Organ donation after ECPR: ethical challenges and clinical implications

Abstract

Extracorporeal cardiopulmonary resuscitation (ECPR) offers a life-saving option for select patients with refractory cardiac arrest, yet a substantial proportion suffer devastating neurological injury and die despite extracorporeal support. In this context, organ donation may emerge as a potential downstream pathway, introducing complex ethical tensions at the intersection of life-sustaining treatment, end-of-life care, and organ preservation. This narrative review examines the ethical challenges associated with organ donation following ECPR, with particular attention to the transition from resuscitative intent to donation-oriented care. We discuss the clinical and ethical challenges of ECPR programs related to patient autonomy, informed consent, conflicts of interest, and equity of access in both adult and paediatric populations. Building on core principles of biomedical ethics, we propose a structured ethical model to guide clinicians and institutions navigating these scenarios. Central elements include strict separation between resuscitative and donation-related decision-making, transparent prognostication, robust safeguards around treatment intent, and early integration of ethics consultation and structured communication processes. We extend the prior evidence by offering ECPR-specific considerations, including concrete governance triggers, bedside tools, the integration of paediatric perspectives, and the translation of ethical principles into operational guidance. By defining clear ethical boundaries and governance mechanisms, this review aims to support the responsible integration of organ donation pathways following ECPR, while preserving public trust and reaffirming the primacy of patient-centred care.

Graphical abstract

Ethical challenges of organ donation following ECPR

Background

Sudden cardiac arrest is a major contributor to global morbidity and mortality and imposes a substantial burden on healthcare systems and society [1]. In addition to conventional resuscitation, extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising strategy for patients with refractory cardiac arrest [2].

Extracorporeal cardiopulmonary resuscitation involves the use of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) to provide temporary cardiopulmonary support, thereby creating a bridge to evaluation and treatment of potentially reversible causes of cardiac arrest or to subsequent therapeutic pathways, such as bridge-to-recovery or bridge-to-transplant and durable mechanical circulatory support [3, 4]. The decision to initiate ECPR relies on predefined criteria and a patient-specific assessment of risks and potential benefits [3, 4].

Despite its potential to improve survival, not all patients receiving ECPR achieve favourable neurological outcomes, and a substantial proportion die while on ECMO or after its withdrawal due to a lack of therapeutic benefit [5]. Early neurological injury remains one of the most important contributors to morbidity and mortality after ECPR. Across age groups, hypoxic–ischemic brain injury represents the predominant mechanism of neurological damage and is a major determinant of long-term neurological and functional outcomes [6–8]. In adult populations, death by neurological criteria (DNC) occurs in approximately 17% of patients [6]. In paediatric cohorts, neurological complications, including DNC, are reported in at least 20% of patients; however, the exact incidence is less clearly defined and may be lower than that observed in adults [9, 10].

In patients with unfavourable neurological outcomes following ECPR, organ donation may emerge as a possible pathway. It can occur following the determination of DNC or after circulatory determination of death, typically following planned withdrawal of life-sustaining treatment—WLST corresponding to controlled DCD Maastricht category III [11, 12]. In this context, a short continuation of ECMO may help maintain adequate organ perfusion, analogous to the prolongation of mechanical ventilation in patients diagnosed with DNC, where support is maintained solely to preserve organ viability [13, 14].

However, transitioning from individual survival to organ preservation raises substantial ethical concerns and engages all core principles of biomedical ethics. Although this approach may offer an opportunity to reduce waiting times and mortality among transplant candidates, the complexity of informed consent and respect for patient autonomy substantially complicate its implementation. While foundational principles are well established [15], ECPR-specific operational guidance remains limited.

This narrative review provides a comprehensive model for ECPR-to-donation transitions, integrating paediatric considerations, governance triggers, and bedside tools, thereby extending beyond conventional DCD/DNC discourse. It advances a structured ethical approach, with particular focus on the evolution from resuscitative intent to organ preservation and donation.

Organ donation following ECPR: determination of death

Extracorporeal cardiopulmonary resuscitation aims to maximize the likelihood of a meaningful recovery with an acceptable neurological and functional outcome [16–18]. However, in the event of an unfavourable outcome, ECMO can maintain hemodynamic stability and organ perfusion, allowing recovery from ischemic injury, resuscitation-related damage, fluid overload, and the effects of high-dose vasopressors and inotropes [19]. These factors may positively influence end-organ perfusion, thereby improving graft recovery and post-transplant outcomes [20–23].

The clinical and practical feasibility of organ donation following ECPR has previously been demonstrated, including the successful transplantation of kidneys, livers, lungs, pancreas, pancreatic islets, and hearts [11, 20, 22]. Most of these organs are obtained from donors after DNC. Donation after circulatory death (DCD) remains variable across countries and institutions, even in settings with extensive experience in DCD [22–25]. Depending on country-specific laws, regulations, and institutional protocols, death may be determined using either circulatory or neurological criteria [8].

Determination of death by neurological criteria

Death by neurological criteria is often defined as the irreversible loss of all functions of the entire brain, including the brainstem [26–28]. Legal definitions of DNC, as well as the procedural requirements for a valid determination, vary across jurisdictions [26]. Standard clinical testing includes the absence of brainstem reflexes and the demonstration of apnoea in the presence of hypercapnia. In patients supported with ECMO, additional challenges may arise due to residual effects of sedatives or neuromuscular blocking agents, profound shock, hypothermia, and metabolic derangements, all of which may confound neurological assessment [8, 29, 30].

Current recommendations from the American Heart Association (AHA) and the American Academy of Paediatrics emphasize strict adherence to established brain death determination protocols, with additional safeguards in ECPR patients. These include ensuring normothermia, hemodynamic stability, and complete clearance of sedative and neuromuscular blocking agents prior to neurological examination [4, 27, 31, 32].

Although international practices vary, there is broad consensus that neurological prognostication cannot reliably be performed earlier than 72 h after cardiac arrest [4]. These recommendations are supported by the AHA, the European Resuscitation Council, and European Society of Intensive Care Medicine [32].

Donation after circulatory death

Donation after circulatory death refers to the retrieval of organs for the purpose of transplantation from patients whose death is diagnosed and confirmed using cardio-respiratory criteria [33, 34]. According to guidance from the AHA and the International Liaison Committee on Resuscitation (ILCOR), death is declared after 5–10 min (significant international variations exist; for example, Italy mandates a 20-min no-touch period) of continuously observed absence of pulse, arterial blood pressure, and ventilation, with no spontaneous cardiac or respiratory activity. Electrical asystole is not required (international variations exist); pulseless electrical activity is acceptable provided there is no mechanical cardiac function [17]. While this reflects current AHA/ILCOR guidance, the role of electrical asystole in the determination of circulatory death remains debated in some jurisdictions and in the bioethics literature.

The distinction between mechanical and electrical cardiac activity as a criterion for death determination (the traditional “moment of death”) reveals a fundamental ethical tension. The persistence of electrical activity in the absence of mechanical output presents a profound ontological challenge, complicating both intuitive and professional understandings of death, as electrocardiographic signals may be misinterpreted as evidence of ongoing life despite the absence of circulation [17, 35, 36]. In such situations, proceeding with organ donation risks moral unease and potential erosion of public trust if the conceptual basis for death determination is not rigorously articulated. Clear communication of the distinction that electrical activity without mechanical function does not signify persistence of life but reflects a transient physiological dissociation that does not alter the determination of death, is essential.

Furthermore, the use of normothermic regional perfusion (NRP) raises concerns regarding the irreversibility of death, particularly if regional circulation is restored after death declaration. Critics argue that incomplete exclusion of cerebral perfusion or resumption of cardiac activity could invalidate the prior determination of death, thereby violating the dead donor rule [37–39]. To address these concerns, DCD protocols mandate rigorous adherence to the permanence principle. Therefore, all post-mortem interventions must be conducted in a manner that excludes cerebral reperfusion. This safeguard is important to uphold the dead donor rule and to maintain ethical legitimacy in DCD practices [40, 41].

The reliable verification of cerebral exclusion after death declaration represents a significant ethical consideration. Because restoring regional circulation could theoretically reperfuse the brain, even brief or partial cerebral blood flow raises questions about the validity of the prior determination of death and adherence to the dead donor rule [42]. Consequently, the ethical permissibility of NRP depends on strict protocol design, meticulous procedural safeguards, and transparent, multidisciplinary oversight to ensure that the permanence principle is fully respected while optimizing organ viability.

The dead donor rule

The “dead donor rule” is a widely accepted ethical principle stipulating that patients should not undergo interventions for the purpose of organ transplantation until after death has been formally determined [43]. However, as the context of organ donation has evolved over time, reevaluation of the dead donor rule is frequently proposed, as in some cases it may be insufficient and, in others, overly restrictive [44, 45]. The primary aim of to the dead donor rule is to prevent conflicts of interest between the potential donors and the transplant recipients. As the boundaries of death become increasingly contested, ensuring that the underlying intent of the dead donor rule is upheld may be more important than its technical application [46–50].

Indeed, ECPR challenges this principle by restoring or maintaining circulation and tissue perfusion, thereby potentially blurring established boundaries. This tension has fuelled ongoing debate regarding the validity and sufficiency of both circulatory and neurological criteria for death in patients supported with extracorporeal technologies [4, 37].

Most critically, initiating ECPR in a patient with no realistic chance of survival, primarily to preserve organs for potential donation, violates the dead donor rule: the patient is subjected to intervention before death is declared, for the benefit of a potential recipient. When ECPR is initiated with therapeutic intent but ultimately proves futile, continuation of ECMO does not violate this rule. In cases where a patient with a poor prognosis is a registered organ donor and the family confirms the patient’s wishes, continuation of ECMO as a bridge to donation may be ethically acceptable. Still, for patients for whom WLST has been initiated but who do not meet neurological criteria for death, carefully designed and jurisdiction-specific protocols may be required to ensure that death is determined in accordance with established legal and medical standards before any organ-preserving interventions are undertaken.

Alternatively, for known organ donors, and where rigorous informed consent is achievable, some jurisdictions may, in light of the aforementioned limitations of the dead donor rule, develop ethically justifiable pathways to permit ECMO in such circumstances.

Ethical challenges and dilemmas in ECPR

Core ethical principles

The initiation of cardiopulmonary resuscitation, and the subsequent initiation of ECPR, are typically undertaken under the principle of presumed consent, as informed consent is rarely obtainable in this setting [3]. In cases of unfavourable outcome, when therapeutic goals shift to organ preservation, the decision-making process becomes substantially more complex. The following paragraphs examine how ECPR may conflict with the core principles of medical ethics.

Patient autonomy and non-maleficence

The principle of autonomy affirms the patient’s right to self-determination and to make free and informed decisions regarding medical care. However, when no explicit prior wishes are known, decisions are guided by the patient’s presumed will, reconstructed from their values, beliefs, and life history. In the setting of cardiac arrest, clinicians are ethically and legally justified in initiating resuscitation under the doctrine of presumed consent, closely related to the principle of in dubio pro vita (from Latin, when in doubt favour life) [51]. Informed consent for subsequent interventions must be obtained at the earliest feasible opportunity once decisional capacity is restored or a surrogate decision-maker becomes available, the latter being particularly relevant in ECPR settings. Ongoing treatment should then be reassessed considering the patient’s expressed or presumed wishes.

Non-maleficence requires the avoidance of harm and precludes interventions in which the burdens outweigh the anticipated benefits. In the context of ECPR, this includes avoiding the prolongation of dying or the maintenance of ECMO when recovery is no longer achievable [3]. Moreover, beneficence imposes a positive obligation to act in the patient’s best interests by promoting well-being and maximizing the likelihood of meaningful survival. Together, these principles support the initiation of ECPR when recovery remains plausible and require continuous reassessment of proportionality during ongoing support [3].

In ECPR-to-donation scenarios, however, these principles may come into tension with respect for autonomy as exercised through surrogate decision-making. For example, in a patient with devastating neurological injury, in the absence of advance directives or known donation preferences, surrogate consent for organ donation and organ-preserving interventions may be ethically permissible where legally acceptable. However, such authorization derives from the obligation to represent the patient’s values, from previously expressed wishes or otherwise reliably known preferences (substituted judgment), not the surrogate’s preferences. When the patient’s wishes regarding donation remain unknown, the continuation of invasive support primarily for organ preservation raises a potential conflict with non-maleficence and may risk instrumentalizing the patient. In such cases, ethical justification requires careful scrutiny of whether ongoing treatment can still be aligned with a defensible interpretation of the patient’s values or best interests, rather than being driven by external considerations.

Importantly, the potential societal benefits of organ donation must never supersede the ethical obligation to prioritize the life and well-being of the individual patient. Under no circumstances should the development or promotion of a two-tier healthcare system be supported, in which some patients receive interventions primarily for organ donation rather than with the intent of recovery.

Equity and justice

Equity and justice are fundamental principles guiding both the implementation of ECPR and the integration of organ donation, particularly given geographic and socioeconomic disparities in access. In the United States, for example, only about 67% of the population resides within 45 min of an ECMO-capable centre, creating an uneven distribution that disproportionately affects rural, low-income, and minority communities [52, 53].

Such disparities create an ethical risk where a patient may receive lifesaving ECPR at one facility but be directed toward comfort-focused care at another lacking ECPR capability, effectively becoming a potential donor rather than a candidate for advanced resuscitation. Equitable regionalized systems of care, including transfer protocols and prehospital ECPR initiation, are crucial to ensure equitable access, modelled after established myocardial infarction and stroke systems.

Ethical considerations also extend to the allocation of scarce resources. In situations of limited ECMO capacity, a tension may arise between beneficence toward an individual patient maintained on extracorporeal support for potential organ donation and justice toward other patients with potentially reversible conditions who may benefit from ECPR [54, 55]. Here, beneficence toward the individual patient (or toward potential organ recipients) must be balanced against justice in the fair allocation of resources. Ethical practice requires that allocation decisions are not made ad hoc but are guided by transparent, prospectively defined criteria that prioritize likelihood of meaningful survival. The use of ECMO primarily for organ preservation should not supersede equitable access to ECPR for salvageable patients. In this setting, the principle of justice may ethically justify the withdrawal or non-escalation of support, if decisions are made independently of donation considerations and in accordance with established governance frameworks.

Another area of tension may arise when ECPR is initiated under presumed consent, but subsequent information from surrogates indicates that such invasive support would not have been desired (autonomy vs. beneficence). In these cases, the initial justification grounded in beneficence and emergency exception to consent may come into conflict with autonomy once patient preferences become known. Ethical practice requires prompt reassessment and, where appropriate, limitation or WLST, even if this precludes downstream opportunities for organ donation.

While the principles of autonomy, non-maleficence, beneficence, and justice provide a robust ethical foundation, their application in ECPR is not linear but requires context-sensitive balancing. Conflicts between principles are not exceptional but inherent to ECPR-to-donation transitions, particularly at the interface between resuscitative intent and organ preservation. Ethical decision-making in this setting therefore depends on the specification of principles within the clinical context and their proportional weighing, supported by structured governance processes, and interdisciplinary deliberation.

Operationalising the transition from rescue to organ preservation

Rationalising the transition from resuscitative intent to donation requires a structured and transparent approach guided by the fundamental principle of sequentiality. To maintain clinical credibility and safeguard ethical integrity, this sequentiality must be translated into an operationalised governance process that renders the transition visible, accountable, and institutionally enforceable [53, 56]. In the context of ECPR, specifying criteria, decision-making authority, documentation, and audit pathways ensures that the boundary between rescue and donation is not only conceptually clear but also institutionally protected.

The transition should be formalized as a clinical governance process that marks the termination of resuscitative intent and defines the earliest point at which organ donation candidacy may be considered, Fig. 1. This includes the explicit, time-stamped, and documented declaration of the transition point, along with the clinical rationale for terminating resuscitative intent, the criteria fulfilled, the names and roles of decision-makers, and a summary of the multidisciplinary discussion. Its legitimacy depends on procedural integrity rather than implicit clinical consensus, and the declaration of the transition point is anchored in predefined clinical and procedural criteria. These include (1) confirmation of an irreversible aetiology following appropriate diagnostic evaluation; (2) failure to achieve or maintain physiological stability despite optimized V-A ECMO support; (3) persistent absence of meaningful neurological recovery; (4) patient preferences; and (5) consensus that continued resuscitative efforts no longer serve the patient’s therapeutic interests. These criteria should be locally specified, formally agreed upon, and periodically reviewed.

Fig. 1.

Structured procedural sequence incorporating the transition point. The transition from rescue to organ preservation begins with an interdisciplinary case review (critical care team, nursing staff, and, when needed, ethics consultation), followed by a formal “time-out” to assess whether continued ECPR serves a therapeutic goal. Once consensus is achieved, the formal declaration of the Transition Point should document the date, time, and responsible team members. In cases of disagreement, predefined escalation pathways should be activated, including ethics consultation, senior or expert review, or temporary continuation with planned reassessment. Only after the Transition Point has been formally declared may organ donation pathways be considered and transplant coordination initiated. This sequence establishes a clear temporal and ethical boundary, ensuring that no preparatory actions for organ preservation occur before the transition. Any deviation from this process may require justification and subsequent review

The authority to declare the transition point should be clearly assigned and structurally separated from donation processes to protect against conflicts of interest and implicit bias [15]. The decision is led by the treating critical care team, with primary responsibility resting on the senior intensivist, and supported when needed by an ECMO specialist, neurologist, or another relevant expert. The involvement of a second independent physician to confirm that the transition criteria are met can further strengthen the robustness of the decision-making process. Members of organ donation teams must not participate in the declaration of the transition point, ensuring that decisions remain grounded in the patient’s best interests. The development of local protocols based on a structured procedural sequence that incorporates a clearly defined transition point can support the decision-making process.

To ensure the credibility of the proposed approach, institutional oversight and external scrutiny are essential. This may include the integration of transition point documentation into ECPR program audits or registries, periodic retrospective case reviews assessing timing, application of criteria, and role separation, as well as the identification of patterns suggestive of premature transition or inconsistent practice. These processes should be embedded within broader quality assurance systems. Although no set of criteria or procedures can fully eliminate prognostic uncertainty or moral tension, making the transition explicit, structured, and reviewable ensures that decisions remain traceable, contestable, and ethically grounded.

Finally, in cases of disagreement or further uncertainty, formal ethics consultation should be initiated, with escalation to the institutional ethics committee where appropriate, to ensure accountability and transparency throughout the process.

Ethical challenges in extracorporeal life support are not novel; however, ECPR introduces specific nuances in death determination and organ donation. Understanding ethical decision-making processes remains essential for navigating these challenges amid evolving therapies.

Healthcare professionals’ perspective

The viability of organ donation following ECPR is ultimately tested at the bedside, where clinicians navigate uncertainty, emotional strain, and relational complexity in real time. The reorientation in care goals is not a discrete shift but a prolonged, morally charged process [57]. Maintaining physiological support while awaiting death under controlled conditions is often described as a state of temporal suspension, marked by heightened vigilance, emotional restraint, and awareness of procedural expectations [58, 59]. The waiting period may be prolonged or may culminate in situations where death does not occur within the required timeframe for donation (organ viability window), leading to discontinuation of the donation pathway. Such outcomes may generate feelings of frustration, disappointment, or moral unease, with potential effects on professional well-being, team cohesion, and attitudes toward both ECPR and organ donation practices.

Nurses occupy a distinct and essential position in ECPR care. Their continuous presence at the bedside places them at the intersection of technical management, patient advocacy, and family support. Nursing staff may encounter specific forms of moral tension, including close engagement with families during emotional discussions, perceived discrepancies between stated goals of care and ongoing interventions, and limited involvement in formal decision-making despite high experiential proximity. These dynamics may contribute to feelings of marginalization when nursing perspectives are not actively incorporated into deliberative processes.

The ethical challenges are not confined to abstract principles or institutional policies; they are lived through the actions, perceptions, and emotions of clinicians at the bedside. By incorporating these dimensions, ethical models can better align with the realities they are intended to guide. In doing so, they move beyond prescribing what ought to be protected toward supporting how such protection can be sustained in practice, even in situations marked by ambiguity and strain.

The family-centred perspective in ECPR

The family-centred perspective emphasizes the critical role of communication and shared decision-making in highly time-sensitive and emotionally charged situations [60]. Cardiac arrest often occurs without prior discussion or advance care planning, leaving families or surrogates unprepared for the complexity and invasiveness of critical illness.

Unlike conventional cardiopulmonary resuscitation, where families are rarely involved in decisions regarding the cessation of resuscitation, discussions surrounding the discontinuation of ECMO frequently involve family members. While such involvement may offer some relatives a meaningful opportunity for presence at the end of life, it may also impose a substantial emotional burden and generate feelings of guilt. Adverse psychological outcomes, including symptoms of depression and anxiety, have been reported and are often associated with the severity of the patient’s condition and prolonged intensive care unit stay [16, 61].

Since ECMO may maintain physiological stability, patients can appear “unchanged” before and after death declaration, which can be confusing or distressing for families. Proactive communication that explains the patient’s condition, the goals of ECMO continuation, and the distinction between therapeutic intent and organ donation objectives is therefore essential. Practical strategies include describing expected physiologic changes, clarifying timelines, providing repeated opportunities for questions, and ensuring the presence of trained personnel to offer emotional support. Framing interventions and discussions relative to the patient’s values can help families understand that actions are guided by ethical principles rather than procedural imperatives [60, 62].

Moreover, transparent communication and ethically robust informed consent are essential for the morally acceptable integration of organ donation pathways [53, 59]. Families and surrogate decision-makers must understand the full spectrum of possible outcomes, including neurologically favourable survival, persistent impairment, death, and scenarios in which organ donation may become relevant. Ethical guidance emphasizes that withholding information about donation pathways may undermine autonomy, erode trust, and risk perceptions of ulterior motives, particularly in the rapidly evolving context of ECPR [11, 53].

Informed consent should address organ-preserving interventions that offer no clinical benefit to the patient, as these measures serve only potential recipients [59, 63, 64]. Consent should be viewed as a dynamic process, revisited as prognostic clarity emerges, supporting shared decision-making throughout the continuum from resuscitation to potential donation. Integrating family perspectives into ECPR protocols can foster a more humane and ethically coherent practice, ensuring that decisions reflect not only clinical judgment but also the values of those most affected.

Special considerations in paediatric populations

Organ donation in the paediatric population introduces additional ethical complexities beyond those encountered in adult practice. Children constitute a uniquely vulnerable population in whom decision-making capacity may be absent or severely limited; consequently, the ethical justification for interventions relies on surrogate consent, best-interest standards, and a heightened duty of protection. This vulnerability necessitates particularly stringent scrutiny of treatment intent, consent processes, and the permissibility of any donor-oriented interventions [59, 65–67]. Taken together, these considerations guide the adaptation of our overarching ethical approach, ensuring that its principles of patient-centred care, proportionality, and ethical rigor are applied appropriately in paediatric contexts.

The best-interests standard is a foundational legal and ethical principle guiding decision-making on behalf of children and requires that the child’s welfare be prioritized above all other considerations. Because children may lack legal decision-making capacity, clinical decisions must be governed by a strict best-interests framework. Any intervention whose primary aim is other than the child’s direct benefit, particularly in situations of medical futility, requires rigorous clinical and ethical justification, as well as clearly documented surrogate authorization [67, 68].

Surrogate decision-making under acute distress presents substantial ethical challenges. Parents and guardians are often approached in the immediate aftermath of catastrophic cardiac arrest, during periods of emotional distress and prognostic uncertainty. Consent processes should therefore be staged, compassionate, and clearly differentiated between consent for life-sustaining interventions (such as ECPR) and consent for non-therapeutic, organ-preserving measures. Where feasible, discussions regarding organ donation should occur after a transparent determination that continued therapy is futile and should be conducted by personnel with specific training in paediatric communication [65]. Institutional protocols should clearly delineate distinct personnel, documentation pathways, and appropriate timing for donation-related discussions [69, 70].

Prognostic uncertainty and the timing of decisions may differ substantially in paediatric patients. Outcomes and recovery trajectories following paediatric ECPR can diverge from those observed in adults and may be less predictable in certain clinical contexts. Decisions regarding WLST should therefore be grounded in a multidisciplinary prognostic assessment involving paediatric critical care, neurology, ECMO experts, and ethics or palliative care services [65, 66].

Technical and diagnostic challenges are particularly salient in paediatric ECPR, as ECMO complicates the DNC due to limitations of conventional monitoring. It also raises specific ethical and technical concerns regarding the use of NRP in children, including the risk of inadvertent cerebral reperfusion and scale-related challenges in smaller patients. Paediatric-specific protocols should address these issues, detailing monitoring strategies, vascular occlusion techniques, and imaging or oxygenation thresholds before NRP is considered [71, 72].

Finally, given the heightened social sensitivity surrounding paediatric organ donation, exceptional transparency is essential. Maintaining public trust requires that families never perceive organ donation as influencing clinical decision-making, necessitating strong institutional safeguards and rigorous ethical governance [66, 71, 73].

End-of-life care and ECPR

End-of-life care (EOL) in the context of ECPR requires particular attention to psychosocial, spiritual, and cultural dimensions of dying, extending beyond the ethical safeguards discussed in preceding sections. Medical futility plays a central role in guiding this transition, encompassing both physiologic futility, defined as the irreversible failure to restore circulation despite maximal support, and qualitative futility, defined as the inability to achieve therapeutic objectives or align with the patient’s goals (e.g., survival with an unacceptable quality of life) [74, 75]. Recognition of futility may trigger or inform EOL care—once an intervention is deemed futile, the focus shifts from attempting cure or life prolongation to prioritizing comfort, quality of life, and the patient’s expressed or presumed wishes.

Extracorporeal support may maintain physiological stability despite irreversible neurological injury, highlighting the importance of prognostic limitations and the timely transition to comfort-focused care. In this subsequent phase, EOL management should prioritize dignity, relief of suffering, and respect for the spiritual and cultural needs of patients and their families [55, 76–78]. Families confronted with sudden loss often experience profound emotional disorientation. Religious, cultural, or personally meaningful rituals can offer structure and significance, assisting families in integrating the patient’s death into a coherent narrative and maintaining a sense of agency [79, 80]. Ensuring access to chaplains, spiritual counsellors, or culturally appropriate mediators may mitigate existential distress and promote adaptive coping during the dying process.

Decisions regarding WLST should adhere strictly to established clinical standards for symptom control, privacy, and family presence [81]. When families experience the dying process as structured, compassionate, and ethically transparent, they are more likely to perceive organ donation as an authentic expression of the patient’s values rather than as a system-driven imperative [24, 59]. Ultimately, high-quality EOL care integrates clinical excellence with humanistic practice [58].

Practical and policy implications

Public trust and societal values

Public trust is essential for integrating ECPR-associated organ donation, as blurred boundaries risk eroding confidence in resuscitation and transplant systems [58]. Effective communication and alignment with prevailing societal values are therefore essential components of ethical and policy frameworks [53].

International variation in legal frameworks and public attitudes significantly shapes the implementation of organ donation following ECPR. Countries operating under presumed-consent (opt-out) organ donation systems (e.g., Spain, Italy, Austria, Czech Republic and Portugal) have more readily integrated ECPR with organ-preservation protocols, as donation is legally presumed unless explicitly refused. In contrast, opt-in systems (e.g., the United States and Australia) require explicit authorization for both donation and organ-preserving interventions, necessitating more complex consent processes and sustained family engagement [53]. However, some countries that are legally classified as opt-out may operate de facto as opt-in systems, because cultural norms, institutional practices, and family involvement in the decision-making process effectively require active authorization regardless of the legal framework. Public perceptions likewise vary across jurisdictions—societies with established organ donation cultures and mature DCD programs may demonstrate greater acceptance of ECPR-mediated donation, whereas populations with historical mistrust of institutions or religious objections to DNC may present substantial barriers, requiring context-specific and culturally sensitive communication strategies [71].

Institutional governance structures should therefore be adapted to local legal and ethical contexts, implementing robust ethical oversight mechanisms and transparent reporting practices [53]. Policies should uphold autonomy, treating donor interventions as optional to responsibly harness ECPR’s life- and organ-saving potential [59, 69]. By aligning communication strategies, governance frameworks, and institutional policies with societal values and legal norms, healthcare systems can strengthen public trust while responsibly realizing ECPR’s dual potential to save lives [58].

Real-world constraints and challenges

While the proposed approach is grounded in the core principles of biomedical ethics, its implementation occurs within complex clinical environments shaped by structural, organizational, and systemic pressures, which may challenge the preservation of intent.

In ECPR programs, the pressures within clinical environments shaped by competing demands, limited resources, and institutional priorities are not incidental; they are structurally embedded and can subtly, but significantly, influence decision-making. If unaddressed, they risk blurring the boundary between therapeutic intent and organ preservation [3, 59]. The credibility of any ethical model therefore depends on its capacity to anticipate, expose, and mitigate these pressures. The most important real-world constraints and challenges are presented in the Table 1.

Table 1.

Real-world constraints and challenges

Factor	Implications for ECPR-to-donation decision-making
Transplant logistics and time sensitivity	▪ Transplant logistics represent a major source of pressure, particularly given the time-sensitive nature of organ viability and allocation processes ▪ Coordination of retrieval teams, operating room availability, ischemic time, crossmatch, recipient readiness and allocation create strong temporal pressures
Variability in institutional culture and expertise	▪ ECPR programs differ in experience, case volume, and ethical climate ▪ High-volume centres may routinize rapid transitions, while lower-volume centres rely on informal judgment, influencing thresholds for futility
Workforce limitations and cognitive load	▪ Fatigue, high cognitive demands, and limited staffing may compress decision-making ▪ Competing clinical duties and restricted access to ethics consultation can blur the line between continuing treatment and preparing for cessation
Financial and resource considerations	▪ High costs and resource intensity of ECPR may compete with other critical care needs ▪ Organ donation may be associated with financial reimbursement or perceived resource justification ▪ Economic dimensions are rarely explicit but may subtly shape institutional and individual decisions
Reputational and programmatic incentives	▪ Outcomes, innovation, and transplant activity contribute to institutional prestige. These pressures may influence decisions to demonstrate program success in survival or organ utilization
Coordination complexity and momentum effects	▪ Multi-team, cross-department coordination generates system-level momentum ▪ Once processes begin, there might be an implicit pressure to continue toward donation, even if initial clinical assumptions remain uncertain

The operational constraints and challenges of ECPR are not aberrations but inherent features of contemporary practice. By integrating predefined criteria, the transition point, explicit documentation, and audit mechanisms, the proposed approach seeks to transform awareness of pressure into procedural protection. In doing so, it aims to preserve the primacy of resuscitative intent not only in principle, but in practice.

To mitigate institutional and cultural variability, standardized criteria for futility, structured communication protocols, and the use of predefined governance triggers are essential. Particular emphasis should be placed on addressing training gaps through targeted education and simulation-based training. Early integration of ethics consultation, with mechanisms ensuring 24/7 access to ethics support, provides an additional layer of oversight and accountability. Where resource limitations exist, the establishment of on-call ethics pathways or regional support systems may help ensure timely access. The use of checklist-based protocols may further support consistency and reduce cognitive and organizational bias in decision-making.

Finally, prospective audit, case review, and transparent reporting processes are important for identifying deviations, reinforcing accountability, and maintaining public trust. By incorporating these measures, alongside practical mitigation strategies, structural pressures can be buffered, and ethical principles can be translated into operationally resilient practices applicable across diverse clinical settings.

Ethical oversight, education, and interprofessional collaboration in ECPR programs

Integrating ethics consultation into ECPR programs may help mitigate moral distress, clarify expectations, and support consistent, high-quality communication. Approaches include embedding an ethics committee member in the ECMO team, offering consultations, establishing protocols mandating consultation for selected patients, and implementing institutional policies. Evidence indicates that such consultations highlight existing ethical concerns about life-sustaining therapies rather than introducing new challenges [82]. However, the role of the ethics committee is primarily advisory. While the treating team should carefully consider the committee’s recommendations, responsibility for the final decision rests with the treating clinicians.

Ethics education is essential for healthcare professionals involved in initiation and WLST decisions. Gaps in training and institutional policies contribute to variability in decision-making and increased moral distress [83]. The European Resuscitation Council emphasizes that ethical reasoning is not innate and should be integrated into resuscitation education and system-level policies. Specialized ethics and communication training also improve organ donation consent rates [83, 84]. Legal and ethical frameworks should not remain static but must continue to evolve with emerging research, supported by clear policies and international guidelines [59].

Conclusions

ECPR represents a transformative strategy in refractory cardiac arrest, yet its capacity to sustain circulation in the setting of devastating neurological injury introduces profound ethical complexity. When neurologically favourable survival becomes unlikely and organ donation emerges as a potential pathway, the transition from life-saving intent to organ preservation demands exceptional ethical clarity and restraint.

The structured ethical approach proposed here affirms the primacy of patient autonomy, the strict separation of resuscitative and donation-related decision-making, transparent prognostic assessment, and proportionality in the continuation of extracorporeal support. Robust safeguards are required to ensure that therapeutic intent remains unequivocally patient-centred and that the organ preservation never supersedes the best interests of the individual.

Embedding early ethics consultation, clear institutional policies, and structured communication processes within ECPR programmes is essential to sustain trust among families, clinicians, and society. Through careful governance and continual ethical reflection, ECPR can be practiced responsibly, preserving its life-saving promise while confronting, with honesty and humility, the difficult realities that arise when survival is no longer attainable.

Methods

This work was conducted on behalf of the EuroELSO ECPR Working Group, Focused Group on Ethics and Organ Donation. The group comprises a multidisciplinary, international panel of experts with an interest in the ethical dimensions of ECMO initiation, management, and withdrawal, EOL care, and organ donation. It brings together diverse professional backgrounds to support structured, inclusive, and ethically informed discussion on challenges surrounding ECPR and organ donation.

The development of this narrative review was informed by a literature search encompassing key concepts related to the ethical complexities of ECPR and organ donation in EOL care, WLST, perspectives of families and healthcare professionals, critical care management, DCD, and donation following DNC. We searched MEDLINE (via PubMed) and Scopus (Elsevier) database, and screened the reference lists of relevant studies, as well as grey literature and Google Scholar. The manuscript was developed through collaborative drafting of sections using online communication tools and meetings. The review was conducted in accordance with the SANRA (Scale for the Assessment of Narrative Review Articles) recommendations for quality assessment of narrative reviews [85].

Limitations

This work has several limitations. First, as a narrative review, it does not follow a systematic methodology for literature identification, selection, or appraisal, and therefore may be subject to selection bias and incomplete representation of the available evidence. Although efforts were made to incorporate relevant and contemporary literature, some pertinent studies may not have been included. Second, the proposed approach was developed through iterative expert discussions within the EuroELSO ECPR Working Group, Focused Group on Ethics and Organ Donation, rather than through a formal consensus process (e.g., Delphi methodology), which may limit reproducibility in how proposed frameworks were derived. Third, while the review integrates ethical principles, clinical expertise, and available literature, it reflects the perspectives of the contributing experts and may not capture the full range of stakeholder views. In particular, direct input from patients, ECPR survivors, donor families, or transplant candidates was not included, representing an important gap. Finally, the proposed approach has not been prospectively validated, and its applicability may vary across healthcare systems, legal frameworks, and cultural contexts. Further empirical research and stakeholder-informed studies are needed to evaluate and refine these concepts.

The statements contained in this work are intended for informational and educational purposes only and do not constitute medical advice or legally binding standards of care. While every effort has been made to ensure accuracy, the authors assume no liability for decisions made on the basis of its content. Responsibility for clinical decisions rests solely with the treating team.

Abbreviations

AHA

American Heart Association

DCD

Donation after Circulatory Death

DNC

Death by neurological criteria

ECMO

Extracorporeal membrane oxygenation

ECPR

Extracorporeal cardiopulmonary resuscitation

EOL

End-of-life

NRP

Normothermic regional perfusion

V-A ECMO

Veno-arterial extracorporeal membrane oxygenation

WLST

Withdrawal of life-sustaining therapy

Author contributions

Conceptualization: SR, EA, SMBH, MMM, AD, SW, RB, GP, JR, MM, MVA, JS, MB, JB; Formal analysis and investigation: SR, EA, SMBH, MMM, AD, SW, RB, GP, JR, MM, MVA, JS, MB, JB; Writing—original draft preparation: SR, EA, SMBH, MMM, AD, SW, RB, GP, JR, MM, MVA, JS, MB, JB; Writing—review and editing: SR, EA, SMBH, MMM, AD, SW, RB, GP, JR, MM, MVA, JS, MB, JB. The graphical elements of the graphical abstract were generated using large language models; the scientific content, structure, and wording were entirely determined by the authors.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Competing interests

EA: Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events: Speaker fees from Getinge. MB Consulting fees: Eurosets srl Italy; Sidam srl Italy; Thereson srl Italy. Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events: Eurosets srl Italy; Jafron China; Getinge spa Italy. Payment for expert testimony: Law court of Milan Italy; Law court of Genova Italy. Support for attending meetings and/or travel: EuroELSO. Patents planned, issued or pending: University of Pavia; Policlinico San Matteo, Pavia; Euroset Italy. Participation on a Data Safety Monitoring Board or Advisory Board: Eurosets srl. MMM: Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events: Gilead; Inari Medical All other authors declare no conflict of interest.