By Stacey Kusterbeck
Normothermic regional perfusion (NRP), which restores a donor’s circulation after death, is an ethically controversial new organ donation technique.
The American Society of Transplant Surgeons recently convened a working group with representation from bioethics, critical care, hepatology, and transplant surgery to formulate guidance for NRP.1
The group offers 14 recommendations for ethical and legal conduct with NRP procedures. “The motivation is to standardize the processes around NRP and the terminology used to describe this procedure, and to communicate how this procedure is consistent with both ethical and legal conceptualizations of death,” says Anji Wall, MD, PhD, lead author of the guidance and a transplant surgeon at Baylor Scott and White Health.
The authors intend the recommendations to provide guidance for transplant centers, organ procurement organizations (OPOs), and donor hospitals who are developing either NRP programs or donation policies that address the use of NRP.
“Clinicians can use the recommendations to establish their practice in NRP cases,” suggests Wall.
The guidance states that clinicians should:
• develop written protocols to share with donor hospitals;
• have pre-arrival phone huddles with other procurement, OPOs, and donor hospital personnel;
• have pre-donation huddles once onsite to explain the procedural details. These should include anyone who will be in the operating room for the procurement procedure or who will be providing end-of-life care for the patient.
Donor hospitals can cite the document in their donation after circulatory death policies to support the ethical and legal acceptability of NRP, says Wall.
Ethicists can help address ethical concerns with NRP in these ways, offers Wall:
• by developing an understanding of the procedure in the context of deceased organ donation, and arguments both for and against this procedure;
• by helping individuals who have questions or concerns about NRP to determine if their views are related to a misconception, miscommunication, or an ontologic belief about death that is not consistent with NRP;
• by helping families who are deciding about NRP determine if there are ethically relevant parts of the procedure that do or do not support their personal values.
For example, family members may be uncomfortable with the idea that the heart restarts inside of the body after it has stopped, which could lead them to decide against NRP. Alternatively, family members may determine that their loved one’s strong desire to be a donor makes NRP the most ethical approach because it is more likely to result in organ donation and transplantation.
• by providing ethics consultation in cases where questions or concerns about NRP are raised, either by families or hospital staff.
“An ethics consultation provides the opportunity for stakeholders to engage with a third party that does not have interest in organ donation or in the patient’s care and can, therefore, provide a more neutral view of the situation,” says Wall.
- Wall AE, Merani S, Batten J, et al. American Society of Transplant Surgeons normothermic regional perfusion standards: Ethical, legal, and operational conformance. Transplantation 2024;108:1655-1659.
