心脏死亡捐献单中心工作实践与思考

背景：心脏死亡捐献是国内现阶段解决器官来源的科学决策。国内外对移植器官受者及其家属的相关指标探讨较多,其次为捐献态度及其影响因素调查和伦理相关问题的研究,基于心脏死亡捐献基础上的供者及家属情况分析探讨较少。目的：回顾性分析吉林大学第一医院自2011年被卫生部和中国红十字会指定为心脏死亡捐献工作第二批试点单位以来的工作经验,汇总供者及其家属的信息,及时审视工作进展并探讨需要改进的方面。方法：以单中心试点工作以来获得的组织经验为基础,结合所接触的供者及其家属的自然状况、社会属性、对心脏死亡捐献的认知等情况,予以统计学处理。结果与结论：吉林大学第一医院心脏死亡捐献工作已逐步正规化,取得了一定成果,工作中总结了现存问题及普遍误区,以指导下一步工作。总结改进要点如下：①采取具体措施协助供者家属应对传统观念、心理压力及伦理问题。②大力发展与地方医院的交流与合作。③不能疏忽伦理评估与审批。④认真准确及时地上报供者信息,并随时更新受者信息库中的资料。⑤遇到特殊案例应进行小组讨论,针对个案探讨成功或失败的经验。⑥培养心脏死亡捐献团队成员整体素养。     

DCD器官捐献者家属访谈心理因素调查分析

目的分析心脏死亡器官捐献者的病因及影响家属捐献的心理因素。方法潜在捐献者符合Maas-tricht分类中第Ⅲ类标准或中国Ⅲ类标准。结果2010年3月～2011年12月访谈潜在捐献者67例,同意捐献者17例,成功捐献器官16例。结论器官捐献工作的开展,社会的认可,器官捐献知识的普及和捐献意识的提高是基础,协调员的坚持与付出,有关部门的支持是器官捐献工作取得成功的重要因素。     

家属对亲属器官捐献决定的影响因素及对策研究

[目的]通过参与协调的潜在心脏死亡遗体器官捐献(DCD)案例,探讨影响家属决定亲属器官捐献的因素及解决对策.[方法]2010年3月至2011年3月,对51例潜在捐献者家属进行开放式访谈,探讨协调介入时间和环境、协调员的专业水平、家属对脑死亡及捐献流程信息的了解、家庭组成对家属捐献决定的影响.[结果]成功捐献的案例,协调...     

儿童心脏死亡器官捐献与肾脏移植1例报告

背景：器官短缺是全球移植界共同面临的难题,为扩大供者来源,缓解日益紧张的器官短缺,回避因脑死亡立法及诊断标准缺位造成的困惑,卫生部和中国红十字会联合推动心脏死亡器官捐献。目的：探讨开展儿童心脏死亡器官捐献的可行性。方法：回顾性分析解放军南京军区福州总医院1例儿童心脏死亡肾脏捐献案例,结合文献进行分析。结果与结论：4岁男孩,心肺复苏后脑死亡,经过2次两组专家时隔24h按脑死亡判定标准（儿童）和脑死亡判定技术规范,以及阿托品试验结果独立作出判定。捐献者父母对捐献方案知情同意,书面表达捐献意愿,且得到医院伦理委员会批准。按中国心脏死亡器官捐献工作指南逐步完成捐献申请、审批、转运、器官维护,以及生命支持治疗撤除、器官切取过程,热缺血时间13min。按年龄、体质量和组织配型结果选择受者,2只肾脏分别植入2例尿毒症受者体内,左肾接受者为13岁女性,右肾接受者为35岁女性,术后未发生肾功能延迟恢复,无移植肾血管栓塞、尿瘘、输尿管梗阻等并发症。术后1年内移植肾由术前7cm增大至10cm,尿蛋白阴性,血肌酐≤60μmol/L,估算肾小球滤过率70-150mL/min。术后至今均未发生严重感染事件,血压正常,无糖尿病、高脂血症、肝功能损害等并发症,现生活自理,精神状态好,遵医行为佳。提示儿童心脏死亡器官捐献是过渡时期解决器官来源的方向之一。必须严格遵守患者救治利益高于一切的基本原则,积极探索儿童心脏死亡器官捐献规范化操作程序。     

心脏死亡器官捐献肝肾联合获取手术护理配合

目的:总结心脏死亡器官捐献(DCD)肝肾联合获取手术护理配合的体会。方法:回顾性总结了28例DCD肝肾联合获取手术的护理配合的临床资料。结果:28例器官捐献者中,25例同时捐献肝脏和双侧肾脏,3例只捐献肾脏,共计获取25个肝脏用于移植,获取的56个肾脏一对在获取过程中未能灌洗弃用,其余54个均用于移植。移植后均取得良好效果。结论:心脏死亡器官捐献的器官获取在时间和地点等方面与普通的亲属活体和尸体器官获取有很大的差别,整个手术过程时时处处体现对DCD供者的敬意是手术实施的前提,完善的术前用物准备和精准、迅速的术中配合是手术成功的关键。     

1例体重<15kg儿童逝世后器官捐献供者单肾成人肾移植的护理

总结1例儿童心脏死亡器官捐献供者单肾成人肾移植的护理。认为儿童心脏死亡器官捐献供者单肾成人肾移植术后的护理有明显特殊性,护理人员除了展开肾移植围术期常规医疗护理外,还应加强对术后的血压、液体管理及潜在并发症、用药等观察与护理,结合供肾的具体情况适当调整免疫抑制剂方案,从而保证肾移植的成功。     

DCD潜在捐献者家属情感体验的质性研究

[目的]了解公民逝世后器官捐献(DCD)潜在捐献者家属的心理感受,并探讨其应对方式。[方法]采用现象学研究法对5例DCD潜在捐献者家属10人进行访谈,运用Colaizzi法分析资料提炼主题。[结果]DCD潜在捐献者家属心理感受可归纳为3个主题:矛盾情感、正向情感、负向情感。[结论]DCD潜在捐献者家属矛盾情感和负向情感可通过移植协调员及医护人员的正确引导转为正向情感,因此,应加强器官移植的正面宣传,倡导社会、家庭支持,关注潜在捐献者家属的心理感受,普及脑死亡知识,提高器官捐献率。     

心脏死亡供者供肾移植2例的护理

随着活体供者的伦理学问题日趋严重,心脏死亡器官捐献(DCD)的数量得到了较快增长,一定程度上缓解了各国移植器官短缺的紧迫现状。卫生部委托中国红十字总会负责主持的DCD工作已于2010年3月2日正式启动。我科2012年10月成功实施心脏死亡供者供肾移植2例,病人经过有效治疗及精心护理,康复出院。现将护理总结如下。     

体外膜肺氧合辅助潜在捐献者院际转运专家共识

<正>2010年，我国正式启动了公民逝世后器官捐献试点工作，并从2013年2月开始在全国范围内推广。从2015年1月1日起，公民逝世后捐献器官成为尸体器官唯一合法来源。在伦理允许的范围内，围绕人体器官捐献的系列流程，开展规范化管理和不断创新器官捐献者器官保护、安全转运的方式方法，是改善捐献器官质量和器官移植受者预后的关键因素，也是实现器官捐献供者价值最大化的保障。     

1例婴儿心脏死亡器官捐献供者双肾整块移植成功病人的护理

我国每年有大量终末期肾病病人等待进行肾移植治疗,但是由于活体器官捐献受严格的法律限制和逐渐减少的尸体器官来源进一步加重了器官的短缺。每年完成的肾移植例数远远不能满足现有的等待移植治疗病人的需求。而心脏死亡器官捐献是现阶段解决器官来源问题的科学决策[1]。心脏死亡器官捐献(donation after cardiac death,DCD)是指公民在心脏死亡后进行的器官捐献,以往也称无心跳捐献(non heart beating,NHBD)[2]。临床上通过双肾整块移植(即将儿童供者的两个肾脏整块移植给同一受者)来弥补单个肾脏肾单位的不足,提高移植近期及远期效果。2013年10月我科采用1例6月龄女婴 DCD 的整块双肾,为1例成年女性尿毒症病人进行了肾移植并取得成功。现报道如下。     

Pro/con debate: In patients who are potential candidates for organ donation after cardiac death,starting medications and/or interventions for the sole purpose of making the organs more viable is an acceptable practice

Several hospitals have been developing programmes for organ donation after cardiac death. Such programmes offer options for organ donation to patients who do not meet brain-death criteria but wish to donate their organs after withdrawal of life-support. These programmes also increase the available organ pool at a time when demand exceeds supply. Given that potential donors are managed in intensive care units, intensivists will be key components of these programmes. Donation after cardiac death clearly carries a number of important ethical issues with it. In the present issue of Critical Care two established groups debate the ethical acceptability of using medications/interventions in potential organ donors for the sole purpose of making the organs more viable. Such debates will be an increasingly common component of intensivists' future practice.     

Intimacy or utility? Organ donation and the choice between palliation and ventilation

Organ donation after brain death provides the most important source for deceased organs for transplantation, both because of the number of potential organ donors that it makes available and also because of the unparalleled viability of the organs retrieved. Analysis of worldwide deceased organ donation rates demonstrates that all countries with high deceased organ donation rates (>20 donors per million population per year) have high brain death rates (>40 brain deaths per million population per year). This analysis makes it clear that countries striving to increase their deceased organ donor rates to world leading levels must increase the rates of donation after brain death. For countries with end-of-life care strategies that stress palliation, advance care planning and treatment withdrawal for the terminally ill, the adoption of initiatives to meaningfully raise deceased donor rates will require increasing the rate at which brain death is diagnosed. This poses a difficult, and perhaps intractable, medical, ethical and sociocultural challenge as the changes that would be required to increase rates of brain death would mean conjugating an intimate clinical and cultural focus on the dying patient with the notion of how this person's death might be best managed to be of benefit to others.     

关于活体器官供者的伦理思考

背景:活体器官伦理问题逐渐成为人们视野中的焦点和难点。目的:对活体器官供体伦理问题进一步研究。方法:应用计算机检索CNKI和VMIS数据库中2001-01/2011-05关于器官移植的文章,在标题和摘要中以"活体、供体"和"器官移植、伦理"为检索词进行检索。纳入与活体供体关联度高、本领域内的文献,主要选择权威杂志、核心期刊或者近期发表的文章。排除与此文目的无关的、内容和观点陈旧的及重复研究的文献。入选18篇文献和4本医学伦理学书籍进行综述。结果与结论:为了生命的健康续存,必须完善器官移植和捐献的法律法规,规范供体来源渠道,避免由于科技利益和经济利益的驱使任由活体供体买卖现象的存在空间,研究器官移植活体供体伦理问题,可促使人们提高活体供体捐赠积极性和主动性,解决器官移植供体短缺状况。     

关于活体器官供者的伦理思考

背景：活体器官伦理问题逐渐成为人们视野中的焦点和难点。目的：对活体器官供体伦理问题进一步研究。方法：应用计算机检索CNKI和VMIS数据库中2001-01/2011-05关于器官移植的文章,在标题和摘要中以＂活体、供体＂和＂器官移植、伦理＂为检索词进行检索。纳入与活体供体关联度高、本领域内的文献,主要选择权威杂志、核心期刊或者近期发表的文章。排除与此文目的无关的、内容和观点陈旧的及重复研究的文献。入选18篇文献和4本医学伦理学书籍进行综述。结果与结论：为了生命的健康续存,必须完善器官移植和捐献的法律法规,规范供体来源渠道,避免由于科技利益和经济利益的驱使任由活体供体买卖现象的存在空间,研究器官移植活体供体伦理问题,可促使人们提高活体供体捐赠积极性和主动性,解决器官移植供体短缺状况。     

Clinical management of the organ donor

There is a critical mismatch between available organs for transplant and acutely or critically ill patients with end-stage organ disease. Patients who may benefit from organ transplantation far outnumber available organs. The causes for this imbalance are multiple. One cause is family refusal to donate. A second cause is nonrecognition or delay in determination of brain death. A third cause is donor loss due to profound cardiopulmonary and metabolic instability consequent to brain-stem herniation and brain death. Family refusal may be addressed by education, public awareness, as well as close attention to social, cultural and ethical issues, and optimal communication with donor families. Brain death may be consequent to traumatic brain injury, ischemic versus hemorrhagic stroke, as well as massive cerebral anoxia/ischemic following cardiac arrest. Nonrecognition or delay in brain death determination may be addressed by clinician education and frequent clinical assessment to detect early stages of brain-stem herniation refractory to aggressive measures for control of intracranial pressure. Donor loss due to profound cardiopulmonary and metabolic instability may be addressed by aggressive, mechanism-based treatment for clinical instability based on affected body system, as well as measures to support metabolic activity at the cellular and tissue level in the brain-dead organ donor. This article explores cerebral physiology related to impending brain death and catastrophic intracranial pressure elevations. In addition, physiologic consequences of brain death are correlated with affected body systems and mechanism-based therapies to support organ function pending transplantation. Ethical/legal issues are explored as related to patient autonomy and optimal family outcomes. Effective family communication, astute clinical assessment, and optimal clinical management of the organ donor are illustrated using a case study approach, highlighting the role of the advanced practice nurse in donor management.     

The management of the sibling hematopoietic stem cell donor

Hematopoietic stem cell transplants are procedures with curative potential for patients with diseased, damaged, or absent stem cells. Because a sibling has the best chance of immunocompatibility with one in need of a transplant, siblings are the most suitable donors of stem cells. However, when siblings are stem cell donors, various ethical issues arise concerning the risks and benefits to the pediatric donor. Because of the critical and potential rapid deterioration of the recipient's condition, the needs of the sibling donor may be overlooked. This potential lack of advocacy for the pediatric sibling donor creates a role for the primary care provider to assess the child's physical and psychological ability to undergo the donation procedure, examine the ethical issues in choosing to use the pediatric sibling as the stem cell donor, prepare the child for the procedure, and follow-up with the sibling donor once the procedure is completed.     

Organ donation after circulatory death: the forgotten donor?

Donation after circulatory death (DCD) can be performed on neurologically intact donors who do not fulfill neurologic or brain death criteria before circulatory arrest. This commentary focuses on the most controversial donor-related issues anticipated from mandatory implementation of DCD for imminent or cardiac death in hospitals across the USA. We conducted a nonstructured review of selected publications and websites for data extraction and synthesis. The recommended 5 min of circulatory arrest does not universally fulfill the dead donor rule when applied to otherwise neurologically intact donors. Scientific evidence from extracorporeal perfusion in circulatory arrest suggests that the procurement process itself can be the event causing irreversibility in DCD. Legislative abandonment of the dead donor rule to permit the recovery of transplantable organs is necessary in the absence of an adequate scientific foundation for DCD practice. The designation of organ procurement organizations or affiliates to obtain organ donation consent introduces self-serving bias and conflicts of interest that interfere with true informed consent. It is important that donors and their families are not denied a 'good death', and the impact of DCD on quality of end-of-life care has not been satisfactorily addressed to achieve this.     

Abstracts of the XXIV Annual Scientific Meeting of the British Blood Transfusion Society. September 21-23, 2006. Bournemouth, United Kingdom

Introduction Hundreds of thousands of patients in Europe undergo therapeutic human allograft treatments. There have been three recent reports of possible transmission of vCJD or of abnormal prion by blood transfusion. There is no validated blood test for vCJD, but there are techniques using tissues, that have been used in vCJD epidemiological studies. The principle of testing tonsil, spleen or other reticulo‐endothelial or neurological tissues deserves discussion including issues of test validation, logistics of biopsy sampling, timeframes, potential implications for other human material procurement and ethical issues. Method The advantages and disadvantages of instituting vCJD tests on deceased donors was considered, legal advice sought and logistical issues considered. The advantages of undertaking vCJD testing of tonsil (i) Possibility of identifying potential vCJD deceased donors in the late latent phase of vCJD infection; and (ii) UK legal precedence suggests that the public is legitimately entitled to expect that blood, and presumably tissues, are 100% safe. Disadvantages to testing (i) Unknown time when in the pre‐clinical phase abnormal PrP may be detectable; (ii) The sensitivity of tests may be less than required; (iii) The impact of false positive and false negative results (iv) Logistical aspects of testing to GMP standards; (v) Impact of laboratory turnaround time for any PrP test on tissues/organs requiring rapid release; (vi) Possible pre‐disposition to vCJD disease impact on counselling donor families; (vii) Implications for lookback on recipients an infected tissue donor where previous donations may have been given, either of blood or tissues; (viii) Risk of contamination of tissues or processing laboratories from biopsies; (ix) Loss of categories of tissue donors due to unwillingness of donor families to consent to testing; and (x) Loss of tissue donors from living donor programmes where tonsil testing could not be undertaken. Results It was concluded that tonsil and splenic biopsies should be investigated logistically to provide analytes for vCJD testing. Conclusion Multidisciplinary work is underway to take forward vCJD testing of deceased donors.     

Informed consent in research to improve the number and quality of deceased donor organs

Improving the management of potential organ donors in the intensive care unit could meet an important public health goal by increasing the number and quality of transplantable organs. However, randomized clinical trials are needed to quantify the extent to which specific interventions might enhance organ recovery and outcomes among transplant recipients. Among several barriers to conducting such studies are the absence of guidelines for obtaining informed consent for such studies and the fact that deceased organ donors are not covered by extant federal regulations governing oversight of research with human subjects. This article explores the underexamined ethical issues that arise in the context of donor management studies and provides ethical guidelines and suggested regulatory oversight mechanisms to enable such studies to be conducted ethically. We conclude that both the respect that is traditionally accorded to the prior wishes of the dead and the possibility of postmortem harm support a role for surrogate consent of donors in such randomized controlled trials. Furthermore, although recipients will often be considered human subjects under federal regulations, several ethical arguments support waiving requirements for recipient consent in donor management randomized controlled trials. Finally, we suggest that new regulatory mechanisms, perhaps linked to existing regional and national organ donation and transplantation infrastructures, must be established to protect patients in donor management studies while limiting unnecessary barriers to the conduct of this important research.