No Chance of Survival: Cardiac Arrest Criteria Rule Out Recovery, Could Boost Organ Donor Pool


By using three objective criteria, researchers were able to identify patients with out-of-hospital cardiac arrest (OHCA) who had essentially no chance of survival, opening the door for the possibility of organ donation, according to a study published online in Annals of Internal Medicine.

There was a 0% survival rate among patients who had OHCA not witnessed by emergency medical services personnel, had nonshockable initial cardiac rhythm, and had no return of spontaneous circulation before receipt of a third 1-mg dose of epinephrine.

“There are many cardiac arrests—around 300,000 per year in the United States—and several thousands of patients die every year waiting for organ transplantation,” Xavier Jouven, MD, PhD, European Georges Pompidou Hospital (Paris, France), told TCTMD in an e-mail. “The possibility to collect organs from a certain proportion of those cardiac arrests represents an important opportunity to fill the gap of organ shortage.”

Out-of-Hospital Arrest

Jouven and colleagues conducted a retrospective assessment to evaluate objective criteria that could be used to identify patients with OHCA who had no chance at survival during the first minutes of resuscitation in order to prompt initiation of organ donation. Data were from 1,771 patients from the Paris Sudden Death Expertise Center (SDEC) prospective cohort, and 5,192 patients from two validation cohorts: the French PRESENCE multicenter cluster randomized trial and the United States King County Washington prospective cohort.

Among those in the Paris SDEC cohort, the survival rate for the 772 patients with OHCA who met all three criteria was 0% (95% CI, 0.0%-0.5%), with 100% specificity. The probably of death when all three criteria were met was 100%, for a 100% positive predictive value.

In the French validation cohort, 486 patients had OHCA and received advanced cardiac life support. Eighteen percent of patients survived to hospital admission and 3% were alive at day 28. No patients who met the three objective criteria survived to day 28. In the US cohort, 1,050 cases of OHCA occurred, with 89% occurring before the arrival of emergency services personnel. Overall, 45% of patients survived to hospital admission. No patient who met the objective criteria survived to discharge.

The researchers calculated that of the 772 patients in the Paris SDEC cohort who had no chance of survival, 12% might have had organs suitable for transplantation according to French organ donation eligibility criteria.

Pursuing Uncontrolled Donation

Availability of organs for donation is a worldwide problem. In 2006, the Institute of Medicine released a paper, Organ Donation: Opportunities for Action, with a wide range of proposals to increase organ donation, including pursuing donation from donors who had died outside of the hospital, or what is called uncontrolled donation after cardiac death (UDCD). 

In some Western countries, like France and Spain, UDCD programs have been successfully put into place, but these programs are not widely available in the United States, Lewis R. Goldfrank, MD, and Stephen P. Wall, MD, of Bellevue Hospital Center and NYU School of Medicine (New York, NY), told TCTMD in a telephone interview.

Goldfrank and Wall were both members of the New York City Out-of-Hospital Uncontrolled Donation After Circulatory Determination of Death Program, which conducted a prospective study in Manhattan from December 2010 to May 2011 that was published in Annals of Emergency Medicine last year. The program gained community buy-in before putting into place a 6-month pilot program where organ preservation units would monitor emergency medical services (EMS) frequencies for cardiac arrests. After EMS providers independently ordered termination of resuscitation, the preservation unit would determine organ donation eligibility and donor status. During the study period the unit entered nine private locations, but no kidneys were recovered.

One big roadblock to the success of the program, according to Wall, was that unlike the program in France, they were unable to get community buy-in to the idea of presumed consent. Presumed consent means that consent for donation is assumed unless a person has “opted out.” Instead, when designing the New York study protocol it was decided that organ donation would only be possible in people who had previously registered for organ donation or had dually executed documentation. 

Adjusting to the idea of presumed consent is an ongoing issue in the United States, Goldfrank added.

“Emergency physicians see people who come into the ER who collapse and could not be resuscitated, and the family wants to donate organs but we are not allowed because we had no first-person consent,” Goldfrank told TCTMD. “Then later you might see someone waiting for a transplant come into the ER and die. There are organs to give, but we don’t do it.”

Public Concern

Wall said that when they tried to incorporate presumed consent into their UDCD program, there was a lot of backlash from the media, including articles that called it a “meat market.”

According to Jouven, these types of concerns about UDCD programs and presumed consent are common among the public and in the healthcare community. In addition, the decision to decide to stop the resuscitation process is never an easy decision for medical personnel.

“He or she always hopes that life will overcome, especially in young patients,” Jouven said. “After 45 minutes, organs are unusable for donation, so this is a loss of life on one side and a loss of an organ on the other side.”

Goldfrank agreed: “We have to find a rational selection process to say who is not going to make it no matter what we do. These people are going to die—are dead in actuality—and could do something constructive for society that would please them and please their families.”

 

Sources
  • Jabre P, Bougouin W, Dumas F, et al. Early identification of patients with out-of-hospital cardiac arrest with no chance of survival and consideration for organ donation. Ann Intern Med. 2016;Epub ahead of print.

  • Wall SP, Kaufman BJ, Williams N, et al. Lesson from the New York City Out-of-Hospital Uncontrolled Donation After Circulatory Determination of Death Program. Ann Emerg Med. 2016;67:531-537.

Disclosures
  • The PRESENCE trial was supported by a grant from the French Ministry of Health.
  • Jouven, Goldfrank, and Wall report no relevant conflicts of interest.

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