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An article titled “National Recommendations on Pediatric Donation” was recently published in Annals of Pediatrics.
The article is a summary of a consensus document prepared by National Transplant Organization (ONT) allí Spanish Association of Pediatrics (AEP) and aims to facilitate the processes of organ and tissue donation in children and infants. The document analyzes the ethical foundations of these techniques in children, in particular Organ donation in controlled asystole (CAD). Other aspects are also discussed, such as the principles of clinical evaluation of potential donors, the diagnostic criteria for brain death, and the criteria for cardiocirculatory and respiratory arrest.
The CAD was developed by Royal Decree 1723/2012, opening the possibility of donation not only based on brain death criteria, but also based on death criteria based on the cessation of cardiorespiratory signs.
From this moment on, a series of bioethical reflections arise when considering possible donors of patients who have a limitation of therapeutic effort (LET), also called limitation or interruption of survival treatment (LTSP, RTSP).
The ethical debate has focused on the following aspects: when and who makes the LTSP decision; the time to cardiorespiratory arrest for the diagnosis of death (five minutes in our country); conservation measures pre mortemsuch as administering drugs or placing intravenous catheters (donor instrumentation); conservation measures To publish mortem which aim to prevent a restart of cerebral circulation.
Particularly interesting are the conclusions and recommendations that the working group created in the Department of Health of the Valencian Community in 2014 prepared on this topic:
– There must be a separation between the decision to limit survival treatments (LLST) and the decision to donate. Obtaining consent for LLST must be based on scientific, technical, and ethical criteria and must be agreed upon, after careful deliberation by the medical team, before being raised with the family.
– Obtaining consent to donate, required by the transplant team, must be obtained after the LLST and before the diagnosis of death. The notification process must be complete and must include the possibility of donation failure.
– When there is a real or perceived conflict between the goal of providing optimal HRV and the goal of obtaining vital organs for transplantation, the priority will be to optimize patient care and comfort.
– Design and scrupulous monitoring of the LLST and Don protocols approved by the Sanitary Bioethics Committee.
– In the donation after the circulatory determination of death, the information process must always be transparent. Respect for the dignity of the body and confidentiality are fundamental, as well as facilitating the process of family mourning.
– The competent authorities must promote educational and information campaigns, highlighting the benefits that transplants bring to people who need human organs, underlining their voluntary, altruistic and selfless nature.
In the particular case of children, and in particular from the consent document between ONT and AEP, other ethical dilemmas emerge, such as: the validity of the consent by proxy to authorize the treatment of the donor (ante mortem); donation to patients in pediatric palliative care (including home palliative care).
“Donation in neural tube defects with limited very short-term ectopic life prognosis” is also presented in this paper as a future goal. In this situation, the parents would have been offered the option to terminate the pregnancy rather than have an abortion (if that had been their decision). At the time of birth, palliative care would be maintained and the limitations of life support and CAD would eventually continue.
Javier Luna González
Pediatric surgeon
Bioethics Observatory
Catholic University of Valencia
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