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Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation or uncontrolled donation after the circulatory determination of death following out-of-hospital refractory cardiac arrest—An ethical analysis of an unresolved clinical dilemma

      Abstract

      Background

      The availability of extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation (E-CPR), for use in refractory out-of hospital cardiac arrest (OHCA), is increasing. In parallel, some countries have developed uncontrolled donation after circulatory determination of death (uDCDD) programs using ECMO to preserve organs for transplantation purposes.

      Aim

      When facing a refractory OHCA, how does the medical team choose between initiating ECMO as part of an E-CPR protocol or ECMO as part of a uDCDD protocol?

      Methods

      To answer these questions we conducted a literature review on E-CPR compared to uDCDD protocols using ECMO and analyzed the raised ethical issues.

      Results

      Our analysis reveals that the inclusion criteria in E-CPR and uDCDD protocols are similar. There may be a non-negligible risk of including patients in a uDCDD protocol, when the patient might have been saved by the use of E-CPR.

      Conclusion

      In order to avoid the fatal error of letting a saveable patient die, safeguards are necessary. We recommend: (1) the development of internationally accepted termination of resuscitation guidelines that would have to be satisfied prior to inclusion of patients in any uDCDD protocol, (2) the choice regarding modalities of ongoing resuscitation during transfer should be focused on the primary priority of attempting to save the life of patients, (3) only centers of excellence in life-saving resuscitation should initiate or maintain uDCDD programs, (4) E-CPR should be clinically considered first before the initiation of any uDCDD protocol, and (5) there should be no discrimination in the availability of access to E-CPR.

      Abbreviations:

      ECMO (extracorporeal membrane oxygenation), CPR (cardio-pulmonary resuscitation), E-CPR (extracorporeal membrane oxygenation assisted cardiopulmonary resuscitation), OHCA (out-of-hospital cardiac arrest), IHCA (in-hospital cardiac arrest), DCDD (donation after circulatory determination of death), uDCDD (uncontrolled donation after circulatory determination of death), ROSC (return of spontaneous circulation), WIT (warm ischemia time), TOR (termination of resuscitation), VF (ventricular fibrillation), VT (ventricular tachycardia), TP (torsade de pointes), PEA (pulseless electrical activity), ACLS (advanced cardiac life support), DBDD (donation after brain death determination), ETCO2 (end tidal CO2)

      Keywords

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