Family and Transplant Professionals' Views of Organ Recovery Before Circulatory Death for Imminently Dying Patients

A Qualitative Study Using Semistructured Interviews and Focus Groups

Christopher J. Zimmermann; Nathan D. Baggett; Lauren J. Taylor; Anne Buffington; Joseph Scalea; Norman Fost; Kenneth D. Croes; Joshua D. Mezrich; Margaret L. Schwarze

Disclosures

American Journal of Transplantation. 2019;19(8):2232-2240. 

In This Article

Abstract and Introduction

Abstract

Donation before circulatory death for imminently dying patients has been proposed to address organ scarcity and harms of nondonation. To characterize stakeholder attitudes about organ recovery before circulatory death we conducted semistructured interviews with family members (N = 15) who had experienced a loved one's unsuccessful donation after circulatory death and focus groups with professional stakeholders (surgeons, anesthesiologists, critical care specialists, palliative care specialists, organ procurement personnel, and policymakers, N = 46). We then used qualitative content analysis to characterize these perspectives. Professional stakeholders believed that donation of all organs before circulatory death was unacceptable, morally repulsive, and equivalent to murder; consent for such a procedure would be impermissible. Respondents feared the social costs related to recovery before death were too high. Although beliefs about recovery of all organs were widely shared, some professional stakeholders could accommodate removal of a single kidney before circulatory death. In contrast, family members were typically accepting of donation before circulatory death for a single kidney, and many believed recovery of all organs was permissible because they believed the cause of death was the donor's injury, not organ procurement. These findings suggest that definitions of death and precise rules around organ donation are critical for professional stakeholders, whereas donor families find less relevance in these constructs for determining the acceptability of organ donation. Donation of a single kidney before circulatory death warrants future exploration.

Introduction

Disparity between organs available for transplant and patients with end-stage organ disease results in 20 transplant waitlist deaths daily.[1] Although living donation can meet some needs, most patients rely on organ recovery from a deceased donor. Because not all individuals with severe brain injury will meet death by neurologic criteria, organ recovery in compliance with the dead-donor rule can proceed only if the donor's heart stops beating after withdrawal of mechanical support within a specific time frame. Failure to die in time precludes the procurement procedure and leads to loss of organs.[2–4] We previously described family member experiences of unsuccessful donation and characterized multiple harms, including waste of precious resources, disrupted bereavement, and inability to honor the donor.[5] Given these harms and the corollary benefits of successful donation, we sought to investigate perspectives about innovative donation strategies from multiple key stakeholders including donor families, medical teams and other organ transplant professionals.

Donation before circulatory death is a proposal that could address the failure to recover organs from all enthusiastic donors.[2,6–11] This strategy would permit organ recovery prior to withdrawal of life sustaining treatments and provide an opportunity for patients with severe neurologic injury to donate. Given estimates that 27% of patients fail to donate after circulatory death (DCD),[12] this proposal has potential to reduce the harms of nondonation, increase organs for transplant, and reduce ischemic damage suffered during withdrawal of mechanical support.[4,13–15]

Despite benefits, recovery of organs before circulatory death raises ethical concerns for stakeholders particularly related to the boundaries between life and death and how donation is causally associated with donor death. Although a 2017 Organ Procurement and Transplantation Network/United Network for Organ Sharing (UNOS) Ethics Committee white paper expressed support for exploring living donation in patients with fatal diseases,[15] data about stakeholder interests are limited. The objective of this study was to explore stakeholders' perspectives about organ recovery before circulatory death.

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