Ethical and logistical concerns for establishing NRP-cDCD heart transplantation in the United States
Ethical and logistical concerns for establishing NRP-cDCD heart transplantation in the United States
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DOI：
10.1111/ajt.15772
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发表时间：
2020-01-21
影响因子：
8.8
通讯作者：
Caplan, Arthur
中科院分区：
文献类型：
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作者：
Parent, Brendan;Moazami, Nader;Caplan, Arthur
循环死亡判定后的受控心脏捐献（cDCD）在国际上已经得到了很好的认可，结果良好，如果伦理和后勤挑战得到全面解决，美国可以采用这种方法来增加心脏供应。缓解停循环后热缺血的最有效和最节省资源的方法是原位常温区域灌注（NRP）。该策略要求在根据循环标准宣布死亡后重新开始循环，这似乎挑战了要求不可逆停止的法律的循环死亡定义。为了挽救生命，必须实现永久性的停止，以减轻这种担忧，结扎主要血管不会使血液流向大脑，这确保了大脑功能的自然进展。这种做法在一些国家是标准的，这引起了人们对优先考虑拯救生命的努力、决策者的知情授权以及临床医生在患者死亡中的作用的独特关注。为了维护公众的信任、医疗诚信和对捐赠者的尊重，在根据患者的治疗目标做出非强制性决定撤回维持生命的治疗之前，不得进行捐赠谈话。决策者必须充分了解cDCD程序，以提供真正的授权，保存/采购团队必须与临床护理团队分开。
Controlled heart donation after circulatory determination of death (cDCD) is well established internationally with good outcomes and could be adopted in the United States to increase heart supply if ethical and logistical challenges are comprehensively addressed. The most effective and resource-efficient method for mitigating warm ischemia after circulatory arrest is normothermic regional perfusion (NRP) in situ. This strategy requires restarting circulation after declaration of death according to circulatory criteria, which appears to challenge the legal circulatory death definition requiring irreversible cessation. Permanent cessation for life-saving efforts must be achieved to assuage this concern and ligating principal vessels maintains no blood flow to the brain, which ensures natural progression to cessation of brain function. This practice-standard in some countries-raises unique concerns about prioritizing life-saving efforts, informed authorization from decision-makers, and the clinician's role in the patient's death. To preserve public trust, medical integrity, and respect for the donor, the donation conversation must not take place until after an un-coerced decision to withdraw life-sustaining treatment made in accordance with the patient's treatment goals. The decision-maker(s) must understand cDCD procedure well enough to provide genuine authorization and the preservation/procurement teams must be kept separate from the clinical care team.