In order to detect the ethical problems innate to DCD, the author conducted a narrative review of the literature in PubMed. Search terms were “donation cardiac death ethics” and snowballing was used as an ancillary search strategy. PubMed was searched on November 26th, 2011, from inception. The literature review revealed six recurring ethical challenges that arise in cDCD, see Table 28.2. The challenges do not appear in any particular order and are explored in detail in the subchapter “Relationship between ethical challenges and research questions”.

As explained above, our study aims at illustrating the Zurich experiences with the first four of the six ethical challenges that were identified in the literature review and described in Table 28.2. The relationship between the ethical challenges and the research questions in the study of DCD donor families is identified in this chapter:

The procedures for cDCD differ greatly from the procedures inherent to DBD. DBD is the more common form of donation. It is important that donors or, in case of their inability to consent, their surrogate decision makers understand what they are consenting to (1st challenge). For this reason, the new Swiss Donor Card comes with an information brochure that explains the difference between a DCD and a DBD donor and the major differences in the donation processes in simple terms. However, if someone filled in an old version of the donor card, it cannot be assumed that they knew about DCD donation. In order to ensure that donors participating in DCD and their families are well-informed, every donor or, where applicable, every surrogate decision maker, regardless of how old the donor card is, should be thoroughly informed about the donation process. This should be done until knowledge about DCD is common enough for transplant requestors to be able to safely assume that donors who signed a donor card were aware of what DCD donation means. Thus, donor autonomy may be respected. Our study aims at illustrating whether donor families felt they had enough information about the donation process. Also, next-of-kins’ narrations give us insight into whether they were aware of the donor’s donation form and whether they understood the need for certain DCD-specific practices, such as the reason for urgency after the advent of cardiac arrest. Our findings show that DCD donor families were not specifically aware (except in one case) that their loved one had donated after cardiac death. It is unclear whether this is because they were not informed, or the information was too complex, or they were unable to retain the information due to the massive stress they were in, or because they did not find the distinction important.

A commonly shared fear in the general population is that of being declared dead too soon if one is in possession of a donor card (Hessing and Elffers 1986) (2nd challenge). The danger of warm ischemia mainly exists in DCD donors, so that time is a much more important factor in these donors than in DBD donors. The organs of a DCD donor become unusable for donation if asystole does not occur quickly enough after extubation. In such cases, physicians have to take care not to feel pressured to hasten the donor’s death in order to ensure that donation can take place (2nd challenge). One way to prevent conflicts of interest is to separate health care providers caring for the donor from those caring for the recipient, and to completely separate the decision to end life-sustaining therapy from the decision to donate. In our study, we ask about the latter separation and whether the family members think that the concern about donor care being compromised for the good of the recipient is realistic. We found that the donor families in general had a very high level of trust in the health care system in general and the doctors specifically.