A new opinion piece by contributor Art Caplan along with Stephen Wall and Carolyn Plunkett, in JAMA:
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.
More than 124 000 patients are wait-listed for organs in the United States, a number that increases annually despite attrition from 10 500 who die or become too sick for transplantation.1 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. […]
Read the full article here.
One of the leading countries in the practice of uDCD is Spain. In Spain the “consent for preservation” is presumed, along with the consent for donation absent explicit opting-out by the individual (although this latter presumption is never enforced in clinical practice). The tricky aspect of uDCD, which is not fully accounted for in the JAMA piece, lies in the fact that you really need a speedy decision to preserve, and the next-of-kin is not typically around to consent to the full panoply of measures (incisions for cannulation, heparinization and so on and so forth), which are no initiated for the benefit of the “patient” (in Spain the death pronouncement is not made until arrival at the hospital). The solution in Spain has been to ask the judge for permission and to establish that his/her silence after 15 minutes is a tacit approval for preservation maneuvers.
Anyone interested in getting a vivid picture of what uDCD consists of in a city such as Madrid should watch the following video, but please, be advised that it may hurt your sensibility (it is very professionally described and filmed, but truly “vivid”):