Outcomes of Lung Transplantation From Organ Donation After Medical Assistance in Dying

First North American Experience

Tatsuaki Watanabe; Mitsuaki Kawashima; Mikihiro Kohno; Jonathan Yeung; James Downar; Andrew Healey; Tereza Martinu; Meghan Aversa; Laura Donahoe; Andrew Pierre; Marc de Perrot; Kazuhiro Yasufuku; Thomas K. Waddell; Shaf Keshavjee; Marcelo Cypel


American Journal of Transplantation. 2022;22(6):1637-1645. 

In This Article

Abstract and Introduction


Over 2.5% of deaths in Canada occur as a result from medical assisting in dying (MAID), and a subset of these deaths result in organ donation. However, detailed outcomes of lung transplant recipients using these donors is lacking. This is a retrospective single center cohort study comparing lung transplantation outcomes after donation using MAID donors compared to neurologically determined death and controlled donation after circulatory death (NDD/cDCD) donors from February 2018 to July 2021. Thirty-three patients received lungs from MAID donors, and 560 patients received lungs from NDD/cDCD donors. The donor diagnoses leading to MAID provision were degenerative neurological diseases (n = 33) and end stage organ failure (n = 5). MAID donors were significantly older than NDD/cDCD donors (56 [IQR 49–64] years vs. 48 [32–59]; p = .0009). Median ventilation period and 30 day mortality were not significantly different between MAID and NDD/cDCD lungs recipients (ventilation: 1 day [1–3] vs 2 days [1–3]; p = .37, deaths 0% [0/33] vs. 2% [11/560], p = .99 respectively). Intermediate-term outcomes were also similar. In summary, for lung transplantation using donors after MAID, recipient outcomes were excellent. Therefore, where this practice is permitted, donation after MAID should be strongly considered for lung transplantation as a way to respect donor wishes while substantially improving outcomes for recipients with end-stage lung disease.


Lung transplantation is an established life-saving therapy for patients with end-stage lung diseases. However, the number of patients in need continues to outpace donor availability. Thus, many centers strive to increase the organ donor pool. Strategies to increase this pool come from increasing overall organ donation consent, improving donor management, utilizing extended criteria organs, and the use of new technologies such as ex vivo lung perfusion (EVLP) to better assess and treat injured donor organs. Currently, both neurologically determined death donors (NDD) and after circulatory death (DCD) have provided donor lungs leading to excellent outcomes for recipients.

In Canada, the provision of medical assistance in dying (MAID) became permissible with the Royal Assent of Bill C-16 in 2016. MAID now accounts for ~2.5% of all deaths in Canada.[1] In Ontario, all citizens are routinely offered the opportunity to donate their organs if eligible, and the Gift of Life Act specifies that patients at risk of imminent death (or their substitute decision makers) should be notified of the opportunity to donate. Consistent with this legal requirement, Trillium Gift of Life Network (TGLN, the agency responsible for organ and tissue donation and transplantation in Ontario) actively raises the possibility of organ and tissue donation with patients who have requested MAID.[2] However, the discussion of organ donation only takes place after the patient has been found eligible for MAID by two independent assessors.[3]

In Europe, North America, and Australia, controlled donation after circulatory death (cDCD, Maastricht category DCD-III) has become a frequent procedure.[4,5] The logistics for organ donation in MAID are somewhat similar to those for cDCD. However, some specific differences are important to note. First, in contrast to cDCD, these donors usually have less testing available such as chest computerized tomography or arterial blood gases. In addition, measures of lung mechanics are not available prior to the organ retrieval procedure. Some donors may request the MAID procedure to be performed at home in the presence of family members, which increases the warm ischemic time for lung retrieval and prevents donation of other organs.[6] However, the absence of mechanical ventilation, hospitalization, lung injury associated with brain injury, and rapid cardiac arrest soon after MAID provision offer countervailing positive aspects mitigating the effects of longer warm ischemic time experienced in cDCD. Donation after MAID has distinctive aspects compared to other types of DCD; therefore, it is considered the fifth category of DCD (DCD-V) by modified Maastricht category.[4] Here, we report initial experience in North America with lung transplantation after MAID, and we describe our donation, lung retrieval, preservation, and evaluation protocol in detail.