Reply to: Organ donation after ECPR: ethical challenges and clinical implications

Dear Editor,

We thank Moya Sánchez and colleagues for their comments on our review addressing the ethical challenges and clinical implications of organ donation following extracorporeal cardiopulmonary resuscitation (ECPR) [1]. Their perspective from protocol-driven donation after circulatory determination of death (DCDD) and normothermic regional perfusion (NRP) programs provides valuable clinical context and an opportunity to further refine our proposed framework [2].

Structural risks and clinical independence

We acknowledge that our discussion of pressure, implicit bias, conflicts of interest, and instrumentalization require careful contextualization. These concerns relate to foreseeable structural risks at the intersection of resuscitation, end-of-life care, resource allocation, and organ donation, rather than the conduct of individual clinicians, donation coordinators, or programmes. Our proposed safeguards aim to protect patient-centred decision-making [1]. Those described by Moya Sánchez et al. in established DCDD programs reflect the same underlying principle: potential conflicts should be anticipated and mitigated through governance, transparency, and institutional oversight [2].

Urgency should not be conflated with undue influence. Time-sensitive logistics are intrinsic to transplantation and critical care, but must neither determine nor alter the independent clinical assessment of whether continued extracorporeal support remains in the patient’s interests. Donation coordinators support legal compliance, traceability, communication, family support, and procedural separation [2], consistent with our proposed governance model.

The Spanish practice described in Moya Sánchez et al. letter illustrates this separation: an independent, documented decision to withhold or withdraw life-sustaining treatment precedes activation of the donation pathway. Coordinators do not participate in prognostic assessment or treatment-withdrawal decisions; they subsequently facilitate donation and exploration of the patient’s wishes and values. This demonstrates how clinical independence and respect for a patient’s opportunity to donate can coexist within the same care pathway [2].

The dead donor rule

We appreciate the authors’ observations regarding our interpretation of the dead donor rule (DDR). Our review considered the DDR within the broader ethical context of donation-oriented interventions, but the rule itself should be distinguished from the additional ethical requirements governing interventions before death.

The DDR requires that donors be determined dead before vital organs are recovered and that procurement must not cause death [3–5]. It does not prohibit all ante-mortem interventions intended to facilitate donation. These require separate ethical justification, including appropriate authorization or informed consent, assessment of benefits and harms, and protection of end-of-life care [4–6]. Ante-mortem interventions should therefore be distinguished from organ procurement when interpreting the DDR [2].

The Bucharest International European Society for Organ Transplantation (ESOT) consensus on controlled DCDD (cDCDD) recognises that some ante-mortem measures may enable donation, including continued cardiorespiratory support during logistical arrangements and blood sampling for screening and tissue typing. Where lawful and clinically appropriate, their permissibility depends on proportionality, patient and family preferences, and preservation of end-of-life care [7]. A narrower interpretation of the DDR does not remove these requirements or the need for independent treatment-withdrawal decisions.

Our proposed Transition Point is conceptually distinct from, and does not extend, the DDR. It establishes a documented, reviewable boundary between treatment directed towards recovery and subsequent donation considerations. Donation-oriented decision-making becomes operationally relevant only after the treating team independently concludes that continued ECPR no longer serves the patient’s therapeutic interests [1]. The safeguards are therefore complementary: the DDR governs the relationship between death and organ procurement, while the Transition Point protects the independence of treatment decisions.

Communication and the Spanish DCDD practice

Communication should follow a clear sequence. Families should first understand the clinical situation, prognosis, and independently reached treatment-limitation decision before trained professionals discuss donation. Once that decision is understood, withholding information about donation may prevent families from acting in accordance with the patient’s wishes and values [2].

Spanish practice also illustrates the distinction between statutory consent frameworks and clinical implementation. Despite Spain’s opt-out framework, Moya Sánchez et al. emphasize that relatives help establish the patient’s wishes and that donation and premortem interventions require explicit written authorization from the family or legal representative [2]. “Opt-in” and “opt-out” classifications alone therefore cannot fully capture the ethical and communicative processes within donation systems.

NRP: evidence and procedural safeguards

We welcome the evidence highlighted by Moya Sánchez et al. on cerebral perfusion during thoraco-abdominal NRP (TA-NRP) [2]. These findings provide reassurance and shift the focus towards standardising, objectively verifying, and auditing cerebral exclusion, which remains essential to the permanence principle and validity of death determination [1].

The ESOT Bucharest consensus similarly advocates effective techniques to maintain cessation of cerebral perfusion and a contingency plan to discontinue TA-NRP if cerebral blood flow or signs of cerebral activity are detected [8]. Continued protocol standardisation, independent replication, verification, and transparent audit remain important to demonstrate compliance with the permanence principle and the DDR.

Moral distress and the role of donation programs

Moral distress may arise from neurological injury, prognostic uncertainty, prolonged support, and end-of-life decisions during ECPR, rather than donation alone. Experienced donation coordinators may alleviate this burden by supporting clinicians and families [2]. Our discussion concerns the additional ethical complexity of transitioning from recovery-directed treatment to donation. Separate decision-making roles, interdisciplinary deliberation, documentation, and ethics support can help preserve patient-centred care.

Conclusion

We welcome of Moya Sánchez et al.´s contribution, which provides valuable clinical context for our framework. The DDR governs the relationship between death and procurement; the Transition Point protects the independence and sequence of treatment and donation decisions. ECPR must be initiated for the patient’s potential benefit, and treatment-limitation decisions must remain independent of donation considerations.

The central principle remains that ECPR must be initiated for the patient’s potential benefit and that any treatment-limitation decisions must remain independent of donation considerations. When this sequence is respected and appropriately safeguarded, organ donation can honour the patient’s wishes and values while preserving the integrity of end-of-life care.

Abbreviations

eCPR

extracorporeal cardiopulmonary resuscitation

DCDD

Donation after circulatory determination of death

DDR

Dead donor rule

NRP

Normothermic regional perfusion

ESOT

European Society for Organ Transplantation (ESOT)

cDCDD

controlled donation after circulatory determination of death

Author contributions

Conceptualisation, R.B. and S.R.; Investigation, R.B. and S.R.; Project administration, S.R.; Supervision, S.R. and R.B.; Writing—original draft, R.B. and S.R.; Writing—review and editing, S.R., E.A., S.M.B.H., M.M.M., A.D., M.V.A., J.R., R.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.