Extracorporeal cardiopulmonary resuscitation dissemination and integration with organ preservation in the USA: ethical and logistical considerations

Abstract

Use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary resuscitation, termed eCPR, offers the prospect of improving survival with good neurological function after cardiac arrest. After death, ECMO can also be used for enhanced preservation of abdominal and thoracic organs, designated normothermic regional perfusion (NRP), before organ recovery for transplantation. To optimize resuscitation and transplantation outcomes, healthcare networks in Portugal and Italy have developed cardiac arrest protocols that integrate use of eCPR with NRP. Similar dissemination of eCPR and its integration with NRP in the USA raise novel ethical issues due to a non-nationalized health system and an opt-in framework for organ donation, as well as other legal and cultural factors. Nonetheless, eCPR investigations are ongoing, and both eCPR and NRP are selectively employed in clinical practice. This paper delineates the most pressing relevant ethical considerations and proposes recommendations for implementation of protocols that aim to promote public trust and reduce conflicts of interest. Transparent policies should rely on protocols that separate lifesaving from organ preservation considerations; robust, centralized eCPR data to inform equitable and evidence-based allocations; uniform practices concerning clinical decision-making and resource utilization; and partnership with community stakeholders, allowing patients to make decisions about emergency care that align with their values. Proactively addressing these ethical and logistical challenges could enable eCPR dissemination and integration with NRP protocols in the USA, with the potential to maximize lives saved through both improved resuscitation with good neurological outcomes and increased organ donation opportunities when resuscitation is unsuccessful or not in accordance with individuals' wishes.

Keywords: Bioethics; Cardiopulmonary resuscitation; Extracorporeal membrane oxygenation; Organ donation; Organ preservation.

Fig. 1

Use of ECMO circuit in eCPR, NRP for cDCD, and NRP for uDCD. ECMO extracorporeal membrane oxygenation; eCPR extracorporeal cardiopulmonary resuscitation; NRP normothermic regional perfusion; cDCD controlled donation after circulatory death; uDCD uncontrolled donation after circulatory death. The ECMO circuit consists of a venous access cannula, draining venous blood to a pump device, which pumps deoxygenated venous blood through an oxygenator membrane that also scavenges carbon dioxide and manages temperature. The oxygenated blood returns to a central artery via an arterial return cannula. In eCPR, the goal is to achieve return of spontaneous circulation with good neurological function. Critical to achieving that goal is providing circulation of oxygenated blood to the brain. In NRP, balloon occlusion in the aorta at the level of the diaphragm (to recover abdominal organs) or surgical ligation of blood vessels to the brain (to recover the heart) is performed to ensure natural progression of complete and irreversible loss of brain function postmortem

Fig. 2

Concept map for integrating eCPR and uDCD programs within opt-in organ donation systems. TOR termination of resuscitation; CPR cardiopulmonary resuscitation; ROSC return of spontaneous circulation; ECMO extracorporeal membrane oxygenation; eCPR extracorporeal cardiopulmonary resuscitation via ECMO; DNC death by neurological criteria; DND donation after neurological death; cDCD controlled donation after circulatory death; NRP normothermic regional perfusion of organs via ECMO; uDCD uncontrolled donation after circulatory death. The figure presents a schematic overview of a clinical protocol for eCPR/NRP integration. Ovals designate starting/ending points, rectangles are processes, diamonds are decision points, circles represent uncertainty in outcomes. Critical steps are represented in colors which correspond to summary boxes highlighting prominent ethical and logistical concerns, which are discussed individually at length in the main text

Fig. 3

Outcome categories after successful cannulation for eCPR. eCPR extracorporeal cardiopulmonary resuscitation; ECMO extracorporeal membrane oxygenation; cDCD controlled donation after circulatory death; uDCD uncontrolled donation after circulatory death; DND donation after neurological death. Broad outcome categories after initiating eCPR are depicted in blue font; transplant recovery considerations are depicted in green filled ovals. One possible outcome is (i) decannulation following return of spontaneous circulation, leading to post-arrest care akin to standard CPR. For those unable to be weaned from ECMO, outcomes include: (ii) poor neurological function without anticipated recovery; (iii) death by neurologic criteria (“brain death”); (iv) good neurological function with eligibility for destination therapy (e.g., left ventricular assistive device or transplantation); and (v) good neurological function with inability to wean from ECMO and ineligibility for destination therapy (i.e., “bridge to nowhere”)