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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.

Donation after circulatory death (DCD) has become an accepted practice in many countries and remains a focus of intense interest in the transplant community. The present study is aimed at providing a description of the current situation of DCD in European countries. Specific questionnaires were developed to compile information on DCD practices, activities and post-transplant outcomes. Thirty-five countries completed the survey. DCD is practiced in 18 countries: eight have both controlled DCD (cDCD) and uncontrolled DCD (uDCD) programs, 4 only cDCD and 6 only uDCD. All these countries have legally binding and/or nonbinding texts to regulate the practice of DCD. The no-touch period ranges from 5 to 30 min. There are variations in ante and post mortem interventions used for the practice of cDCD. During 2008-2016, the highest DCD activity was described in the United Kingdom, Spain, Russia, the Netherlands, Belgium and France. Data on post-transplant outcomes of patients who receive DCD donor kidneys show better results with grafts obtained from cDCD versus uDCD donors. In conclusion, DCD is becoming increasingly accepted and performed in Europe, importantly contributing to the number of organs available and providing acceptable post-transplantation outcomes.

It is well known that families frequently overrule the wishes of dying patients who had previously expressed a wish to donate their organs. Various strategies have been suggested to reduce the frequency of these ‘family overrules’. However, the possibility of families overruling a patient’s registered decision not to donate has not been discussed in the medical literature, although it is legally possible in some countries. In this article, we provide an ethical analysis of family overrule of a relative’s refusal to donate, using the different jurisdictions of the UK, Switzerland, Germany and the Netherlands to provide some context. Despite some asymmetries between overruling consent and overruling refusal, there are some cases in which donation should proceed despite a recorded refusal to do so.

Donation after circulatory death (DCD) donors are a unique group of patients who do not fulfil the conventional classification of brain death but in whom further resuscitation or treatment is considered futile. Once cardiac arrest and the cessation of circulation has been confirmed, either due to unsuccessful resuscitation or planned withdrawal of treatment they can proceed to organ donation. Donation is performed by rapidly preserving and cooling the organs followed by surgical removal.

Introduction. The goal of the Eurotransplant renal allocation scheme is to provide every patient on the waiting list with a reasonably balanced opportunity for a donor offer. New initiatives were taken in order to maximize donor usage while maintaining a successful transplant outcome. Methods. Two Eurotransplant projects were launched in order to accommodate changes in donor and recipient profiles. A re-addressing of the non-heart-beating donor pool was undertaken and an allocation scheme in which organs from donors aged >65 are allocated to recipients aged >65 [the Eurotransplant Senior Programme (ESP)] was introduced. Results. Especially in The Netherlands, an enormous increase in the number of non-heart-beating donor kidneys has been observed, however with a pace-keeping reduction in heart-beating donors. The organization-wide implementation of the ESP has been successful. The 3 year graft survival rates for these age-matched transplants were as good as the human leukocyte antigen (HLA)-matched transplants (64 vs 67%) (P=0.4). Conclusion. Within the framework of sound research, the utmost flexibility and creativity is needed to keep or even increase the number of renal transplants when faced with a quantitatively stagnating but qualitatively deteriorating donor pool. Both the non-heart-beating donor protocol and the ESP have proven to be quite successful in achieving this goal without compromising the outcome for the individual end-stage renal disease patient.

Objectives: The role of the European Union in influencing health care policies in member states is of increasing importance. The Eurotransplant Foundation is an organization which provides donor organs to the most suitable transplant recipients. It covers a region of five countries (Austria, Belgium, Germany, Luxembourg, The Netherlands). As there is a severe shortage of donor organs within its region, registration of so-called non-resident patients on the waiting lists aggravates this shortage. Could European Community law, especially rules on competition, limit Eurotransplant's freedom to introduce a restrictive policy on non-residents? If so, could participating transplant centres or patients initiate legal action against Eurotransplant to stop the execution of such a policy? Methods: Quantitative descriptive data on organ donation and use by the Eurotransplant Foundation during 1994 and 1995, by residents and non-residents. Analysis on basis of economic and legal framework. Results: Solidarity between potential donors and potential recipients is organized in a different manner in an organization such as Eurotransplant as compared to a national organization under national law. National regulations may introduce a restrictive policy for the acceptance of non-resident patients. Eurotransplant — as a matter of its own policy — has to consider international solidarity. The scope of the non-resident issue is dealt with, and it is explained why it is considered to be a problem. On the basis of a discussion of the economic and the legal framework for a non-resident policy, an answer to the question is suggested. Conclusion: It might be possible for Eurotransplant to introduce a restrictive policy on the admission of non-residents without violating the European Community Treaty.