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BACKGROUND: Heart transplantation is an effective treatment offering the best recovery in both quality and quantity of life in those affected by refractory, severe heart failure. However, transplantation is limited by donor organ availability. The reintroduction of heart donation after the circulatory determination of death (DCD) in 2014 offered an uplift in transplant activity by 30%. Thoraco-abdominal normothermic regional perfusion (taNRP) enables in-situ reperfusion of the DCD heart. The objective of this paper is to assess the clinical outcomes of DCD donor hearts recovered and transplanted from donors undergoing taNRP. METHOD: This was a multicentre retrospective observational study. Outcomes included functional warm ischaemic time, use of mechanical support immediately following transplantation, perioperative and long-term actuarial survival and incidence of acute rejection requiring treatment. 157 taNRP DCD heart transplants, performed between February 2, 2015, and July 29, 2022, have been included from 15 major transplant centres worldwide including the UK, Spain, the USA and Belgium. 673 donations after the neurological determination of death (DBD) heart transplantations from the same centres were used as a comparison group for survival. FINDINGS: taNRP resulted in a 23% increase in heart transplantation activity. Survival was similar in the taNRP group when compared to DBD. 30-day survival was 96.8% ([92.5%-98.6%] 95% CI, n = 156), 1-year survival was 93.2% ([87.7%-96.3%] 95% CI, n = 72) and 5-year survival was 84.3% ([69.6%-92.2%] 95% CI, n = 13). INTERPRETATION: Our study suggests that taNRP provides a significant boost to heart transplantation activity. The survival rates of taNRP are comparable to those obtained for DBD transplantation in this study. The similar survival may in part be related to a short warm ischaemic time or through a possible selection bias of younger donors, this being an uncontrolled observational study. Therefore, our study suggests that taNRP offers an effective method of organ preservation and procurement. This early success of the technique warrants further investigation and use. FUNDING: None of the authors have a financial relationship with a commercial entity that has an interest in the subject. ispartof: ECLINICALMEDICINE vol:58 ispartof: location:England status: published

The number of potential pediatric heart transplant recipients continues to exceed the number of donors, and consequently the waitlist mortality remains significant. Despite this, around 40% of all donated organs are not used and are discarded. This document (62 authors from 53 institutions in 17 countries) evaluates factors responsible for discarding donor hearts and makes recommendations regarding donor heart acceptance. The aim of this statement is to ensure that no usable donor heart is discarded, waitlist mortality is reduced, and post-transplant survival is not adversely impacted.

The procedure combining medical assistance in dying (MAiD) with donations after circulatory determination of death (DCDD) is known as organ donation after euthanasia (ODE). The first international roundtable on ODE was held during the 2021 WONCA family medicine conference as part of a scoping review. It aimed to document practice and related issues to advise patients, professionals, and policymakers, aiding the development of responsible guidelines and helping to navigate the issues. This was achieved through literature searches and national and international stakeholder meetings. Up to 2021, ODE was performed 286 times in Canada, the Netherlands, Spain, and Belgium, including eight cases of ODE from home (ODEH). MAiD was provided 17,217 times (2020) in the eight countries where ODE is permitted. As of 2021, 837 patients (up to 14% of recipients of DCDD donors) had received organs from ODE. ODE raises some important ethical concerns involving patient autonomy, the link between the request for MAiD and the request to donate organs and the increased burden placed on seriously ill MAiD patients. ispartof: AMERICAN JOURNAL OF TRANSPLANTATION vol:22 issue:12 pages:2759-2780 ispartof: location:United States status: published

Kidney transplantation (KT) is the best therapeutic option for patients with end-stage renal disease in terms of survival, quality of life and cost-effectiveness. The fundamental difference of KT with respect to other therapies is that the process depends on the availability of organs for clinical use, availability that is insufficient to cover the increasing transplantation needs of the population. Another relevant feature of transplantation is that it entails a risk of transmission of diseases from donor to recipient, a risk that can be minimized, but not completely eliminated. Due to its characteristics and its unique nature (the human being), KT requires a specific regulation that guarantees the protection of all those who participate in the process: donors and their families, patients in need of a transplant, recipients of organs and healthcareprofessionals involved. In this article, we reviewthe ethical-legal standards that regulate the practice of kidney donation and transplantation at the international level and analyze the ethical-legal framework that is applicable in Spain.El trasplante renal (TR) es la mejor opción terapéutica para los pacientes con insuficiencia renal crónica en términos de supervivencia, calidad de vida y relación coste-efectividad. La diferencia fundamental del TR con respecto a otras terapias es que su realización depende de la disponibilidad de órganos para uso clínico, disponibilidad que resulta insuficiente para cubrir las crecientes necesidades de trasplante de la población. Otro aspecto relevante del trasplante es que conlleva el riesgo de transmisión de enfermedades de donante a receptor, riesgo que puede minimizarse, pero no eliminarse por completo. Por sus características y su naturaleza única (el ser humano), el TR exige una regulación específica que garantice la protección detodos los participantes en el proceso: los donantes y sus familias, los pacientes con necesidad de un trasplante, los receptores de órganos y los profesionales sanitariosimplicados. En este artículo se revisan los estándares ético-legales que regulan la práctica de la donación y el TR a nivel internacional y se analiza el marco ético-legal que resulta de aplicación en España.

IntroductionThere is a discrepancy in the literature as to whether authorising or refusing the recovery of organs for transplantation is of direct benefit to families in their subsequent grieving process. This study aims to explore the impact of the family interview to pose the option of posthumous donation and the decision to authorise or refuse organ recovery on the grieving process of potential donors’ relatives.Methods and analysisA protocol for mixed methods, prospective cohort longitudinal study is proposed. Researchers do not randomly assign participants to groups. Instead, participants are considered to belong to one of three groups based on factors related to their experiences at the hospital. In this regard, families in G1, G2 and G3 would be those who authorised organ donation, declined organ donation or were not asked about organ donation, respectively. Their grieving process is monitored at three points in time: 1 month after the patient’s death, when a semistructured interview focused on the lived experience during the donation process is carried out, 3 months and 9 months after the death. At the second and third time points, relatives’ grieving process is assessed using six psychometric tests: State-Trait Anxiety Inventory, Beck Depression Inventory-II, Inventory of Complicated Grief, The Impact of Event Scale: Revised, Posttraumatic Growth Inventory and Connor-Davidson Resilience Scale. Descriptive statistics (means, SDs and frequencies) are computed for each group and time point. Through a series of regression models, differences between groups in the evolution of bereavement are estimated. Additionally, qualitative analyses of the semistructured interviews are conducted using the ATLAS.ti software.Ethics and disseminationThis study involves human participants and was approved by Comité Coordinador de Ética de la Investigación Biomédica de Andalucía (CCEIBA) ID:1052-N-21. The results will be disseminated at congresses and ordinary academic forums. Participants gave informed consent to participate in the study before taking part.

The access of non-resident patients to the deceased donor waiting list (DDWL) poses different challenges. The European Committee on Organ Transplantation of the Council of Europe (CD-P-TO) has studied this phenomenon in the European setting. A questionnaire was circulated among the Council of Europe member states to inquire about the criteria applied for non-residents to access their DDWL. Information was compiled from 28 countries. Less than 1% of recipients of deceased donor organs were non-residents. Two countries never allow non-residents to access the DDWL, four allow access without restrictions and 22 only under specific conditions. Of those, most give access to non-resident patients already in their jurisdictions who are in a situation of vulnerability (urgent life-threatening conditions). In addition, patients may be given access: (i) after assessment by a specific committee (four countries); (ii) within the framework of official cooperation agreements (15 countries); and (iii) after patients have officially lived in the country for a minimum length of time (eight countries). The ethical and legal implications of these policies are discussed. Countries should collect accurate information about residency status of waitlisted patients. Transparent criteria for the access of non-residents to DDWL should be clearly defined at national level.

With the aim of consolidating recommendations about the practice of initiating or continuing intensive care to facilitate organ donation (ICOD), an ad hoc working group was established, comprising 10 intensivists designated by the Spanish Society of Intensive Care and Coronary Units (SEMICYUC) and the Spanish National Transplant Organization (ONT). Consensus was reached in all recommendations through a deliberative process. After a public consultation, the final recommendations were institutionally adopted by SEMICYUC, ONT, and the Transplant Committee of the National Health-Care System. This article reports on the resulting recommendations on ICOD for patients with a devastating brain injury for whom the decision has been made not to apply any medical or surgical treatment with a curative purpose on the grounds of futility. Emphasis is made on the systematic referral of these patients to donor coordinators, the proper assessment of the likelihood of brain death and medical suitability, and on transparency in communication with the patient's family. The legal and ethical aspects of ICOD are addressed. ICOD is considered a legitimate practice that offers more patients the opportunity of donating their organs upon their death and helps to increase the availability of organs for transplantation.

Resumen: A pesar de ser una referencia internacional en donación y trasplante, España precisa mejorar los procesos de donación en niños, en particular la donación tras la determinación de la muerte por criterios circulatorios (donación en asistolia). El presente artículo, resumen del documento de consenso elaborado por la Organización Nacional de Trasplantes y la Asociación Española de Pediatría, pretende facilitar los procesos de donación en niños y neonatos y analizar los conflictos éticos que plantea. Se comentan los fundamentos éticos de la donación pediátrica, los principios de la evaluación clínica de los posibles donantes, los criterios diagnósticos de muerte encefálica en niños, los cuidados intensivos para el mantenimiento de los donantes, los conceptos básicos de la donación en asistolia y los procesos de donación en neonatos con malformaciones muy graves del sistema nervioso incompatibles con la vida y en niños en cuidados paliativos. Considerar sistemáticamente la donación de órganos y tejidos cuando un niño fallece en condiciones de ser donante es un imperativo ético y ha de constituir un estándar profesional, tanto por la necesidad de órganos para trasplante, como por asegurar un cuidado integral centrado en la familia. Abstract: Despite being an international reference in donation and transplantation, Spain needs to improve pediatric donation, including donation after the circulatory determination of death. The present article, a summary of the consensus report prepared by the Organización Nacional de Trasplantes and the Spanish Pediatrics Association, intends the facilitation of donation procedures in newborns and children and the analysis of associated ethical dilemma. The ethical basis for donation in children, the principles of clinical assessment of possible donors, the criteria for the determination of death in children, intensive care management of donors, basic concepts of donation after the circulatory determination of death and the procedures for donation in newborns with severe nervous system's malformation incompatible with life, as well as in children receiving palliative care are commented. Systematically considering the donation of organs and tissues when a child dies in conditions consistent with donation is an ethical imperative and must become an ethical standard, not only because of the need of organs for transplantation, but also to ensure family centered care.

Despite being an international reference in donation and transplantation, Spain needs to improve pediatric donation, including donation after the circulatory determination of death. The present article, a summary of the consensus report prepared by the Organización Nacional de Trasplantes and the Spanish Pediatrics Association, intends the facilitation of donation procedures in newborns and children and the analysis of associated ethical dilemma. The ethical basis for donation in children, the principles of clinical assessment of possible donors, the criteria for the determination of death in children, intensive care management of donors, basic concepts of donation after the circulatory determination of death and the procedures for donation in newborns with severe nervous system's malformation incompatible with life, as well as in children receiving palliative care are commented. Systematically considering the donation of organs and tissues when a child dies in conditions consistent with donation is an ethical imperative and must become an ethical standard, not only because of the need of organs for transplantation, but also to ensure family centered care. Resumen: A pesar de ser una referencia internacional en donación y trasplante, España precisa mejorar los procesos de donación en niños, en particular la donación tras la determinación de la muerte por criterios circulatorios (donación en asistolia). El presente artículo, resumen del documento de consenso elaborado por la Organización Nacional de Trasplantes y la Asociación Española de Pediatría, pretende facilitar los procesos de donación en niños y neonatos y analizar los conflictos éticos que plantea. Se comentan los fundamentos éticos de la donación pediátrica, los principios de la evaluación clínica de los posibles donantes, los criterios diagnósticos de muerte encefálica en niños, los cuidados intensivos para el mantenimiento de los donantes, los conceptos básicos de la donación en asistolia y los procesos de donación en neonatos con malformaciones muy graves del sistema nervioso incompatibles con la vida y en niños en cuidados paliativos. Considerar sistemáticamente la donación de órganos y tejidos cuando un niño fallece en condiciones de ser donante es un imperativo ético y ha de constituir un estándar profesional, tanto por la necesidad de órganos para trasplante, como por asegurar un cuidado integral centrado en la familia.

The high discard rate of pediatric donor hearts presents a major challenge for children awaiting heart transplantation. Recent literature identifies several factors that contribute to the disparities in pediatric donor heart usage, including regulatory oversight, the absence of guidelines on pediatric donor heart acceptance, and variation among transplant programs. However, a likely additional contributor to this issue are the behavioral factors influencing transplant team decisions in donor offer scenarios, a topic that has not yet been studied in detail. Behavioral economics and decision psychology provide an excellent foundation for investigating decision-making in the pediatric transplant setting, offering key insights into the behavior of transplant professionals. We conducted a systematic review of published literature in pediatric heart transplant related to behavioral economics and the psychology of decision-making. In this review, we draw on paradigms from these two domains in order to examine how existing aspects of the transplant environment, including regulatory oversight, programmatic variation, and allocation systems, may precipitate potential biases surrounding donor offer decisions. Recognizing how human decision behavior influences donor acceptance is a first step toward improving utilization of potentially viable pediatric donor hearts.

The presence of patients' families during cardiopulmonary resuscitation (CPR) is a controversial topic, due to its repercussions for clinical practice. While family members' presence may help them to overcome their grief, it could be detrimental, as it may case posttraumatic stress disorder (PTSD), and there is the possibility that family members may interfere with the procedure. For these reasons, families' presence during CPR has rejected by some healthcare providers. To research concerns about families' presence among providers dealing with CPR in the Fundación Hospital Alcorcón (Madrid), I performed this study. Of the 190 providers surveyed, 115 submitted a complete questionnaire. The most frequently reported concerns were interference (78.3 percent of respondents), and PTSD (69.6 percent of respondents). Fewer pediatric providers were concerned about PTSD than other providers (41.2% percent versus 74.5 percent, p = 0.01). Providers were reluctant to offer families the option of being present unless they had requested it, and would only permit it under certain conditions. Having a staff member to support the family was of great value to most respondents. The author believes families have a negative right to be present during CPR and so should be invited to stay.

In this paper we defend that elective ventilation (EV), even if conceived as the instrument to maximise the chances of organ recovery, is mainly the means to provide the patient who is dying with a dignified death in several ways, one of them being the possibility of becoming an organ donor. Because EV does not harm the patient and permits the medical team a better assessment of the patient's clinical trajectory and a better management of the dying process by the family, EV does not violate the principle of non-beneficence nor the principle of autonomy if we restrict the initiation of EV to those cases in which it is not known what the previous wishes of the patient were as regards to his or her care at the end of life.