Investigating Donor Authorization and Public Perceptions of Normothermic Regional Perfusion to Inform Ethical Organ Donation Practices

PROJECT SUMMARY Among the most promising efforts to reduce the shortage of organs for transplant is increasing recovery and donation of organs after circulatory determination of death in hospital settings (cDCD). One of the key challenges associated with cDCD is mitigating organ damage from warm ischemic time, meaning the duration of time an organ is without blood circulation. In situ thoraco-abdominal normothermic regional perfusion (TA- NRP) via extracorporeal membrane oxygenation initiation is a cost-effective method for reducing organ injury from ischemic time, which also allows for organ function assessment. By re-perfusing organs after circulatory death, TA-NRP leads to recipient outcomes on par with those from organs transplanted after death by neurologic criteria. TA-NRP has been used internationally for decades, and its use is increasing rapidly across the United States. Prior to initiating TA-NRP, the donor is taken off life-sustaining treatment pursuant to patient wishes, and the donor’s circulation ceases naturally. After the patient is declared dead, organ recovery surgeons surgically cut off blood flow to the brain, and then the deceased donor is put on circulatory support to perfuse transplantable organs prior to procurement. This process significantly improves organ quality, leading to better outcomes for transplant recipients. Some are concerned that even though blood flow to the brain is surgically prevented, there might remain other pathways for blood to reach the brain, for example, via vessels around the spinal column. If there is blood flow to the brain during TA-NRP, there is concern that the donor might have some ability to experience harm when their organs are recovered. If true, TA-NRP protocol would need to be modified to ensure total brain blood flow occlusion prior to reinitiating circulation. If this is not possible, then TA-NRP practice might be unethical. This study seeks to ask experts with the greatest knowledge about brain blood flow and its connection to brain function about their perceptions of TA-NRP. By surveying and interviewing neurointensivists, we can better understand the gravity of concerns about restoration of blood flow and the possibility of brain function during TA-NRP, and how different elements of TA-NRP protocols mediate these concerns. Our survey and interview data could determine the urgency with which we must proceed to research studies of brain blood flow during TA-NRP, and would strengthen recommendations around how TA-NRP should be standardized. This information will inform how Organ Procurement Organizations discuss TA-NRP with donor families when seeking authorization for organ donation.