© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Clin Transplant 2014: 28: 47–51 DOI: 10.1111/ctr.12276

Clinical Transplantation

Does comfort therapy during controlled donation after circulatory death shorten the life of potential donors? Ledoux D, Delbouille M-H, Deroover A, Lambermont B, Meurisse M, Damas P, Joris J, Detry O. Does comfort therapy during controlled donation after circulatory death shorten the life of potential donors? Abstract: Introduction: Controlled donation after circulatory death (DCD) remains ethically controversial. The authors developed a controlled DCD protocol in which comfort therapy is regularly used. The aim of this study was to determine whether this policy shortens the DCD donors’ life. Methods: The authors retrospectively analyzed prospectively collected data on patients proposed for DCD at the University Hospital of Liege, Belgium, over a 56-month period. The survival duration of these patients, defined as duration between the time of proposal for DCD and the time of circulatory arrest, was compared between patients who actually donated organs and those who did not. Results: About 128 patients were considered for controlled DCD and 54 (43%) became donors. Among the 74 non-donor patients, 34 (46%) objected to organ donation, 38 patients (51%) were denied by the transplant team for various medical reasons, and two potential DCD donors did not undergo procurement due to logistical and organizational reasons. The survival durations were similar in the DCD donor and nondonor groups. No non-donor patient survived. Conclusions: Survival of DCD donors is not shortened when compared with non-donor patients. These data support the ethical and respectful approach to potential DCD donors in the authors’ center, including regular comfort therapy.

le ne Didier Ledouxa, Marie-He b Delbouille , Arnaud Derooverb, Bernard Lambermontc, Michel Meurisseb, Pierre Damasa, Jean Jorisa and Olivier Detryb a

Department of Anaesthesiology and Intensive Care, CHU Liege, University of Liege (ULg CHU), bDepartment of Abdominal Surgery and Transplantation, CHU Liege, University of Liege (ULg CHU) and cDepartment of Internal Medicine and Intensive Care, CHU Liege, University of Liege (ULg CHU), Wallonia, Belgium Key words: end-of-life – ethics – non-heart beating donors – organ donation – policy – transplantation Corresponding author: Pr. Olivier Detry, Department of Abdominal Surgery and Transplantation, University of Liege, CHU de Liege, Liege B4000, Wallonia, Belgium. Tel.: +32 4 366 76 45; fax: +32 4 366 40 69; e-mail: [email protected] Conflict of interest: This study did not receive any external funding. The authors have no conflict of interest to disclose involving this study. Accepted for publication 7 October 2013

Donation after circulatory death (DCD) has been recently re-introduced as a means of partially reducing the shortage of deceased donor organs. Most DCD performed worldwide are controlled donations corresponding to Maastricht category III (1, 2). In this DCD category, patients hospitalized in intensive care units (ICU) and in whom further medical care is deemed futile are considered for withdrawal of care. After family agreement, planned withdrawal of cardiovascular and respiratory support can be performed in the ICU or in the operative room (OR) (2). After declaration of patient’s death on circulatory criteria and a predefined stand-off period, surgical organ procurement is performed rapidly.

Controlled DCD may raise several important ethical issues (3, 4). First, the possibility of deliberately planning the withdrawal of life support and therefore to medically determine the timing of a patient’s death may be subject to debate and is legally forbidden at present in some countries, such as Germany (5). Moreover, controlled DCD process might be suspected to hasten potential DCD donor death, especially if comfort therapy is administered during the withdrawal process. Additionally, it could be questioned whether a small proportion of controlled DCD donors could be long-term survivors if DCD was not performed. At the University Hospital of Liege, Belgium, controlled DCD donation and transplantation

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programs were initiated in 2002 (6). According to our protocol, DCDs are scheduled in normal working hours and performed in OR by senior anesthesiologists (7). Before withdrawal, most DCD donors receive comfort therapy that may shorten agony (7). The aim of this study was to determine whether this DCD policy shortens the donor’s life. As a primary endpoint, the authors determined the survival duration of patients proposed for DCD by the ICU physicians and compared the survival of those who underwent controlled DCD with those who did not undergo DCD because of medical reasons or opposition to organ donation. As secondary endpoints, to ensure that this policy does not modify the management of potential DCD donors, the authors compared the duration of ICU hospitalization before DCD proposals by the ICU staff between both groups, and the outcome of potential DCD donors who did not undergo organ donation.

To determine whether controlled DCD actually shortens the survival of potential donors, the authors retrospectively compared the survival time defined as the duration between the time of the first call by the ICU to the transplant coordinator to notify the WD in terminal patients and the time of declaration of patient death, in patients who actually became effective DCD donors (DCD donors group) and also in patients who did not (nondonors group). In addition, the authors compared the duration of ICU hospitalization before WD between these two groups. Finally, the outcome of patients who did not undergo DCD was recorded. All data were retrospectively retrieved from the prospective donor database of the transplant department of the University Hospital of Liege and from the patient medical files. All potential DCD donors from January 2008 to September 2012 were included in this study. Statistics

Patients and methods

The protocol of controlled Maastricht III DCD developed within the University Hospital of Liege was approved by the local ethical committee and has been described elsewhere (7). In summary, ICU patients with extensive and irreversible brain lesions and whose aggressive medical support is deemed futile are considered for support withdrawal and initiation of end-of-life care. This decision is discussed within the ICU team and with the family. If withdrawal of life support is decided and agreed upon by three physicians (withdrawal decision – WD), the hospital transplant coordinator is contacted, and potential controlled DCD organ donation is proposed and explained to the family. If DCD is accepted, the procedure is scheduled in normal working hours and performed in OR by senior anesthesiologists. According to the protocol, the analgosedation of DCD patients initiated in the ICU by intensivists can be switched to volatile anesthetics (sevoflurane) until respiratory and medical support withdrawal in OR (7). This comfort therapy could inhibit respiratory reflexes and shorten the agony. Intravenous heparin is also administered before support withdrawal. Circulatory arrest is diagnosed as pulseless arterial pressure below 40 mm Hg measured on a femoral artery catheter. After a five-min no-touch period, circulatory death is declared by three physicians unrelated to the procurement or transplant team. Organ harvesting is then performed by a senior and experienced transplant surgeon using the super-rapid laparotomy technique (8).

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Data are expressed as median values and interquartile ranges (IQR), and were compared using the Mann–Whitney U test. p Values

Does comfort therapy during controlled donation after circulatory death shorten the life of potential donors?

Controlled donation after circulatory death (DCD) remains ethically controversial. The authors developed a controlled DCD protocol in which comfort th...
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