris, France
- Intensive Care Unit, University Hospital, Rennes, France
| | - Jean-Christophe Venhard
- Department of Anesthesia and Critical Care Medicine, French Society of Organ Procurement Medicine, University Hospital, Tours, France
| | - Pierre-François Perrigault
- Ethics Committee of the French Society of Anesthesia and Critical Care Medicine (SFAR), Paris, France
- Department of Anesthesia and Critical Care Medicine, University Hospital, Montpellier, France
| | - Olivier Lesieur
- Ethics Commission of the French Intensive Care Society (SRLF), Paris, France
- Intensive Care Unit, General Hospital, La Rochelle, France
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Le Dorze M, Martin-Lefèvre L, Santin G, Robert R, Audibert G, Megarbane B, Puybasset L, Dorez D, Veber B, Kerbaul F, Antoine C. Critical pathways for controlled donation after circulatory death in France. Anaesth Crit Care Pain Med 2022; 41:101029. [PMID: 35121185 DOI: 10.1016/j.accpm.2022.101029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/22/2021] [Accepted: 12/06/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION In 2015, France authorised controlled donation after circulatory death (cDCD) according to a nationally approved protocol. The aim of this study is to provide an overview from the perspective of critical care specialists of cDCD. The primary objective is to assess how the organ donation procedure affects the withdrawal of life-sustaining therapies (WLST) process. The secondary objective is to assess the impact of cDCD donors' diagnoses on the whole process. MATERIAL AND METHODS This 2015-2019 prospective observational multicentre study evaluated the WLST process in all potential cDCD donors identified nationwide, comparing 2 different sets of subgroups: 1- those whose WLST began after organ donation was ruled out vs. while it was still under consideration; 2- those with a main diagnosis of post-anoxic brain injury (PABI) vs. primary brain injury (PBI) at the time of the WLST decision. RESULTS The study analysed 908 potential cDCD donors. Organ donation remained under consideration at WLST initiation for 54.5% of them with longer intervals between their WLST decision and its initiation (2 [1-4] vs. 1 [1-2] days, P < 0.01). Overall, 60% had post-anoxic brain injury. Time from ICU admission to WLST decision was longer for primary brain injury donors (10 [4-21] vs. 6 [4-9] days, P < 0.01). Median time to death (agonal phase) was 15 [15-20] minutes. CONCLUSIONS French cDCD donors are mostly related to post-anoxic brain injury. The organ donation process does not accelerate WLST decision but increases the interval between the WLST decision and its initiation.
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Affiliation(s)
- Matthieu Le Dorze
- Université de Paris, INSERM, U942 MASCOT, F-75006, paris, france, Department of Anaesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, F-75010, Paris, France.
| | - Laurent Martin-Lefèvre
- Organ Donation Service, Service de Médecine Intensive Réanimation, boulevard Stéphane Moreau, 85000 La Roche-sur-Yon, France
| | - Gaëlle Santin
- Agence de la biomédecine, Medical and Scientific Department, 1, avenue du stade de France, 93212 Saint-Denis, France
| | - René Robert
- University of Poitiers, CHU de Poitiers, Service de Médecine Intensive Réanimation, CIC Inserm 1402, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Gérard Audibert
- University of Lorraine, Department of Anaesthesiology and Critical Care Medicine, Nancy University Hospital, 29, avenue du Maréchal de Lattre de Tassigny, 54035 Nancy, France
| | - Bruno Megarbane
- University of Paris, INSERM UMRS-1144, Department of Medical and Toxicological Critical Care, AP-HP, Lariboisière Hospital, 2, rue Ambroise Paré, 75475 Paris cedex 10, France
| | - Louis Puybasset
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Didier Dorez
- Organ Donation Service, Centre Hospitalier Annecy-genevois, 1, avenue de l'Hôpital, 74370 Epagny Metz-Tessy, France
| | - Benoît Veber
- SFAR Ethics Committee, Surgical Intensive Care Unit, Rouen University Hospital, 37, boulevard Gambetta, 76000 Rouen, France
| | - François Kerbaul
- Agence de la biomédecine, Medical and Scientific Department, 1, avenue du stade de France, 93212 Saint-Denis, France
| | - Corinne Antoine
- Agence de la biomédecine, Medical and Scientific Department, 1, avenue du stade de France, 93212 Saint-Denis, France
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Taherkhani N, Sepehri MM, Khasha R, Shafaghi S. Determining the Level of Importance of Variables in Predicting Kidney Transplant Survival Based on a Novel Ranking Method. Transplantation 2021; 105:2307-2315. [PMID: 33534528 DOI: 10.1097/tp.0000000000003623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Kidney transplantation is the best alternative treatment for end-stage renal disease. To optimal use of donated kidneys, graft predicted survival can be used as a factor to allocate kidneys. The performance of prediction techniques is highly dependent on the correct selection of predictors. Hence, the main objective of this research is to propose a novel method for ranking the effective variables for predicting the kidney transplant survival. METHODS Five classification models were used to classify kidney recipients in long- and short-term survival classes. Synthetic minority oversampling and random undersampling were used to overcome the imbalanced class problem. In dealing with missing values, 2 approaches were used (eliminating and imputing them). All variables were categorized into 4 levels. The ranking was evaluated using the sensitivity analysis approach. RESULTS Thirty-four of the 41 variables were identified as important variables, of which, 5 variables were categorized in very important level ("Recipient creatinine at discharge," "Recipient dialysis time," "Donor history of diabetes," "Donor kidney biopsy," and "Donor cause of death"), 17 variables in important level, and 12 variables in the low important level. CONCLUSIONS In this study, we identify new variables that have not been addressed in any of the previous studies (eg, AGE_DIF and MATCH_GEN). On the other hand, in kidney allocation systems, 2 main criteria are considered: equity and utility. One of the utility subcriteria is the graft survival. Our study findings can be used in the design of systems to predict the graft survival.
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Affiliation(s)
- Nasrin Taherkhani
- Faculty Member of Computer Engineering, Payam-e-Noor University, Saveh, Iran
| | - Mohammad Mehdi Sepehri
- Department of Healthcare Systems Engineering, Faculty of Industrial and Systems Engineering, Tarbiat Modares University, Tehran, Iran
| | - Roghaye Khasha
- Center of Excellence in Healthcare Systems Engineering, Tarbiat Modares University, Tehran, Iran
| | - Shadi Shafaghi
- Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Murphy N, Weijer C, Smith M, Chandler J, Chamberlain E, Gofton T, Slessarev M. Controlled Donation After Circulatory Determination of Death: A Scoping Review of Ethical Issues, Key Concepts, and Arguments. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2021; 49:418-440. [PMID: 34665091 DOI: 10.1017/jme.2021.63] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Controlled donation after circulatory determination of death (cDCDD) is an important strategy for increasing the pool of eligible organ donors.
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The patient with severe traumatic brain injury: clinical decision-making: the first 60 min and beyond. Curr Opin Crit Care 2020; 25:622-629. [PMID: 31574013 DOI: 10.1097/mcc.0000000000000671] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies. RECENT FINDINGS Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome. SUMMARY Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.
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Zhang P, Cao P, Fang J, Li G, Zhang L, Xu L, Mo S, Lai X, Liu L, Xiong Y, Yin W, Li L, Chen R, Xu H, Zhang T, Wan J, Guo Y, Ma J, Chen Z. Impact of the use of vasoactive drugs in cardiac death donors on the early postoperative renal function and related complications in renal transplant recipients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:116. [PMID: 32175409 DOI: 10.21037/atm.2019.12.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To explore the impact of the use of vasoactive drugs in donation after cardiac death (DCD) donors on graft function, with an attempt to guide the clinical practices of organ preservation and DCD kidney transplantation. Methods The clinical data of 187 DCD donors and 304 recipients who were operated on in our center from February 2018 to May 2019 were retrospectively analyzed. Based on whether vasoactive drugs were used for maintaining blood pressure in DCD donors, the renal donors and recipients were divided into a high-dose group (norepinephrine ≥1.3 µg/kg/min or in combination with dopamine), a low-dose group (norepinephrine <1.3 µg/kg/min or in conjunction with dopamine), and a no-medication group (without the use of vasoactive drugs). The clinical features, post-transplant renal function, and complications were compared among these three groups. Results The early renal function 1 and 7 days after surgery was significantly superior in the high-dose group and no-medication group (P<0.05) but showed no significant difference between the low-dose group and the no-medication group (P>0.05). Blood urea nitrogen (BUN) on the 1st postoperative days was significantly higher in the high-dose group than in the low-dose group and the no-medication group (P<0.05). Renal function indicators, including serum creatinine (CRE), BUN, and blood uric acid (UA) on the 30th postoperative day, showed no significant difference among these three groups (P>0.05). The incidence of delayed graft function (DGF) after renal transplantation was significantly higher in the high-dose group than in the low-dose group and the no-medication group (P<0.05), whereas there was no significant difference between the groups in the incidences of graft rejection and infections (P>0.05). Conclusions The use of vasoactive drugs in DCD donors can affect the early recovery of renal function in renal transplant recipients, particularly for those donors who are administered a high dose of vasoactive drugs. Therefore, donor maintenance should be performed cautiously with vasoactive drugs.
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Affiliation(s)
- Peng Zhang
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Peihua Cao
- Clinical Research Center, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - Jiali Fang
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Guanghui Li
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Lei Zhang
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Lu Xu
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Shijing Mo
- Department of Intensive Care Unit, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - Xingqiang Lai
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Luhao Liu
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Yunyi Xiong
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Wei Yin
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Li Li
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Rongxin Chen
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Hailin Xu
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Tao Zhang
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Jiao Wan
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Yuhe Guo
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Junjie Ma
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
| | - Zheng Chen
- Organ Transplant Center, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou511447, China
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