Ethical considerations regarding heart and lung transplantation and mechanical circulatory support during the COVID-19 pandemic: an ISHLT COVID-19 Task Force statement

Abstract

To understand the challenges for thoracic transplantation and mechanical circulatory support during the current coronavirus disease 2019 pandemic, we propose separating the effects of the pandemic into 5 distinct stages from a healthcare system perspective. We discuss how the classical ethical principles of utility, justice, and efficiency may need to be adapted, and we give specific recommendations for thoracic transplantation and mechanical circulatory support centers to balance their clinical decisions and strategies for advanced heart and lung disease during the current pandemic.

Keywords: COVID-19; MCS; SARS-CoV-2; ethics; thoracic transplant.

Figure 1

Adjustment of transplant activity during various stages of the COVID-19 pandemic. The black curve illustrates the admission rate of patients with COVID-19. The thin horizontal black line illustrates the capacity of the healthcare system. The gray dotted line marked A illustrates an exaggerated reduction of transplant and MCS in the Anticipation stage, and the gray dotted line marked B illustrates a total cessation of transplant and MCS activity during the Overwhelmed stage of the pandemic and a reduced volume after the pandemic. The gray dotted line marked C illustrates a measured reduction, balancing resource allocation to patients with COVID-19 and those without. COVID-19, coronavirus disease 2019; MCS, mechanical circulatory support.

Figure 2

Recipient selection for the adjustment of transplant activity during the COVID-19 pandemic. The left rectangle illustrates the spectrum of patients accepted for transplant in normal times. During the pandemic, only highly urgent patients may be prioritized (middle left rectangle) or only those expected to require little resources after the transplant, that is, no ECMO, short ICU stay, etc. (middle right rectangle). The right rectangle illustrates an activity reduction balancing both urgency and resource allocation. COVID-19, coronavirus disease 2019; ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit.