After reading the comment published in your journal1 on the decisions to be made after suffering an irreversible cardiopulmonary arrest (CPA) when it comes to the optimal duration of the resuscitation attempts,2 and where the possibility of donor asystole is discussed after conducting unsuccessful attempts of cardiopulmonary resuscitation (CPR) maneuvers, I would like to make a few comments in this regard.

We need to emphasize how important it is to extend the donor asystole programs as much as possible, even though I understand that this is not an easy task to do, and that it needs to be based not only on the characteristics of every cardiac arrest and victim, but also on the location and area where it occurs. The maintenance of resuscitation maneuvers by the emergency teams without an exact knowledge of the existence of an established donation program may lead to the unsuccessful continuation of such maneuvers, with the corresponding fatigue from the healthcare team, or wear and tear of the family's expectations on potential donors and receivers.

On the other hand, and as it has been published recently, if the aforementioned conditions are present, the prospective victim without survival possibilities should be identified as soon as possible, and then considered a potential donor. In this regard, Jabre et al.’s trial3 establishes three criteria in order to conduct early identifications. These criteria would require it to be a CPA unwitnessed by the emergency teams; initial non-shockable rhythm; and inability to recover spontaneous circulation before the administration of a third dose of adrenaline.

Yet despite all this, both in Europe and Spain there is an important variability in the ethical approach to both CPR and the decisions to be made to achieve resuscitation,4 and based on the ethical recommendations from the 2015 European Resuscitation Council, it may be necessary to identify very clearly the cases of refractory CPA that may benefit from prolonged interventions. The publications that discuss the recovery of victims of prolonged CPAs are not an exception, especially in cases such as hypothermia, or patients included in donor asystole programs, where the prolonged maintenance of CPR maneuvers led to an initially unexpected recovery.5 The advances made in CPR techniques may change previously established paradigms, which is why we should remain cautious and not establish any strict recommendations for all cases and situations, since it seems evident that in many situations, the healthcare providers make decisions not based on validated criteria, but on intuitions and perceptions of the victim's possibilities of recovery or potential donation.