The ethics of DCD heart transplantation continues to be debated, in particular the diagnosis of death in these circumstances and the preservation techniques used to minimise ischaemic injury. The authors formed a group of clinical ethicists, transplant surgeons, transplantation researchers and perfusionists to address the ethical issues from the perspective of the donor, the donor’s family, and the recipient. The group then created decision making diagrams to guide whether DCD heart transplantation is ethically justified right for the patient, the family, and the recipient. Much of the decision making issues attributed to the recipient may be equally important from the perspective of the donor or their family. The diagrams are useful in raising the right questions but are likely to be developed and modified further in the future as DCD heart transplantation programs are develops further. Involvement of donation specialists would be useful in enhancing and upgrading the diagrams for use in ICU’s looking after donors and their families.

A publication on policy that highlights the legal, and practical difficulties in meeting the requirements of the 1980 Uniform Determination of Death Act (UDDA) in the United States when diagnosing brain death using accepted medical standards. Currently acceptable medical standards and technologies used to diagnose brain death cannot demonstrate “irreversible cessation of all functions of the entire brain, including the brain stem” as required by the UDDA. The authors propose four possible ways of addressing this problem: a) improving testing to meet the requirements of the UDDA; b) amending the UDDA to align the law more closely with actual clinical practice; c) accepting the mismatch between the requirements of the law and what can be achieved in clinical practice; d) revising both the legal criteria and the clinical and diagnostic criteria for confirming brain death.

Organ donation and transplantation cannot happen if the initial step of the donation pathway, identifying and referring potential donors, is missed. In Germany, the number of organ donors has decreased by one third since 2010, primarily due to potential organ donors not being identified and referred. The authors sought to clarify the distribution of these potential donors according to the type of hospital and in which region of the country. This involved an analysis of over 20 million inpatients in 2016. All deaths from primary or secondary brain injury with no contraindication to donation were considered potential donors if they were mechanically ventilated. They identified 28,087 potential donors. The largest proportion of potential organ donors (42%) were in the smaller hospitals without a neurosurgical unit rather than larger university hospitals (21%) or those with a neurosurgical unit (28%). The same hospitals also had the lowest referral rate of potential donors (6% compared to 10.6% and 10/9%) and the lowest conversion rate of potential donors to actual donors (1.7% compared to 4.6% and 4.8%). There was no difference in referral and donation practice between urban and rural regions. The authors suggest the development of strategies to increase identification and referral of potential donors particularly from non-university hospitals without a neurosurgical unit.

Abstract: The legal shift to an opt-out system of consent for deceased organ donation is now official in England, Wales and Scotland. While it is commendable that national governments across the United Kingdom have publicly signalled their serious engagement with organ donation, it remains questionable that opt-out policy can in and of itself solve the public health issue of organ shortage. Opt-out policy risks becoming a futile solution if it fails to attend to key factors in clinical practice. Thus, this article provides critical insights and practical considerations in order to work towards increasing the availability of organs for transplantation: 1) organ donation specialists on their own are not enough, a collaborative hospital culture of donation is also needed; 2) investment in innovative perfusion technologies is fundamental to increase both the quantity and quality of organs utilised for transplants; and 3) opt-out does not solve the enduring problem of consent or authorization for donation, rather than hoping that opt-out will shift the societal culture of donation and make donation the default choice, it is necessary to acknowledge that families' authorization remains essential and their emotional experience can neither be minimized nor excluded altogether. Importantly, consent rates are not the only factor to account for overall deceased donation rates. The organ shortage cannot be solely attributed to a matter of negative public attitudes reversible by law. Doing that does a disservice to the public and diverts strategic attention and resources from fostering the organisational and technological enablers of organ donation in clinical practice.

Controlled donation after circulatory death (cDCD) occurs after a decision to withdraw life-sustaining treatment and subsequent family approach and approval for donation. Data on factors that affect the decision-making process on withdraw life-sustaining treatment (WLST) and whether time from admission to family approach influences the consent rate are lacking. Such insights could be important in improving the management of potential cDCD donors and how their families are approached for organ donation. This prospective multicentre observational study from the Netherlands evaluated the impact of timing and of the clinical factors during the end-of-life decision-making process in potential cDCD donors. Characteristics of 409 potential cDCD donors admitted to the intensive care units (ICUs) were assessed. A medical decision that continuing active treatment was not in the patient’s best interest was reached after a mean time of 97 hours after ICU admission and mostly during the daytime rather than at night-time. Intracranial haemorrhage or ischemic stroke and a high APACHE IV score were associated with a short decision-making process. Preserved brainstem reflexes, high Glasgow Coma Scale scores, or cerebral infections were associated with longer time to decision-making. The families of all 409 patients were approached and consent to donation was obtained from 127 (31%). The authors suggest that the organ donation request could be made shortly after the decision to stop active treatment and consent rates were not influenced by daytime or night-time or by the duration of the ICU stay

Organ recovery agencies are responsible for the evaluation and recovery of organs from donors who have died but controversy exists regarding what measures should be used to evaluate their performance. This is an interesting study of data from the US organ transplantation system from January 2008 through December 2017 suggesting that significant variability in the performance rankings of organ recovery agencies, depending on which donation metric is used. There were significant differences in performance of agencies, even after accounting for differences in potential donor populations. The data suggest significant variation in use of ineligible donors among organ recovery agencies and that this is a source for increased donors. They also suggest that performance of agencies should be evaluated using a range of donation metrics. These issues highlight the difficulties in comparing performance between agencies in a single country and indeed performance between different nations.

The impact of SARS-COV2 on wait-listed patients and solid organ transplant recipients and strategies for testing potential donors to exclude current infection and reduce the risks of transmission have been published in recent months. Previous guidance documents have been published regarding organ donation from individuals with a prior history of COVID-19 infection but less is known about the transplantation of organs from donors who had previously tested positive for SARS-COV2 or those who have recovered from COVID-19. This case series from the USA up to 31st July 2020 reports six deceased donors with a history of COVID-19 from whom 13 organs were recovered and transplanted through several of the nation's organ procurement organizations (OPOs). In addition, at least two potential donors were authorized for donation but with no organs were successfully allocated and did not proceed to recovery. No transmission of SARS-CoV-2 was reported from the six donors to recipients, members of the organ retrieval teams, or hospital personnel. The follow up of recipients was short and more longer term studies are needed to define the acceptance criteria for deceased donors who have recovered from COVID-19 to ensure safe transplantation. These criteria will evolve over time and this case series highlights the need to encourage referral of donors recovering or recovering from COVID-19.