Knowledge gaps in heart and lung donation after the circulatory determination of death: Report of a workshop of the National Heart, Lung, and Blood Institute

James L Bernat; Kiran K Khush; Sam D Shemie; Matthew G Hartwig; Peter P Reese; Anne Dalle Ave; Brendan Parent; Alexandra K Glazier; Alexander M Capron; Matt Craig; Teneille Gofton; Elisa J Gordon; Andrew Healey; Mary E Homan; Keren Ladin; Simon Messer; Nick Murphy; Thomas A Nakagawa; William F Parker; Rebecca D Pentz; David Rodríguez-Arias; Bryanna Schwartz; Daniel P Sulmasy; Robert D Truog; Anji E Wall; Stephen P Wall; Paul R Wolpe; Kathleen N Fenton

doi:10.1016/j.healun.2024.02.1455

Knowledge gaps in heart and lung donation after the circulatory determination of death: Report of a workshop of the National Heart, Lung, and Blood Institute

J Heart Lung Transplant. 2024 Mar 2:S1053-2498(24)01499-2. doi: 10.1016/j.healun.2024.02.1455. Online ahead of print.

Authors

James L Bernat¹, Kiran K Khush², Sam D Shemie³, Matthew G Hartwig⁴, Peter P Reese⁵, Anne Dalle Ave⁶, Brendan Parent⁷, Alexandra K Glazier⁸, Alexander M Capron⁹, Matt Craig¹⁰, Teneille Gofton¹¹, Elisa J Gordon¹², Andrew Healey¹³, Mary E Homan¹⁴, Keren Ladin¹⁵, Simon Messer¹⁶, Nick Murphy¹⁷, Thomas A Nakagawa¹⁸, William F Parker¹⁹, Rebecca D Pentz²⁰, David Rodríguez-Arias²¹, Bryanna Schwartz²², Daniel P Sulmasy²³, Robert D Truog²⁴, Anji E Wall²⁵, Stephen P Wall²⁶, Paul R Wolpe²⁷, Kathleen N Fenton²⁸

Affiliations

¹ Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, New Hampshire. Electronic address: bernat@dartmouth.edu.
² Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.
³ Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, PQ, Canada.
⁴ Division of Thoracic Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina.
⁵ Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
⁶ Kennedy Institute of Ethics, Georgetown University, Washington, District of Columbia.
⁷ Division of Medical Ethics and Department of Surgery, NYU Grossman School of Medicine, New York, New York.
⁸ Brown University, School of Public Health, Providence, Rhode Island; New England Donor Services, Waltham, Massachusetts.
⁹ Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, California.
¹⁰ Lung Biology and Disease Branch, National Heart, Lung and Blood Institute, Bethesda, Maryland.
¹¹ Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
¹² Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee.
¹³ Department of Medicine McMaster University and William Osler Health System, Hamilton, Ontario, Canada.
¹⁴ CommonSpirit Health, Chicago, Illinois.
¹⁵ Research on Ethics, Aging, and Community Health (REACH Lab); Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts.
¹⁶ Department of Transplant, Golden Jubilee National Hospital, Clydebank, Scotland UK.
¹⁷ Departments of Medicine and Philosophy, Western University, London, Ontario, Canada.
¹⁸ University of Florida College of Medicine-Jacksonville, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Jacksonville, Florida.
¹⁹ Department of Medicine and Public Health Sciences, University of Chicago, Chicago, Illinois.
²⁰ Winship Cancer Institute, Emory University, Atlanta, Georgia.
²¹ FiloLab-UGR, Philosophy I Department, Universidad de Granada, Granada, Spain.
²² Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, Maryland; Department of Cardiology, Children's National Medical Center, Washington, District of Columbia.
²³ The Kennedy Institute of Ethics and the Departments of Medicine and Philosophy, Georgetown University, Washington, District of Columbia.
²⁴ Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital; Center for Bioethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.
²⁵ Department of Surgery, Baylor University Medical Center, Dallas, Texas.
²⁶ Ronald O. Perelman Department of Emergency Medicine; NYU Grossman School of Medicine and Department of Population Health, NYU, New York, New York.
²⁷ Center for Ethics, Department of Medicine, Emory University, Atlanta, Georgia.
²⁸ Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, and Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland.

PMID: 38432523
DOI: 10.1016/j.healun.2024.02.1455

Abstract

In a workshop sponsored by the U.S. National Heart, Lung, and Blood Institute, experts identified current knowledge gaps and research opportunities in the scientific, conceptual, and ethical understanding of organ donation after the circulatory determination of death and its technologies. To minimize organ injury from warm ischemia and produce better recipient outcomes, innovative techniques to perfuse and oxygenate organs postmortem in situ, such as thoracoabdominal normothermic regional perfusion, are being implemented in several medical centers in the US and elsewhere. These technologies have improved organ outcomes but have raised ethical and legal questions. Re-establishing donor circulation postmortem can be viewed as invalidating the condition of permanent cessation of circulation on which the earlier death determination was made and clamping arch vessels to exclude brain circulation can be viewed as inducing brain death. Alternatively, TA-NRP can be viewed as localized in-situ organ perfusion, not whole-body resuscitation, that does not invalidate death determination. Further scientific, conceptual, and ethical studies, such as those identified in this workshop, can inform and help resolve controversies raised by this practice.

Keywords: Uniform Determination of Death Act; dead donor rule; normothermic regional perfusion; organ donation after the circulatory determination of death; unified brain-based determination of death.