Elsevier

Resuscitation

Volume 108, November 2016, Pages 87-94
Resuscitation

Clinical paper
Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation or uncontrolled donation after the circulatory determination of death following out-of-hospital refractory cardiac arrest—An ethical analysis of an unresolved clinical dilemma

https://doi.org/10.1016/j.resuscitation.2016.07.003Get rights and content

Abstract

Background

The availability of extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation (E-CPR), for use in refractory out-of hospital cardiac arrest (OHCA), is increasing. In parallel, some countries have developed uncontrolled donation after circulatory determination of death (uDCDD) programs using ECMO to preserve organs for transplantation purposes.

Aim

When facing a refractory OHCA, how does the medical team choose between initiating ECMO as part of an E-CPR protocol or ECMO as part of a uDCDD protocol?

Methods

To answer these questions we conducted a literature review on E-CPR compared to uDCDD protocols using ECMO and analyzed the raised ethical issues.

Results

Our analysis reveals that the inclusion criteria in E-CPR and uDCDD protocols are similar. There may be a non-negligible risk of including patients in a uDCDD protocol, when the patient might have been saved by the use of E-CPR.

Conclusion

In order to avoid the fatal error of letting a saveable patient die, safeguards are necessary. We recommend: (1) the development of internationally accepted termination of resuscitation guidelines that would have to be satisfied prior to inclusion of patients in any uDCDD protocol, (2) the choice regarding modalities of ongoing resuscitation during transfer should be focused on the primary priority of attempting to save the life of patients, (3) only centers of excellence in life-saving resuscitation should initiate or maintain uDCDD programs, (4) E-CPR should be clinically considered first before the initiation of any uDCDD protocol, and (5) there should be no discrimination in the availability of access to E-CPR.

Introduction

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death in developed countries, with an incidence varying between 2 and 17 per 10,000 inhabitants.1 The prognosis of OHCA remains poor, with a rate of survival to discharge estimated at 9.5% in the U.S. in 2013,2 and survival with good neurological outcome estimated at 6%.3

Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation (E-CPR) has been used to treat refractory cardiac arrest since 1976.4 E-CPR is a recognized therapy for refractory cardiac arrests after severe accidental hypothermia, heart surgery and cardiotoxic intoxications.5 Studies show promising results principally when E-CPR is used as a rescue therapy for in-hospital cardiac arrest (IHCA).6, 7, 8, 9 Results for OHCA are more controversial but remain encouraging10, 11, 12, 13, 14 with E-CPR increasingly available in large emergency departments.

Uncontrolled donation after circulatory determination of death (uDCDD) programs15 (also known as Maastricht Category II donations) have been developed, principally in Spain since the late 1980s, in France since 2006 and in the Netherlands, USA and the UK more recently. Typically, in such programs, patients in refractory cardiac arrest who meet the criteria for inclusion in a uDCDD protocol, have CPR continued until arrival at a uDCDD center. At this point either cold renal perfusion16 or ECMO regional perfusion is implemented.16, 17 Both these techniques minimize warm ischemic damage until the organs, most commonly the kidneys, can be surgically recovered for donation and transplantation. ECMO regional perfusion usually involves the insertion of a supra-diaphragmatic aortic balloon,18 in order to avoid cardiac and brain perfusion following the initiation of ECMO circulation.19

In cases of refractory cardiac arrest, how should the treating physician choose between initiating ECMO as part of an E-CPR protocol in an attempt to save the life of the patient or initiating ECMO as part of a uDCDD protocol in an attempt to preserve the organs for donation and transplantation? Which ethical issues are raised by this choice? Without robust and defensible clinical practices there is a risk of providing a standard of resuscitation below that expected in wealthy western countries, even as the donation practice is of the highest and most technologically advanced standard.

To answer these questions, we chose to conduct a review of existing recommendations on E-CPR and uDCDD, which included a comparison of protocols and outcomes. Our focus is ECMO assisted uDCDD protocols rather than other uDCDD protocols that use cold perfusion. We then analyze the ethical issues and propose several recommendations to guide policy in this currently unresolved clinical dilemma.

Section snippets

Methodology

As our goal is to conduct an ethical analysis by identifying and comparing the inclusion criteria for E-CPR protocols with those for uDCDD protocols, we conducted a review of E-CPR and uDCDD protocols.

A review of prospective studies on E-CPR for OHCA over the last ten years

Of the eight identified studies all but one measured functional outcome by the use of the cerebral-performance category (CPC) score. LeGuen et al. used the Glasgow outcome scale (GOS).20 Most studies used a protocol which as well as E-CPR included mechanical CPR, hypothermia for 24 h, and coronary angiography if necessary.10, 11, 12, 20

Survival with good neurological outcome in OHCA varied broadly among these studies between 2%21 and 45%.12 The neurological outcome depended on the duration of

Discussion

From our review, we identify three key clinical decision points with ethical implications when considering initiating ECMO as part of a uDCDD protocol. These are the decision to terminate resuscitation, the choice regarding modalities of ongoing resuscitation during transfer to hospital, and determining whether to initiate ECMO as part of an E-CPR protocol in an attempt to save the life of the patient or initiate ECMO as part of a uDCDD protocol in an attempt to preserve the organs for donation

Conclusion and recommendations

The availability of ECMO technology in emergency departments is increasing. This technology can be used for E-CPR in an attempt to save the life of the patient or as part of a uDCDD protocol. It can be difficult to choose between the two uses, as the inclusion criteria are very similar and the goal of treatment for one use competes with the other. UDCDD programs run the risk of denying life-saving treatments while favoring the promotion of organ donation in case of OHCA.

In order to avoid the

Conflict of interest statement

Dr Gardiner is deputy national clinical lead for organ donation in the UK for NHS Blood and Transplant.

Financial support

None.

Authors’ contributions

Dr. Dalle Ave conceived the idea for the article, performed the literature search and read the papers, wrote the first draft of the article and contributed to the edits of subsequent revisions. Dr. Shaw and Dr. Gardiner worked with Dr. Dalle Ave to develop the lines of arguments of the article, and edited and rewrote sections of the article during an iterative series of drafts. The three authors take responsibility for the arguments presented in the article.

Disclaimers

The opinions expressed are the views of the authors and do not reflect the policy of their related institutions, the Federal Office of Public Health, or any national organizations/associations.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.07.003.

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