Organ donation in patients on extracorporeal membrane oxygenation: considerations for determination of death and withdrawal of life support

The use of extracorporeal membrane oxygenation (ECMO) is increasing globally, although mortality in this setting remains high. Patients on ECMO may be potential organ donors in the context of withdrawal of life-sustaining measures (WLSM) or neurologic determination of death (NDD). Nevertheless, there are currently no Canadian standards to guide clinicians on NDD or WLSM for the purposes of organ donation in this patient population. Apnea testing remains fundamental to determining NDD and is an area where ECMO may alter routine procedures. In this review, we outline protocols for the performance of apnea testing and WLSM for patients supported with ECMO, highlighting important technical and physiologic considerations that may affect the determination of death. In addition, we review important considerations for NDD in ECMO, including management of potential confounders, strategies for controlling oxygen and carbon dioxide levels during apnea testing, and the appropriate use of ancillary tests to support NDD. In the context of ECMO support, there is limited evidence to guide NDD and WLSM for the purposes of organ donation. Drawing upon extensive clinical experience, we provide protocols for these processes and review other important considerations in an effort to maximize donor potential in this growing patient population.