The Use of Normothermic Regional Perfusion Increases The Burden of Organ Donation After Euthanasia

Post-mortem introduction of normothermic regional perfusion (NRP) is increasingly used in organ donation. In this procedure, after declaration of death according to circulatory-criteria and "no touch" time of 5 minutes, organ donors’ circulation is restored by extracorporeal membrane oxygenation (ECMO). Before restoring circulation during NRP, surgeons block arteries perfusing brain to avoid regaining of brain functions. The mechanics and set-up of NRP may difficult understand for patients and medical professionals alike. In addition, restoration of circulation puts permanence of circulatory death into question, especially in the context where blocking of arteries perfusing brain after death is already declared is considered necessary. An outsized role that autonomy and consent play for a growing number of euthanasia patients considering organ donation exacerbates these already significant issues. A planned nature of euthanasia donors’ death invites numerous perimortem interventions to optimize organ quality, with NRP joining an already long list of premortal donor interventions. The growing burden of donation in euthanasia patients increases the odds that patients and their families do not fully understand this process, and raises significant ethical and potentially legal questions

Airborne spread of SARS-CoV-2 – a commentary by the Division of Internal Medicine, University Medical Centre Ljubljana

Slovenia is one of the countries that have been most affected by the autumn/winter 2020/21 wave of the COVID-19 pandemic regarding the incidence and excess mortality among the general population as well as regarding the incidence among health care workers and nursing personnel. The World Health Organization has underestimated the importance of the airborne spread of SARS-CoV-2 and the recommended safety measures have not been entirely sufficient. When people breathe, talk, sing, cough, or sneeze, they emit respiratory droplets of various sizes, most of which are always smaller than 1 μm. Respiratory droplets smaller than 5 μm stay airborne in indoor spaces for a long time and travel over distances much longer than 2 m. Thus, an infected person in an indoor environment creates an infectious aerosol that may infect other people without close interpersonal contact. This short review presents the mathematical model and internet application by authors from the Massachusetts Institute of Technology for calculating the safe time before probable airborne infection occurs in indoor spaces. The importance of ventilation, air filtration, air humidity, and air disinfection by ultraviolet light is briefly discussed. The principles of preventing the airborne spread of SARS-CoV-2 are summarized

Organ donation: a hidden factor in support for euthanasia

The role of organ transplantation in expanding euthanasia legislation has often been underappreciated. While popular and ethical discussion regarding legalization often focus on the issues of autonomy, right to die and dignity, an interest for euthanasia among medical professionals and decision-makers may be driven by more pecuniary and practical considerations. This is especially true for the transplant community which prioritizes quick harvesting of organs from euthanasia patients while barely engaging with the ethical issues and their own incentives regarding euthanasia. Thus, following a recent legalization of euthanasia in Quebec the most pressing concern expressed among professionals engaged in transplantation appears to have been the ways to swiftly proceed with organ harvesting without hurting family. (Achille M. Using Canadian code of ethics for psychologists to determine acceptability of organ donation following medical assistance to die. In: Massey et al, eds. Ethical, legal and psychosocial aspects of transplantation. Global challenges. Pabst Science Publishers, Lengerics 2017; 113-122 ) Similarly, a discussion at a recent ELPAT congress in Rome 2016 was focused mainly on logistics of harvesting organs from euthanasia patients without acknowledgment of the role that incentive to obtain organs might play in their own attitudes toward euthanasia. As discussed elsewhere transplant community has been myopically focused on increasing the supply of organs, recently suggesting abandonment of such long standing postulates as dead donor rule (Nair-Collins M, JME 2014), and embracing ever widening indications for euthanasia (e.g. mental disorders, Alzheimer disease), all while often ignoring numerous promising alternatives to transplantation such as regenerative medicine, artificial and bioartificial organs. Recently, organ donation euthanasia procedure was suggested, consisting in euthanasing the candidate, remove all organs from the person while he is still alive, with heart removal concluding the procedure (Wilkinson, Savulescu, Bioethics 26: 1: 32-48). None of this is necessary. Slovenian ethics committee in 2012 has declared against the use or organs from donors killed by euthanasia. Slovenian model of organ transplantation is a living proof that an adequate transplantation program can be sustained without resorting to ethically controversial practices

Organ Harvesting From Donor Killed By Euthanasia May Undermine Public Trust In Transplantation

Ethical controversies in transplantation are mainly the consequence of organ shortage. Organ trading and use of organs from executed prisoners are condemned by transplant community. However, in align with euthanasia legalization and expansion, there is a growing interest in another controversial issue, organ harvesting from donors killed by euthanasia. Eurotransplant has embraced use of organs from euthanasia donors more than a decade ago. In 2012 ethicists from Oxford has proposed a step further compared to Eurotransplant approach: instead of first killing the patient by euthanasia, declare death and then harvest the organs, they have suggested to put euthanasia candidate into general anesthesia, start organ harvesting while the patient is still alive, harvest the heart as the last organ and actually perform euthanasia by harvesting the heart. Such approach requires abandonment of a long-standing principles of transplantation ͞dead-donor rule͟ meaning that the person should be declared dead before vital organ is removed. Calls for abandoning dead-donor rule are fully mainstreamed with a recent article in New England Journal of Medicine arguing that number and quality of organs will be maximized if harvesting begins while the donor is still alive (Ball IM et al, NEJM September 6,2018 ) and implying that suicidal thoughts about being more valuable dead than alive should be encouraged rather than treated. At the same time, criteria for euthanasia is becoming ever more lax and more expansive. While initially advertised as a procedure for the sickest of the sick, euthanasia is now available to psychiatric patients, disabled and children. It was reported that a significant number of euthanasia procedure in Belgium is performed without signed consent (Smets T et al, BMJ October 5, 2010). In short, euthanasia may rapidly become a tool for getting rid of the weak, confused and expensive. Transplant community should not ignore alternatives like regenerative medicine, artificial organs, xenotransplantation and prevention of end-stage organ failure. Slovenian ethics committee in 2012 has declared against the use or organs from euthanasia donors. Slovenian model of transplantation, assuring enough organs from brain dead donors with acceptable waiting time, focused on quality and long-term survival is a proof that transplantation program can be sustained without resorting to ethically controversial practices. Harvesting organs from euthanasia donors and abandoning dead-donor rule will not solve the problem of organ shortage and may open Pandora's box

Razširjenost Covid-19 med zdravstvenim osebjem Univerzitetnega kliničnega centra Ljubljana do zaključka leta 2020 in koncentracija CO₂ v zraku bolniških sob, prezračevanih skozi okna, v letu 2021/22

In autumn and winter 2020/21 and again in 2021/22 Slovenia has ranked among countries with the highest incidence of COVID-19 per million inhabitants and high excess mortality over the average of previous years. Many patients on non-COVID-19 hospital wards were in fact infected by SARS-CoV-2. Health care personnel at the University Medical Centre Ljubljana (UMCL) were falling ill by Covid-19 in large numbers despite wearing surgical masks and eye protection when dealing with patients. We compared the prevalence of COVID-19 among health care personnel of the Division of Internal Medicine, UMCL by the end of December 2020 with the national average of Slovenia. After instructions had been issued to increase room ventilation by opening windows every hour for at least 10 minutes, ambient air CO₂ was measured in an intensive care room and in an outpatient clinic room during a 10-month period, from April 2021 to February 2022. The prevalence of COVID-19 by the end of December 2020 was 42 % among nurses, 21 % among registered nurses and 17 % among medical doctors, whereas the national of average of the population was significantly lower at 5.5 %. Between April 2021 and February 2022, the average CO₂ (ppm) in the intensive care was 633 (standard deviation 198, range 376 – 1540), while in the outpatient clinic the average was 552 (standard deviation 199, range 380 - 1910). During 2020, before the instructions for the use of personal protective equipment were up-graded and before regular window-opening was advised, the prevalence of Covid-19 among health care personnel at the Division of Internal medicine, UMCL exceeded the national average by 3- to 8-fold. After regular window-opening was advised, the peak CO₂ levels still often exceeded the recommended “safe” level of 750 ppm

Outcome expectations for exercise and decisional balance questionnaires predict adherence and efficacy of exercise programs in dialysis patients

The purpose of this study was to define if Outcomes Expectations for Exercise (OEE) and Decisional Balance (DB) scales predict adherence to guided exercise programs and associate with the improvement in physical performance in the dialysis population. Participants (n = 40age 63.6 ± 12.5 years) completed OEE and DB questionnaires before randomization to the experimental group (n = 20) and control group (n = 20) of a two-phased exercise program—the experimental group received eight weeks of supervised functional exercise and exercise counseling (1st phase) before commencing eight weeks of home-based exercise on non-dialysis days (2nd phase). Both groups performed intradialytic cycling on dialysis days during both study phases. Patients with above-median OEE and DB scores (>3.15 and >1.3, respectively) expressed significantly better adherence to intradialytic cycling (89% vs. 76%, 89% vs. 77%, respectively, p < 0.05). Experimental group patients with an above-median OEE (but not DB) score had significantly better adherence to supervised and home-based functional exercise (93% vs. 81% and 85% vs. 60%, respectively, p < 0.05). Baseline DB score predicted the final result in the hand-grip test and 6-min walk test. Low OEE and, to a lesser degree, low DB questionnaire scores associate with inferior adherence to dialysis bundled and home-based exercise programs and may help define patient subsets in need of intensified motivational input by exercise caregivers