What follows refractory cardiac arrest: Death, extra-corporeal cardiopulmonary resuscitation (E-CPR), or uncontrolled donation after circulatory death?


What follows refractory cardiac arrest: Death, extra-corporeal cardiopulmonary resuscitation (E-CPR), or uncontrolled donation after circulatory death?

Alexander R. Manara, Beatriz Dominguez-Gil, Jose Miguel Pérez-Villares, Jasmeet Soar


Many healthcare staff are particularly uncomfortable at the interface between end-of-life care and organ donation after circulatory death (DCD).1 This is true for both controlled DCD (Maastricht category 3)2 and for uncontrolled DCD (Maastricht Category 2).2 The issues for controlled DCD (cDCD) arise because decision making and interventions to facilitate organ retrieval are made after a decision to withdraw life-sustaining treatments has been reached but while the dying patient is still alive. Concerns regarding the diagnosis of death, perceived conflicts of interest and the legality of ante-mortem and post-mortem interventions have all been addressed in countries practicing this form of deceased donation to ensure that the practice of cDCD is based on a robust ethical, legal and professional framework.3 Different issues arise in uncontrolled DCD (uDCD) where donation is only considered when cardiopulmonary resuscitation (CPR) has failed after an unexpected cardiac arrest, usually in the out-of-hospital setting. Again countries practicing this form of donation have established appropriate frameworks to underpin their practice.4

When CPR fails to achieve the restoration of spontaneous circulation (ROSC) after an unexpected out-of-hospital cardiac arrest (OHCA) the emergency medical services (EMS) at the scene have three choices:


Abandon CPR and declare death after allowing sufficient time for the possibility of auto-resuscitation (spontaneous return of the circulation after circulatory arrest) to have passed.5


Continue CPR to allow the initiation of other technologies such as extracorporeal resuscitation during cardiopulmonary resuscitation (E-CPR), that buy time for the treatment of underlying reversible conditions and may have the potential to restore the circulation in selected patients.6


Enter the patient in an uDCD pathway and continue interventions to maintain organ viability during transfer to hospital.

In the linked article, Dalle Ave et al. argue that healthcare providers face an ethical dilemma when deciding which of these options to select when CPR fails, in particular whether E-CPR is used as a means of maintaining the patient’s circulation in an attempt to achieve ROSC, or as a means of maintaining organ viability in potential uDCD donors.7 The authors are to be congratulated in raising these issues which need to be addressed if uDCD programmes are to maintain public and professional confidence in the future. However many of the arguments used are currently theoretical and opinion based. Moreover, an analysis of current evidence and of existing uDCD protocols could equally lead to a conclusion that such ethical dilemma does not exist in current clinical practice.

The decision to start CPR is a relatively straightforward one. The difficulties in assessing the reversibility of an OHCA are such that the default position is always to start CPR8except in situations that enable recognition of life extinct (ROLE)9 or when the patient has a documented and known wish not to receive CPR. While efforts are being made to develop international consensus criteria for the diagnosis of death,10 these do not provide guidance on when to stop CPR. That decision is more challenging. Variables such as no ROSC, no shocks administered, EMS personnel or bystanders not witnessing the arrest, no bystander CPR, the call response time and patient demographics are all predictive of futility.11 Use of such predictors to prognosticate can be very accurate for both defibrillation only rescuers12 and also advanced level rescuers regarding stopping CPR and advanced life support (ALS) at scene or transfer with on-going CPR.13 For example, if the arrest is not witnessed by EMS personnel, there is no ROSC, no shocks are administered, and the response time is greater than eight minutes, then only 0.3% of OHCA patients will survive. If in addition the OHCA was not witnessed by a bystander, no patient survives.12 Persistent asystole for more than 20 min during resuscitation is also an accepted reason for stopping resuscitation in the absence of reversible causes.11However, the quality of resuscitation and its outcomes continue to improve14 and such predictive rules need to be updated regularly. Therefore while the use of such predictive rules is helpful in many situations, they should only be seen as guidance and clinicians must continue to use their clinical judgement to decide whether to follow the rules and stop CPR or whether to ignore the rules and continue CPR and ALS for longer.11 and 15This decision will be influenced by the presence of factors such as signs of life during CPR, the continued presence of shockable rhythms, younger age, potentially reversible factors and hypothermia amongst others. The need to develop guidelines for the termination of resuscitation to reduce variability in decision-making in OHCA is well recognised.8 However, it is unlikely that workable termination of resuscitation rules with 100% sensitivity and specificity will be developed. Until then it is essential that EMS continue to be legally and ethically supported in using a combination of termination of resuscitation rules and clinical judgement to stop resuscitation.

Extracorporeal life support techniques use a blood pump and an oxygenator to restore a circulation of oxygenated blood to the body, allowing further time for continued resuscitation, treatment of reversible conditions and return of the spontaneous circulation. The role of E-CPR for refractory OHCA is currently being evaluated by individual centres.16 and 17 It is a promising technology that has the potential to increase survival and neurological outcomes particularly when there is a reversible cause for cardiac arrest.6 and 11 However the provision of E-CPR involves considerable resources and training, and its availability is very limited.11 A recent systematic review on E-CPR concluded that the indications for its use remain undefined and large prospective studies are still required to clarify patient selection, modifiable outcome variables, risk-benefit and cost-effectiveness,6 a view echoed by both the European Resuscitation Council (ERC) and the American Heart Association (AHA).11 and 18 The need for this is further highlighted by a large national registry study showing that, at a population level OHCA victims who received E-CPR did not show better survival outcomes than those who did not.19 Clinical trials comparing the outcomes of E-CPR with continuing traditional CPR for patients with refractory cardiac arrest are also required.18 At present high quality CPR does not routinely include E-CPR.14 Piecemeal introduction of E-CPR services should be avoided until current randomised controlled trials are completed. The further development of international registries on the use of E-CPR and its outcomes may also provide much needed answers before clinical equipoise is lost. On current evidence there is no clinical or ethical imperative for hospitals to hurry and introduce such technology, even if they are engaged in an uDCD programme. However, some hospitals may wish to do so as a means of increasing the evidence base for E-CPR, but that decision should be independent from any decision related to organ donation. In the meantime current efforts to improve patient outcomes should continue to focus on the development of regional systems of care for out-of-hospital cardiac arrest as recommended by the American Heart Association.20 This provides access for patients to hospitals with facilities and expertise to provide the most effective interventions such as percutaneous coronary intervention and post resuscitation care.20 As the role of E-CPR becomes clearer, it would make sense for a hyper-invasive approach to CPR that could include E-CPR to be introduced in regional centres for use in those patients that are most likely to benefit.

In France and Spain, two countries with large, established uDCD programmes, the decision to stop CPR is only made by doctors, having exhausted the measures recommended in the AHA and ERC guidelines, regardless of whether an EMS participates in an uDCD programme or not. No patient with a persistent shockable rhythm is ever considered as a potential uDCD donor. Once the EMS have decided that the resuscitation attempt is unsuccessful then consideration of organ donation as an end-of-life care option is appropriate.8 In this situation uDCD is the donation pathway that the patient would enter. CPR and ventilation are continued during transfer to hospital to declare death and to allow assessment of suitability for donation. It is reasonable to withhold the administration of adrenaline during transport since although the pre-hospital administration of adrenaline may increase the number of patients achieving ROSC, its effects on long term survival and neurological outcome are uncertain.11 and 21 Similarly there is no evidence that the administration of fluid in the absence of hypovolaemia improves outcome, and may actually be harmful.11 and 22 Neither is there any evidence to suggest that potential donors being transported to hospital receive suboptimal CPR. Indeed continued CPR and ventilation during transport can result in the occasional potential donor achieving ROSC and exceptionally surviving with good neurological function.23 This is perhaps unsurprising given that, at least for in-hospital resuscitation, longer durations of CPR are associated with an increased number of patients achieving ROSC, and can also result in good functional outcome.24 For this reason the patient remains monitored during transfer to the hospital: should ROSC occur, usual post resuscitation care measures are commenced.

When the patient arrives at the Emergency Department death can be diagnosed using the criteria accepted within that jurisdiction and organ preservation techniques instituted. This involves catheterisation of the femoral vessels to allow perfusion of organs to maintain their viability for potential transplantation. Although some programmes still use cold perfusate to the abdominal organs, more recently normothermic regional perfusion (NRP) has been developed as it may improve transplant outcomes.4 and 25 Normothermic regional perfusion uses an extracorporeal pump to circulate oxygenated blood but is fundamentally different to E-CPR in that the circulation is only delivered to the organs to be transplanted, and not to the whole body, and CPR can be stopped when this is achieved. This clearly differentiates NRP from E-CPR as an organ preservation technique and not one for continued resuscitation. The catheters used to achieve cold perfusion or NRP use balloons to limit circulation to the abdominal cavity, hence not interrupting the dying process.5 It also clarifies the decision making in that both the EMS and the medical team in the Emergency Department agree with the decision to stop CPR and ALS. Only after death is declared, is NRP initiated by the organ procurement team. On current evidence teams that chose to use E-CPR do so primarily as a means of saving a patient’s life and will consider organ donation only when it fails to do so.6 When E-CPR fails it is possible that the patient may be suitable for consideration of cDCD or donation after brain death (DBD) as well as uDCD. In practice, EMS do not face the decision to choose between the use of E-CPR for therapeutic purposes or for organ preservation strategies.

The criteria used to stop CPR or the point when cardiac arrest is defined as refractory, need constant reconsideration in view of new developments in resuscitation science and practice. It is also crucial to define which patients might benefit from more advanced rescue therapies and specific circumstances-related interventions. When this happens, termination of resuscitation guidance will require integration with guidance on suitability for E-CPR or uDCD.8 and 26

Conflict of interest statement

ARM is the Regional Clinical Lead for Organ Donation for the South West Region. BD-G is a medical officer at Organización Nacional de Trasplantes. JMP-V is a donor coordinator at Complejo Hospitalario Universitario de Granada. JS is a paid editor of Resuscitation. He is the ALS Task Force Co-chair for the International Liaison Committee on Resuscitation (ILCOR), and Chair of the ERC ALS Working Group.


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