Consensus on Science and Treatment Recommendations (CoSTR)
Alonso Mateos Rodriguez
Another important point that is exposed in the development is the part of the effectiveness of the UDCD. In kidney transplantation the evolution of renal grafts is superimposable to renal grafts of encephalitic death or controlled donation. The main difference is the delay in kidney function that usually doubles the kidneys of another type, although creatinine at 6 months and 12 years is normal in most cases.
With respect to lung transplants, in the cases in which the transplant is performed, the evolution is equally satisfactory, although it is true that these lungs undergo a very important validation ex vivo with a perfusion ventilation machine.
The organ that has not shown a fully satisfactory evolution is the liver.
And do not forget the important source of tissues that correspond to these donors.
In brief I will insert bibliography in this regard that we are compiling.
In Spain for many years a type of donation that has suffered a considerable increase is the Donation in Uncontrolled Asystolia or UDCD.
This type of donation involves the emergency services as detectors of the possible donor. These patients are victims of PCR that have not been recovered from it. It is important as a first point to note that spontaneous pulse recovery attempts have to be carried out to their full extent. That is, all the mechanisms that the emergency team can use should be used. Even therapies even in research like ECMO or similar.
Once the emergency team has decided that resuscitation can not be continued for spontaneous pulse recovery because of its futility, this resuscitation becomes maintenance of the possible donor,
This point is essential because this change of therapeutic objective must be informed to the family, the change of my objective as recovery of pulse to maintenance of a possible donor.
But with the information to the family we found a first barrier and is that the family at those times is not able to receive much information. In Spain according to the Consensus Document of the National Transplant Organization 2012 on the Promotion of the donation in asystole, four situations of information to the family are established. These four situations are actually summarized in a message:
Please ensure there are front line paramedics and EMS medical directors representing on this work as there are significant ethical and operational implications to adjusting practice to include consideration of organ donation and organ harvesting from OHCA (especially patients that previously would have had resuscitation discontinued in the field). There are already many complexities around out of hospital cardiac arrest (withholding or ceasing resuscitation, alignment with patient wishes/goals for resuscitation or not (goals of care and/or do not resuscitate orders), having difficult conversations with little historical information under time pressure to initiate resuscitation, etc.) and the general public's understanding of the outcome of out of hospital cardiac arrest (assumption that good outcome is the norm) that place paramedics in very difficult ethical decision making situations on a daily basis. The general public does not talk about their wishes for care and/or document these in a coordinated fashion currently (most patients have wills, but few have easily accessible documentation about their health care wishes in their homes (most paramedics do not have access to any other health system records), these conversations are not consistently happening with patients and their primary care teams and health systems across North America are in varying stages of implementing consistent documentation re: resuscitation wishes in hospitals, let alone across community). The addition of continued resuscitation for the purpose of organ harvesting (rather than perceived outcome of ROSC) is going to add another layer of ethical complexity for paramedics and families when patients suffer OHCA. In the field, there will not be a different team of experts to transition the patient to when the discussion changes from resuscitation for ROSC vs continued resuscitation for transport for organ harvesting (this will be the same paramedic crew that will be required to shift gears and own the discussion, with no other support, like teams in hospital that specialize in organ donation conversations with families). I 100% support this discussion and see opportunity for the potential for increased organ donation related to patients that suffer cardiac arrest out of hospital, however paramedics would need to be better prepared to have difficult discussions with families at the time of the event (which is already extremely difficult and stressful). A greater emphasis on public discourse around goals of care, advance care planning and how that information is shared with paramedics at the time of OHCA is required to support a shift in this direction as well. There are already circumstances where resuscitation is performed against family/patient wishes and/or not an appropriate intervention based on the patient's medical history and prognosis (based on an assumption that everyone would want CPR and resuscitation). There will need to be a greater commitment from the whole healthcare system to prioritize those difficult conversations about advance care planning, wishes/goals and end of life with all patients as a standard practice across their whole lives (not just when nearing end of life or at diagnosis of a life limiting condition or illness). Additionally, current paramedic education (length of educational programs and focus on technical skills) is limiting this type of expansion of care, which requires a strong foundation in ethical decision making, critical thinking, communication skills and comfort with having difficult conversations. Paramedics (US and Canada) are not currently appropriately prepared in their education for these types of ethical discussions and that support will be needed to implement alternative pathways for OHCA that consider continuance of resuscitation for the purpose of organ harvesting at hospital. There are learnings in Canada (Alberta, Nova Scotia and PEI) that would aid in this discussion based on work that has been done around advance care planning, goals of care and paramedics supporting palliative/end of life care patients in community (knowledge gap for paramedics around grief/bereavement, need for documentation of patient wishes easily accessible to paramedics in community, skill deficit for having difficult conversations with family members, identity shift from resuscitation (fix, fix, fix) to supportive care/symptom management for actively dying who do not want (and it's not appropriate) resuscitation) . Learnings and experience in this area would translate directly to some of the anticipated ethical challenges and skills needed for paramedics to be able to support organ donation pathways from OHCA. I also encourage that there be patient and family advisers (with personal experience with OHCA in their home) directly involved in this work to help inform what needs to be considered from the family's perspective (there are far more supports for families in hospital than out - again, paramedics would be alone in what they can provide at the time of this difficult decision or shift in care). I also advocate for the involvement of palliative care and experts in grief and bereavement (we know that how a loved one dies has high impact on the survivor's grief and bereavement and care misaligned with pre-identified preference often leads to complicated grief for families). Happy to share learnings or connect the group to others from Canada who can speak to what we have learned around ethical challenges re: resuscitation, palliative care, advance care planning, in relation to EMS (paramedics) - firstname.lastname@example.org
Just a little but important nuance regarding on Categories on Deceased Donation. Hope will be of interest and clarifying for the workgroup.
Although the classification presented above on "Scope of work of the proposed scientific statement for clinicians and scientists; Definitions" was originally this presented by the work group (Maastricht Classification from Prof Koostra, 1996) it was modified at Paris International DCD conference (2012) to better accommodate to real practice regarding on uDCD. Particularly, because IA Category (Found dead) never has been reported (not a single case worldwide for organ recovery and only few ones for tissues).
However, Category II needed changes. First, the uDCD case is "After Unsuccessful Resuscitation" , as is not certain that is always "witnessed"; e.g. Spain protocols accept no-flow time ranging from 0 to 30 min. Second, practices were very heterogeneous worldwide depending on IHCA vs OHCA event origin. In fact, logistics, I/E criteria to select potential donors, no-flow and low-flow times, consent request and timing, family presence and approach to them, organ preservation techniques as also final outcomes and quality/quantity of organs recovered were very different in the two situations, as easy to understand.
That was why in Paris 2012 was suggested, and lately accepted and integrated by both clinicians and Academia, to modify the original Maastricht Category (1996) to Paris (2012) one.
Today, Category I ( Found dead) is only testimonial (for tissues recovery due to WIT starting point is "too much uncontrolled"/unknown), Category II (after unsuccessful CPR instead of "witnessed cardiac arrest" said) includes A type: after unsuccessful IHCA resuscitation and B type: after unsuccessful OHCA resuscitation. This is the classification accepted in reported cases, series,SRs and interbational recommendations/guidelines according with benchmark.
I hope to have been useful.
Excellent approach that were really necessary: A comprehensive approach to refractory OHCA according with best evidence on both Resuscitation and Deceased Organ Donation. Already conducted SR on uDCD and ECPR suggest that both strategies are compatible when priorities are clear (life-saving ECMO for recovery with QOL first and then Organ Preserving ECMO). And not only compatible but also more efficient that current practice (saving more lives one way or another). Finally, when process is based on a truthful and honest approach to relatives or proxies in such a critical events, confidence on organ donation system is reinforced. Knowledge gap already exists regarding on predictive model to dilucidarse to whom offer ECPR/uDCD when at the scenario of refractory both IHCA and OHCA. We will continue working on it!
I appreciate that this is a topic that needs to be addressed and the proposed approach will consider the perspective of different "stakeholders". However, I do hope that the primary goal of ILCOR remains saving the life of the cardiac arrest victim (and returning them to a good quality of life). My concern is that inappropriate early prognostication risks becoming a self-fulfilling prophecy.
Dear Simon. Thank you for your comment. The function of the ILCOR task force is to examine the published literature, produce a consensus on science (CoS) using GRADE methodology and then provide a treatment recommendation(TR) based on the consensus on science. We qualify our treatment recommendation with a values and preferences statement where we have further qualified the recommendation on swallowing. As with previous ILCOR CoSTR statements it is for the national councils to interpret the recommendation into local practice.
Considering the treatment recommendations will need to be implemented at the most rudimentary BLS level, the use of tablets (a hard choking block for someone with hypoglycaemic induced dysphagia) and despite oral vs buccal administration being faster (but not necessarily safer), where is the practical and evidence-based swallowing function test that should be central to this recommendation? So far it is subjective for people without clinical experience. Australia changed there guideline with no definitive test procedure, however I would expect ILCOR to be more rigorous in ensuring that mitigating one risk does not create another.
Thank you for your comment which the First Aid Task Force has considered carefully.
This was a challenging review due to the limited number of studies to include, and the very low level of certainty of evidence. The First Aid Task Force use the accompanying GRADE Evidence to Decision tables and extensive discussion to help create an expert consensus recommendation appropriate for first aid providers caring for individuals with suspected hypoglycaemia (which is often accompanied by some degree of altered mental status) and who are able to swallow and follow commands. We will clarify the use of the Evidence to Decision framework for these recommendations in the Values and Preferences statement.
For those individuals who are no longer able to swallow or follow commands, parenteral routes remain preferable, but a recommendation of which treatment or route would be outside the scope of the first aid task force. This will be reflected in the Values and Preferences section.