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A donor after cardiac death (DCD) is a donor who has suffered devastating and irreversible brain injury and may be near death, but does not meet formal brain death criteria. In these cases, the family has decided to withdraw care. When the patient's heart stops beating, the organs are then recovered in the operating room. The surgeons involved in transplantation cannot be part of the end-of-life care or in the declaration of death. This type of donation does not cause or hasten death. Organs recovered from a donor after cardiac death have some degree of oxygen deprivation during the time after the heart stops beating. This may make kidneys from this type of donor "slow to start".
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ore than 250,000 people in the U.S. are currently at the end stages of heart failure, up to 15% of whom are in desperate need of a transplant. A new method of “reanimating” donor hearts from those who have died from cardiac failure is currently being tested in the U.S., and may soon ease that burden.
As part of the new procedure, known as “donation after cardiac death,” or DCD, transplants, organs are retrieved from those who have died because their heart stopped — either naturally or because physicians discontinued life support. That work is made possible by a machine that allows the heart to not only be perfused with warm blood after it has been removed from the donor, keeping the heart functional and “alive” enough to be transported and transplanted several hours after retrieval, but also allows surgeons to assess the heart’s functionality in a way that wasn’t previously possible.
Last month, a team at Duke University was the first in the U.S. to perform the procedure in an adult as part of a multicenter clinical trial. And just last week, Massachusetts General Hospital in Boston and the University of Wisconsin in Madison, which are also a part of the trial, reported their first such transplant.
“There’s a tremendous disconnect between people who need a transplant, and the number who actually get it,” said Dr. Jacob Schroder, a thoracic and cardiovascular surgeon who is a part of Duke’s DCD heart transplant team. “[DCD heart transplants] will expand the donor pool by 30%, or 3,400.”
“If proven successful and safe through this study, transplanting DCD hearts on a wider basis would be another great tool in our arsenal to utilize more organs and increase the number of lives saved through transplantation,” said Dr. David Klassen, chief medical officer of the United Network for Organ Sharing, the nonprofit that manages organ transplantation in the U.S.
Ten such heart transplants have already been performed among the three centers in the past month since the trial was initiated. Three other research centers — Vanderbilt, Stanford University, and Emory University — will soon be joining the trial, which is scheduled to run until 2021. In all, 15 sites across the U.S. will be involved.
“If done correctly, a DCD donor heart may outperform a brain dead donor heart [because] the effects of prolonged brain death on the heart is quite jarring,” said Dr. Mandeep Mehra, an advanced cardiovascular specialist at Brigham and Women’s Hospital in Boston, who is not involved in the trial. “This is a necessary addition to our armamentarium for organ donor recovery.”
For years, DCD transplants in U.S. adults have been done with other organs, including the lungs, kidney, and liver. And the very first heart transplant in 1967 could very well have been a DCD transplant, Mehra pointed out, because there was no legal definition of brain death at the time. And at least one team in Colorado has performed a small number of DCD heart transplants in pediatric patients in the U.S., according to Mehra.
But in recent years, and for adults, the heart has been a major exception for DCD transplants because its inability to pump oxygenated blood after death has meant a higher risk for damage, in which heart tissue begins to die or otherwise deteriorate. Traditional cold storage has also not allowed physicians to assess the heart’s function for any signs of damage, since a heart that is injured is less likely to help a prospective transplant recipient. As the need for heart transplants has risen, physicians have looked for ways to overcome the barriers to using DCD hearts.
Other countries, including the U.K. and Australia, have been performing DCD heart transplants for several years now. The procedure was first performed by a group in Sydney’s St. Vincent’s Hospital in July 2014. The Royal Papworth Hospital in the U.K. followed soon after in February 2015. There have been over 100 DCD heart transplants combined at the two locations.
Five of the six hospitals that do heart transplants in the U.K. have used the DCD method, according to Dr. Pedro Catarino, who is part of the DCD heart transplant team at Royal Papworth Hospital. He added that in the next six months, the U.K. will have a national retrieval system for DCD hearts. In contrast, physicians in Australia can perform the procedure, but it’s not covered by the government, said Dr. Kumud Dhital, who performed the first DCD transplant and who is now director of cardiothoracic surgery and transplantation at the Alfred Hospital in Melbourne. Transplants there have thus far have been paid for by philanthropic donations.
“With the Organ Care System, time is no longer a limitation,” said Dr. Waleed Hassanein, CEO of TransMedics. “The OCS is always supplied with oxygenated blood and we’ve transplanted organs 21 hours after [they have been placed in the machine],” a feat that he said is not possible with traditional cold storage used to preserve organs. The system has been used for nearly 170 DCD heart transplants worldwide, Hassanein said.
The time it takes to remove the organ from the body, before it’s placed in the TransMedics machine, can be a limiting factor, as is this is the time that can lead to the most injury to the heart. “The longest we have heard of is 40-45 minutes, but we usually expect that time to be around 30 minutes,” Hassanein said. “Even with that limit of 30-45 minutes, you can triple or quadruple the number of heart transplants,” he added.
Importantly, the organ care system also allows transplant surgeons to measure the function of the heart before they transplant it to a recipient, allowing them to assess the organ’s viability. The system “replenishes the energy stores and you can see the heart beating,” Catarino said. “It’s not doing work, but you can measure the heart’s metabolic consumption, if it’s stressed or had coronary artery disease.”
The procedure does have risks, including that some patients need to be connected to an external machine that pumps oxygenated blood to the body until the heart recovers its full function. But Hassanein said the company hasn’t heard of risks other than what’s expected with regular transplants, like organ rejection and death.
“Organ transplantation is the most cost-effective treatment for end-stage disease,” Hassanein said. “The DCD heart trial is a big deal and it’s very exciting for the field. It could make heart transplantation more of a reality for all those patients who are on the waiting list.”
Good article BUT it is most unfortunately that the wrong terminology was used i.e. donation after CARDIAC death. The heart may have stopped in these donors but the heart is not dead. It is the donor who is dead as a result of the brain circulation having stopped for long enough to cause permanent loss of brain function.
These potential donors are already in a coma due to pre-existing severe brain injury and have no chance of survival. Artificial life-supporting therapy only prolongs suffering and delays the inevitable. Withdrawing this treatment and allowing them die is an act of kindness, complies with ethical principles and is in the best interest of the patient. That is what donation after circulatory death is about.
we know CPR can reactivate a heart that stopped yet some patients never become responsive . so I am thinking this machine works like CPR.. Therefore if there is no damage to the heart the heart becomes available to a donor this is most likely why the machine cannot be used to keep the patient alive as it only works on the heart and patients suffer from lack of brain waves leadi g to brain death right ? Who would be a candidate for this procedure is it strict guidelines on qualifying for the procedure ? when does USA expect to be able to have this approved through FDA? This is another majot break through for those with heart disease .. God Bless all the doctors worki g so hard to improve and extend life for so many ..
Because once cardiac death occurs in a patient, the blood supply to his brain stops ultimately leading to death, as brain cells(neurons) can’t be repaired they die. But with this technique the heart is kept alive so it can be if use to someone else !
The lifesaving benefits of organ donation and transplantation are widely known and accepted. What many don’t realize is how critical and complex the time frame for transplanting organs from donor to recipient can be. If you’re wondering how long organs are viable after death, the short answer is – it depends.
Thanks to advances in medical technology, recovered organs can be transported hundreds, or even thousands of miles to give the gift of life to recipients in need. However, each organ is different, so the UNOS allocation criteria is unique to account for the medical complexity of each organ. For example, thoracic organs like the heart and lungs, can only remain viable for transplant after being outside of the body for four to six hours, while the liver can function for up to 12 hours and kidneys up to 36 hours. Therefore, the location of the donor and the potential recipient is more critical for matching hearts and lungs than it is for kidneys or livers.
In addition to medical urgency, blood type and other biological factors, those waiting for a heart transplant are also matched based on location because of the critical timing for this organ. The heart is only viable for 4-6 hours. Body size is also significant in heart matching, as the donor’s heart must fit comfortably inside the recipient’s ribcage.
Similar to heart matching, location and body size are also important considerations in lung allocation, since the lungs are viable for 4-6 hours after donation. That information is combined with the criteria listed above to determine a donor recipient.
Candidates who need a liver transplant are assigned a MELD or PELD score (Model for End-Stage Liver Disease or Pediatric End-Stage Liver Disease) that indicates how urgently they need the organ. A donor liver is offered first to the candidate who matches on the common matching criteria and has the highest MELD or PELD score. Location is also taken into consideration, but since the liver can function for a longer time (8-12 hours) outside of the body, it is able to travel farther than the heart and lungs.
Kidney allocation is heavily influenced by waiting time, or how long the recipient has been listed for transplant. Fortunately there is a bridge treatment for many in end-stage renal disease, called dialysis, which allows candidates to survive while awaiting a transplant. In addition, blood type and other biological factors, as well as body size of the donor and recipient are always key factors. Medical urgency and location are also factors but less so than other organs as they kidney can remain viable outside the body for 24-36 hours under the proper conditions.
The waiting list is not simply a list of people who are eligible for transplant. It’s a dynamic, complex algorithm based on carefully developed policy that ensures scarce organs are allocated to recipients as fairly and accurately as possible within highly constricted time frames. Learn more about the waiting list and how patients are added here.
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With the advent of organ transplantation, patients suffering from end-stage organ failure no longer face inevitable death or a lifetime of complex medical care and those receiving a transplanted organ can often return to a normal lifestyle. As a result of this success, coupled with an ageing population, there are increasing numbers of patients seeking organ transplantation.1 However, the advances in transplant medicine have brought about a demand which has outstripped the availability of organs. There are currently around 8000 people listed as waiting for an organ transplant in the UK but less than half that number received a transplant last year. Current trends show that as demand for organ transplants increases, the actual numbers of organs available have decreased. Additional measures are necessary to meet this deficit. One such measure is donation after circulatory death (DCD) and this article will explore some of the associated practical challenges.
DCD can be considered in a patient who does not fulfil brain death criteria but has no hope of recovery, and it is in the best interest of the patient to withdraw life-sustaining treatment. Initially, all retrieved organs came from DCD donors. However, after the recognition of brain stem death, there was a preference for retrieving organs from heart-beating donors (or donation after brain death/DBD) to minimize organ hypoxia.2 During DBD organ retrieval, the organ continues to be perfused as cardiac output is maintained. Potential DBD donors are in unresponsive apnoeic coma resulting from an identifiable irreversible cause. Before organ retrieval, the patient must have been declared dead after brain stem testing by at least two independent clinicians.
The main difference between DCD and DBD organs is the duration of warm ischaemia. Warm ischaemia commences when there is inadequate oxygenation or perfusion of the organ as defined by an SAP <50 mm Hg, oxygen saturation <70%, or both such as during withdrawal of treatment or cardiac standstill. The period of warm ischaemia continues until the initiation of cold perfusion. Cold ischaemic time extends from initiation of cold preservation until restoration of warm circulation after transplantation. Cold perfusion will slow down tissue metabolism, resulting in a reduction in the rate of ischaemic injury. During DBD, organs undergo cold perfusion before organ retrieval and thus warm ischaemia is minimal. However, DCD by definition will incur some degree of warm ischaemia as there will be an interval after asystole where organs are not being perfused and have not yet been cooled. As a result, organs from DCD donors have the potential to develop irreversible damage due to the accumulation of ischaemic metabolites.
The number of patients fulfilling brain stem death criteria has decreased in recent years. This is because fewer young people are dying as a result of severe injury or catastrophic cerebrovascular events and advances in the treatment of traumatic brain injury and intracranial haemorrhage have led to improvement in outcome.3 With the number of DBD donors declining, there has been renewed interest and an increased drive for referring DCD donors to reduce the current organ shortfall. Currently, DCD makes up ∼35% of all deceased donors. This is increasing on an annual basis thanks to the increased drive for all organ donation.
Consideration of DCD should be given to all patients in whom life-sustaining therapy is being withdrawn and whose death is expected to be imminent. The decision to withdraw life-sustaining treatment should be made independently of any decision to donate organs or tissue.4
Uncontrolled DCD, although uncommon, is worth considering, provided strict protocols are instituted to minimize warm ischaemic time. For Category I, patients to be considered death would need to have been witnessed and the time documented and also any pre-admission resuscitation. Category II patients in whom resuscitation has been attempted require additional information about the duration and efficiency of resuscitation to be known. For these uncontrolled DCDs, the transplant co-ordinator and surgical retrieval team need to attend promptly which may not be feasible for most units.
Organs from DCD considered suitable for transplantation include the kidneys, liver, pancreas, lung, and tissue (cornea, bone, skin, and heart valves). Kidneys are the largest group of transplanted DCD organs and although may be slow to function, the 10 yr success rate may be the same as kidneys from DBD donors. However, this delay in function leads to increased morbidity in the recipient with prolonged length of post-transplant dialysis and extended duration of postoperative stay which contributes to the higher cost of DCD donor kidney transplants.
The organ shortage for patients suffering end-stage liver disease is a serious problem, given the lack of efficacious alternatives. At present, only donors who have minimal warm ischaemic time can be used for liver transplantation. Compared with DBD, there is a higher incidence of primary non-function of transplanted livers and also poorer 1 and 3 yr graft survival. Currently, DCD makes a modest but rising contribution to the donor pool.
The lung may be the ideal organ for DCD because unlike other solid organs, it tolerates the absence of a circulation, provided the lungs remain inflated with oxygen. At present, lung transplantation from DCD is in its infancy but has been associated with good outcomes.
Either the whole pancreas (often in combination with a renal transplant) or islet cells alone can be used. For combined pancreas–kidney transplant, there is no difference in outcome between those retrieved from DCD and DBD donors.
Contraindications include a history of previous thoracic surgery (not cardiac surgery or thoracocentesis) or empyema, and lung disease (chronic obstructive pulmonary disease, pulmonary embolism, or asthma requiring systemic steroids).
All potential donors should be discussed with the local transplant co-ordinator at the earliest opportunity. The transplant co-ordinator is able to confirm whether or not the patient is on the UK Organ Donor Register and advise as to their suitability. After referral, the transplant co-ordinator will attend the donor unit to undertake donor assessment and instigate appropriate investigations.4
In cases where there is any doubt as to the cause of death or suspicion as to the nature of death, then the case requires to be discussed with the Coroner (or the Procurator Fiscal in Scotland) to ensure that they have no objections to donation proceeding. In these cases, organ donation can often proceed with steps taken to preserve potential evidence. Given that only good-quality organs are deemed suitable for transplantation, any organ connected to the cause of death is likely to be inappropriate. However, other organs can be retrieved without interfering with evidence. Further measures during the retrieval procedure may also be required including photography, additional sampling, and the presence of a home office pathologist.
The request for donation of organs may be made by the medical staff or transplant co-ordinator. Before any approach, the family must first understand the concept of futility of further medical intervention and assent to the withdrawal of organ support.
Arrangements for the withdrawal of treatment should be agreed between the family and critical care staff. In the interim, the current level of support ought to continue, but there is controversy regarding escalation of treatment to facilitate donation. Legal guidelines only recommend measures that facilitate donation but that do not cause the donor harm or distress. This can include increases in oxygen concentration and ventilatory support where required, changing the rate of fluid administration or inserting venous cannulae. Agents can be used to maintain arterial pressure (if in accordance with local policy) but should not be used to elevate the pressure higher than that at the time when the decision was made to withdraw treatment. Antibiotics should not routinely be given unless clinically indicated.6
Once the retrieval team is prepared in the operating theatre and the family are ready, the team should proceed with withdrawal of treatment. This should be in accordance with the usual practice of the unit and not be altered because organ donation is being considered. In some patients, respiration will continue after withdrawal of support and may lead to abandonment of organ donation due to prolonged warm ischaemic time and subsequent loss of organ viability.
After cardiorespiratory arrest, death is confirmed by a medical practitioner independent from the retrieval team. Examination should be made according to the recommendations from the Academy or Royal Colleges. Cessation of cardiorespiratory function should be monitored for a period of 5 min before certification of death. Absence of a circulation can be confirmed by using an arterial line or, in the absence of an arterial line, asystole on an ECG. Palpation of a central pulse is not sufficient for diagnosis.6 In the unusual event that cardiac or respiratory activity returns during this 5 min observation period, a further 5 min observation after further cessation should occur.4
After certification of death, the relatives may spend, up to 5 min with the patient, before transfer to the operating theatre. If the relatives require longer with their loved one, the donation process should be reviewed. The process of retrieving donor organs does not begin until at least 10 min have elapsed from circulatory arrest. For most cases, this is taken up with the initial family and subsequent transfer time.
In cases of lung donation where the patient has been extubated, reintubation will be required after confirmation of death. This is either performed by the treating clinician or by a member of the retrieval team. Reinstitution of ventilation should not be commenced before exclusion of the cerebral circulation (either by balloon occlusion or cross-clamping); however, a ‘recruitment' manoeuvre after 10 min after death is appropriate.6
Should the family wish, they can be contacted by the transplant co-ordinator regarding the outcome of the transplanted organs, this information is also conveyed to the staff involved with the care of the patient.
When considering whether a patient should be considered for organ donation, it is essential to establish the patient's wishes by reviewing the UK Organ Donor Register and by discussing with the next of kin regarding the patient's known or predicted position on organ donation. Having engaged the family regarding futility, it has been proposed that it is paternalistic not to offer them the option of organ donation as a component of end-of-life care. However, most would agree that these conversations should occur at separate interviews. None of the interventions necessary to facilitate controlled DCD, even the prolongation of the current cardiorespiratory support, are easy to attribute to being in the patient's best physical interests. However, the Mental Capacity Act 2005 emphasizes the importance of including a person's social, emotional, cultural, and religious interests, including past behaviours and habits when making decisions about their best interests. Relevant factors are inclusion on the Organ Donation Register or relatives' awareness of the patient's wishes. This would empower the clinician to take reasonable steps to facilitate donation.
In other countries, specific interventions are carried out premortem to improve organ viability including the administration of drugs and the cannulation of vessels to allow early cold perfusion. However, the UK Intensive Care Society strongly advises against any of these measures.4 Furthermore, no procedure which may hasten the patient's death may be administered in the interests of organ donation. Since its inception, organ transplantation has been guided by the ethical requirement known as the dead donor rule, which simply states that patients must be declared dead before the removal of any vital organs for transplantation. For DBD, this is by brain stem testing and pronouncement of brain death. The circulatory definition of death requires the irreversible cessation of cardiac function. This is the requirement for DCD.
Concerns over the minimum acceptable period of cardiac standstill are based on anxieties that a return of spontaneous circulation after the onset of apparently irreversible asystole might result in a return of neurological function. There is no evidence that spontaneous circulation has ever returned after a period of 7 min asystole in patients who have undergone resuscitation; nor has there been a return of circulation in those in whom resuscitation was not attempted. In the UK, both the ICS and the Academy of the Royal Medical Colleges recommend that death should be confirmed after a minimum of 5 min of continued cardiorespiratory arrest.7 In addition, there is a further 5 min grace period after pronouncement of death before organ retrieval, giving a total time of 10 min asystole.
In December 2006, the UK Government set up the Organ Donation Taskforce to identify barriers to organ donation and recommend actions needed to increase procurement within the current legal format. The Taskforce published its first report ‘Organs for Transplants’ in January 2008.8 It made a number of recommendations (Table 2) to the Government which could potentially result in a 50% increase in organ donation in the next 5 yr, ultimately saving thousands of lives.
Organ transplantation has the potential to reduce burden of disease and also improve quality and quantity of life. With the number of patients waiting for transplants increasing, it seems prudent to consider all possible sources of organs. In addition to the important health benefit acquired by the recipient after successful transplantation, organ donation can provide benefits to the donor family. This altruistic act may be the most comforting aspect of an otherwise tragic event and DCD gives previously excluded potential donors the opportunity to donate. At present, DCD donors are an under-utilized resource and given the positive outcomes after DCD, it should be considered for all eligible patients.
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Donation after Circulatory Death (DCD), previously referred to as donation after cardiac death or non-heartbeating organ donation, refers to the retrieval of organs for the purpose of transplantation from patients whose death is diagnosed and confirmed using cardio-respiratory criteria.
There are two principal types of DCD, controlled and uncontrolled. Uncontrolled DCD refers to organ retrieval after a cardiac arrest that is unexpected and from which the patient cannot or should not be resuscitated.
In contrast, controlled DCD takes place after death which follows the planned withdrawal of life-sustaining treatments that have been considered to be of no overall benefit to a critically ill patient on ICU or in the Emergency Department.
World-wide, there is considerable variation in the contributions that DCD makes to deceased donation overall. While some countries have no DCD programmes whatsoever, in others such as the UK, Netherlands and Australia the contributions are significant.
The relatively high potential for controlled DCD in the UK is likely to be a reflection of the number of deaths in intensive care that follow a decision to limit or withdraw life-sustaining treatments that are considered to be of no overall benefit to a critically ill patient
The success of the UK DCD programme can be attributed to the resolution of the apparent legal, ethical and professional obstacles to this model of donation. The underpinning principle of the programme is that donation can on many occasions be legitimately be viewed as part of the care that a person might wish to receive at the end of their lives.
In the UK, an average of 2.7 transplantable organs are retrieved from DCD donors, compared to 3.3 from DBD donors. The biggest contribution of DCD is to kidney transplantation, with 36% of all deceased donor kidney transplants coming from this source in 2020-2021.
The lower donation potential of DCD donors is in large part a result of the ischaemic injury suffered by solid organs in the time interval between treatment withdrawal and cold perfusion, with the liver and pancreas being particularly vulnerable.
For kidney grafts this is reflected in a higher incidence of delayed graft function (requiring a short period of post-implantation renal support), although long term outcomes are similar to DBD grafts.
Although some of this is dependent upon post mortem interventions such as regional normothermic recirculation and ex vivo reperfusion, a closer adherence to the standards for the confirmation and diagnosis of death as defined by the Academy of the Medical Royal College report and described in the Consensus statement on DCD from the Intensive Care Society and British Transplantation Society will also make an important contribution by limiting the initial warm ischaemic injury.
Due to a combination of factors the number of hearts available to transplant in the United Kingdom (UK) falls significantly short of demand. In order to balance the limited supply of donated hearts with the increasing demand alternative approaches continue to be explored.
The UK is the world leader in DCD heart retrieval and transplantation, to date the UK has carried out over 125 heart transplants. The outcome for recipients are comparable to hearts following DBD transplants and significantly has allowed many more donors to give a lifesaving transplant, an important outcome for donor families.
DCD donors account for a high percentage of the total deceased donor pool in the UK and in an attempt to increase organ supply a 12-month UK wide pilot has been launched to support Cardio-Thoracic (CT) centres to successfully utilise hearts from DCD donors.
CT teams have worked together to develop and implement the national pilot to facilitate heart retrieval and transplantation from DCD donors. In collaboration with stakeholders, including critical care and abdominal transplant teams, a DCD heart retrieval protocol and passport have been developed to support consistent and successful outcomes in this pilot phase.
When your physician determines that your loved one has no chance for recovery, and, as the next of kin you decide to withdraw life-support, you may be offered the opportunity of Donation After Circulatory Death.
The Gift of Life Transplant Coordinator will engage you and your family in a donation conversation that provides full information on the power, meaning and life-transforming nature of the donation decision, share questions that other families of potential donors commonly ask and answers any questions that you may have about any aspect of this process.
Your loved one’s physicians and Gift of Life professionals will work with you to decide on the time to discontinue life-support. The withdrawal of treatment process is most often moved to the operating room so that the organ recovery process can begin as soon as possible after the patient’s heart stops and the patient’s doctor has determined they have died. The patient’s physician and nurse will be in attendance, providing end-of-life support and care exactly as they would have in the critical care unit.
Today, organ donation after circulatory death has increased the donation of life-saving organs; mostly kidneys, livers and pancreas. Thanks to advances in research and technology, we are now also able to transplant lungs and hearts using the DCD pathway to donation.
The gift of organ and tissue donation can change someone's life and rewrite their story. Here, donor families, transplant recipients and others share inspiring stories about how donation and transplant transforms lives.
Donation after circulatory death (DCD) describes the retrieval of organs for the purposes of transplantation that follows death confirmed using circulatory criteria. The persisting shortfall in the availability of organs for transplantation has prompted many countries to re-introduce DCD schemes not only for kidney retrieval but increasingly for other organs with a lower tolerance for warm ischaemia such as the liver, pancreas, and lungs. DCD contrasts in many important respects to the current standard model for deceased donation, namely donation after brain death. The challenge in the practice of DCD includes how to identify patients as suitable potential DCD donors, how to support and maintain the trust of bereaved families, and how to manage the consequences of warm ischaemia in a fashion that is professionally, ethically, and legally acceptable. Many of the concerns about the practice of both controlled and uncontrolled DCD are being addressed by increasing professional consensus on the ethical and legal justification for many of the interventions necessary to facilitate DCD. In some countries, DCD after the withdrawal of active treatment accounts for a substantial proportion of deceased organ donors overall. Where this occurs, there is an increased acceptance that organ and tissue donation should be considered a routine part of end-of-life care in both intensive care unit and emergency department.
Organ donation after circulatory death (DCD) has been endorsed by the World Health Organization and is practiced worldwide. This overview examines current DCD practices, identifies problems and challenges, and suggests clinical strategies for possible improvement. Although there is uniform agreement on DCD donor candidacy (ventilator-dependent individuals with nonrecoverable or irreversible neurologic injury not meeting brain death criteria), there are variations in all aspects of DCD practice. Utilization of DCD organs is limited by hypoxia, hypotension, reduced – then absent – organ perfusion, and ischemia/reperfusion syndrome. Nevertheless, DCD kidneys exhibit comparable function and survival to donors with brain death kidneys, although they have higher rates of primary graft nonfunction, delayed graft function, discard, and retrieval associated injury. Concern over ischemic organ injury underscores the reluctance to recover extrarenal DCD organs since lack of medical therapy to support inadequate allograft function limits their acceptability. Nevertheless, limited results with DCD pancreas, liver, and lung allografts (but not heart) are now approaching that of donors with brain death organs. Pretransplant machine perfusion of DCD kidneys (vs. static storage) may reduce delayed graft function but has no effect on long-term organ function and survival. Normothermic regional perfusion used during DCD abdominal organ retrieval may reduce ischemic organ injury and increase the number of usable organs, although critical confirmative studies have yet to be done. Minor increases in usable DCD kidneys could accrue from increased use of pediatric DCD kidneys and from selective use of DCD/ECD kidneys, whereas a modest increase could result through utilization of donors declared dead beyond 1 hr from withdrawal of life support therapy. A significant increase in transplantable kidneys could be achieved by extension of the concept of living kidney donation in relation to imminent death of potential DCD donors. Progress in research to identify, prevent, and repair DCD-associated organ retrieval injury should improve utilization of DCD organs. Recent results using ex situ pretransplant organ perfusion of DCD organs has been encouraging in this regard.
Solid organs for transplantation are recovered from deceased donors with brain death (DBD) or by donation after circulatory death (DCD). Originally called non-heart-beating-donation and later donation after cardiac death, the current terminology (donation after circulatory death) more precisely reflects identification of the cessation of peripheral blood flow by the absence of peripheral pulses and blood pressure over asystole to declare death. In the United States, most organ procurement agencies (OPOs) abandoned DCD after brain death legislation was adopted in 1968, although some centers continued to use DCD donors (1). In the 1990s, the Maastricht (Netherlands) group rekindled interest in DCD in Europe where it is currently practiced in 10 of 27 EU nations (2, 3) as well as the United States, Canada, Australia, Japan, China, the Far East, and a few South American nations (4, 5).
Individuals with nonrecoverable or irreversible neurologic injury with ventilator dependency not meeting criteria for brain death are considered candidates for controlled type III DCD donation. The family designates the donor candidate Do Not Resuscitate (DNR) order and gives permission for organ retrieval upon declaration of death (DOD). Protocols for DCD organ retrievals vary with local practices (10, 11). Withdrawal of life support therapy (WLST) is usually initiated in the intensive care unit or other specifically designated hospital area, and the patient is serially monitored for peripheral circulation. Death may be declared on cessation of circulation. In some countries, there is a mandatory stand-off or waiting period usually of 5 min, and in others, the verification of death can only be done 5 min after circulatory arrest. Some OPOs use the mandatory 5-min interval to transport the donor to the operating room (OR). Upon verification of death, organ retrieval begins. The entry event in uncontrolled DCD donation is cardiopulmonary arrest rather than a neurological insult. In type II DCD, once cardiopulmonary resuscitation (CPR) is deemed unsuccessful, simultaneous efforts are engaged to obtain family consent or document first-person consent by the newly deceased and to preserve the organs by cold perfusion in anticipation of expeditious organ retrieval. After declaration of death, CPR is resumed in some protocols, although not in others (10). A 5- to 10-min stand-off period is observed after cessation of CPR to ensure that death has occurred. The potential donor is transported to the OR or procedure area. Organ retrieval techniques for DCD donations are different from those for DBD in terms of cannulation, perfusion, tempo, and extent. Some centers initiate cold perfusion via direct aortic cannulation after rapid celiotomy, whereas other centers begin cold perfusion outside the OR via femoral artery cannulation instilling a preflush with thrombolytic medication followed by up to 20 L of cold kidney perfusion fluid. In Europe, normothermic regional perfusion (NRP) is practiced widely replacing cold perfusion. It is achieved (12) using occlusive balloon catheters placed in the thoracic aorta and in the vena cava at the level of the diaphragm/hepatic veins via the femoral vessels while separate contralateral femoral arterial and venous lines are connected to a circuit consisting of reservoir, pump, oxygenator, and heater for regional perfusion.
Brain death causes variations in catecholamine levels, leading to hemodynamic perturbations (hypotension, organ hypoperfusion) that may be further exacerbated by inflammatory molecules, including interleukin-1, -6, and -8 that adversely affect renal allografts (25). Injury from hypoperfusion and the proinflammatory milieu before ischemia–reperfusion may explain the lower graft survival from DBD donors when compared with that from living donors. Whether the proinflammatory milieu is substantially different in the setting of severe, irreversible head injury without herniation (DCD) versus brain death (DBD) has not been established. DCD grafts may not be as immunogenic in the recipient because of this potential difference (26).
Although only 32 (9%) of liver transplants from 400 potential type II DCD donors could be performed because 59% (236) and 32% (130) were rejected for absolute and relative contraindications, respectively (12), the 1-year patient and graft survival was 82% and 70%. Improved preservation technology and expanded transplant criteria might significantly improve DCD utilization (see below). Type III liver recipients exhibit more acute kidney injury (AKI) versus DBD liver recipients (DCD [n=88] 53.4%, DBD [n= 86] 31.8%, P=0.004) and AKI is a risk factor for CKD (P=0.035) and mortality (P=0.017) (46). The cumulative 3-year CKD incidence was 53.7% and 42.1% for DCD and DBD patients, respectively. Peak postoperative AST, a surrogate marker for hepatic ischemia reperfusion injury, was the only predictor of renal dysfunction after DCD liver transplant (AKI, P<0.001; CKD, P=0.032). Hepatic reperfusion injury may cause renal dysfunction after DCD liver transplantation.
The timing of the death declaration has been one of the most controversial parts of DCD protocols particularly as to whether the brain is irreversibly damaged after 5 min of circulatory arrest and, as such, whether DCD adheres to the dead donor rule—the guiding principle that the donor must be dead before organs are recovered (63–67). Some ethicists (65) and clinicians (67) argue that the DCD donor is not dead, but rather in the process of dying; others emphasize the difference between “irreversible” and “permanent” cessation of cardiac function (68)—a crucial factor in end-of-life care.
Legal concerns, primarily the family’s right to consent to this surgical procedure, and ethical considerations such as providing a foothold to circumvent the dead donor rule have been raised as challenges to this proposal (76). Others have claimed that the concept requires review and serious discussion among the transplant community (77). Involvement of the hospital ethics committee and the local OPO would provide further oversight and scrutiny for each donor as well as assurances for the surgical team and donor family.
Organ transplantation represents the best, if not the only, therapeutic option for patients with end-stage organ failure. However, the inability to properly satisfy the needs of patients limits the full expansion of transplant therapies. In 2017, almost 140 000 solid organ transplants were carried out in the world,1 an activity that barely covered 10% of a global need that is expected to increase.2 Meeting the demand of organs for transplantation is further challenged by the declining incidence of brain death that has been described in some settings.3
The reduced number of active programs—and the declining activity in existing ones—can be explained by the apparent complexity of the uDCD procedure, its reduced effectiveness in terms of organs deemed suitable for transplantation, the limited knowledge about the quality of uDCD organs, the resources required, and the ethical dilemmas that the procedure poses,8 issues that are subject to review in this article (Table 1).
Figure 3 represents the uDCD process, as carried out in the most successful European IIa programs. After a witnessed CA, out-of-hospital EMS apply aCPR according to national protocols that are aligned with international standards,16,17 aiming for ROSC. The first duty of the EMS is to resuscitate the patient, whenever possible. The patient is only considered a potential uDCD donor when aCPR has been exhausted and considered unsuccessful by the treating team, and a set of strict inclusion criteria are met. The EMS contacts the donor coordinator at a receiving hospital for a joint evaluation based on initial on-site inclusion criteria (Table 2). After determining the donor suitability, the uDCD protocol is activated. Cardiac compression and mechanical ventilation are then extended beyond futility to preserve organs during the transfer of the potential donor to the hospital and thus retain the option of organ donation until their wishes are known. In some countries, the uDCD protocol is only activated once the irreversibility of the CA has been determined in the in-hospital setting following the transfer of patients to the hospital with a therapeutic purpose.
The process of uncontrolled donation after circulatory death (uDCD). aCPR, advanced cardiopulmonary resuscitation; CA, cardiac arrest; HRP, hypothermic regional perfusion; NRP, normothermic regional perfusion.
In existing programs, death is always certified in the hospital by physicians who are independent from the EMS and from the donor coordination and transplant teams. These professionals must ensure the irreversibility of the CA and observe a period of complete absence of spontaneous circulation and respiration. In most programs, this no-touch period is of 5 minutes.8 After death has been determined, cardiac compression and mechanical ventilation are restored for organ preservation purposes in some countries,18 where this is permitted, since death follows exhausted aCPR efforts and prolonged no-flow and low-flow periods.18,19 In the Spanish program, cardiac compression and ventilation are continued until legal permission for in situ organ preservation is obtained, which is required in most cases.
Following the determination of death and the legal authorization (when appropriate), a central vascular catheter is inserted to collect blood samples for medical purposes and for the legal authorities. Heparin is administered to the potential donor, and in situ preservation methods are then initiated. In situ preservation strategies may consist of the cooling of organs with the triple-lumen double-balloon catheter technique or the use of hypothermic regional perfusion (HRP) or normothermic regional perfusion (NRP). In HRP/NRP, an extracorporeal membrane oxygenation (ECMO) device is established to reperfuse organs with oxygenated blood. The cannulation procedures have been described previously.20,21 To restrict preservation to the abdominal cavity, an aortic occlusion balloon catheter is introduced through an arterial cannula. The proper positioning of the balloon is confirmed by a chest radiograph. Pump flow is maintained at 1.7–2.4 L/min, temperature at 36°C (NRP) or 4°C (HRP). Normothermia is always used if liver donation is considered. The maximum duration of HRP/NRP has been empirically established at 240 minutes. This time is critical to complete consent and authorization requirements and the characterization of the donor and the organs for transplantation. NRP not only facilitates the logistics of the process, but it also has the potential to regenerate ischemically damaged tissue and allows a better evaluation of the viability of organs based on the behavior of biochemical markers (aspartate aminotransferase, alanine aminotransferase, and lactate).
If lungs are preserved, a 24F tube is inserted into each hemithorax (anterior second intercostal space) and a preservation solution is instilled at 4°C for topical cooling. The orotracheal tube is left open to the exterior. Two additional tubes may be placed to allow the recirculation of the perfusion solution through a heat exchanger. Esophageal temperature is maintained below 21°C.19,22,23
Donor coordinators must assess the position of the patient towards organ donation through the donor or the advanced directives registries and a dedicated interview with their family. Discussion about donation opportunities may take place at different moments throughout the process, from the moment when aCPR is terminated, to after the initiation of in situ preservation measures. In Spain, different scenarios are considered to decide the time for this conversation, a decision that is driven by the emotional situation of relatives and their request for information.24 Once consent has been obtained and legal permission granted, organ recovery is performed.
Organs are validated in a similar way to donation after brain death (DBD) donor organs, based on function, macroscopic appearance, and histology, when appropriate. Biochemical parameters monitored during NRP are of particular interest for the validation of the liver. It has been established that livers should not be considered suitable for transplantation if alanine aminotransferase/aspartate aminotransferase levels are 4× beyond the upper normal limit at the beginning and 5× beyond the upper normal limit at the end of NRP.24 To assess the viability of lungs, after lungs have been perfused, 300 mL of donor blood are infused through the pulmonary artery and samples are taken from the effluent through the left atria to perform gasometries corrected by temperature. A Pao2/Fio2 ratio equal to or above 400 is considered appropriate. Centers, where machine perfusion (MP) is routinely applied for ex situ preservation of organs, may use specific parameters to anticipate organ viability. However, the precise role of these parameters in uDCD is still to be elucidated.
Because of the urgency of the uDCD procedure, not all organs may be able to be recovered if the donor hospital lacks a specific transplant program or a well-trained and readily available recovery team. The use of in situ preservation strategies can provide time for dedicated recovery teams from other centers to reach the donor hospital in time. Therefore, it is essential that procedures are agreed upon either with local transplant teams or with reference centers that describe organ-specific selection criteria and the way organ recovery will be taking place upon the activation of uDCD.
NRP, critical if liver transplantation is considered, can preclude cold in situ preservation of lungs before recovery. This has made teams either consider liver or lung donation, and hence NRP or HRP, when activating uDCD.23 A case-by-case assessment must be made to consider either lung or liver donation, depending on organ suitability, size of the waiting list, and availability of the corresponding recovery or transplant teams. A preliminary experience with a bithermia approach to simultaneously preserve lungs in cold while using NRP has been published, but further information on this strategy is required.28
In contrast with earlier experiences, contemporary reports on uDCD liver transplantation have all included the use of postmortem NRP. Series from Spain, France, and Italy have been published in recent years and described incidences of 8%–23% PNF, 8%–16% ITBL, and 1-year graft survival (not censored for patient death) of 69%–74% following transplantation of these grafts (Table 4). These results are inferior to those achieved with standard DBD and even with well-selected cDCD livers, though it has been noted that posttransplant results have improved from the initial to the more recent period of each group’s experiences, with 1-year graft survival rates surpassing 80% in the latter periods.52,56 Aside from meticulous donor and recipient selection criteria (recipients <60 y and low model for end-stage liver disease scores/compensated liver disease), optimized perioperative management of uDCD liver recipients, with an aggressive correction of hemodynamic and coagulation abnormalities and the prophylactic administration of tranexamic acid before graft reperfusion in all cases,57 have played an important role in the improvements in outcomes that have been observed over time.
In addition to in situ NRP, ex situ MP is a technique currently under investigation to increase the number and improve the quality of DCD livers in general, and uDCD livers in particular. MP provides a continuous supply of oxygen and other substrates during the ex situ preservation period, clears metabolic wastes, and offers an opportunity to assess graft function before transplantation.54,58,59 To date, clinical experience with 15 uDCD livers undergoing in situ NRP followed by ex situ MP (14 hypothermic oxygenated MP—HOPE—and 1 normothermic MP) has been reported.54,60 While preliminary results of the aforementioned case studies have been promising, other recent reports on viability testing of marginal livers have described relatively high rates of posttransplant ITBL among cDCD recipients (25%–30%),59,61 indicating the need for further refinement of the MP technique and the selection criteria for marginal DCD grafts.
In summary, results of uDCD lungs are acceptable in general terms and comparable to those obtained from conventional donors. Since a prolonged warm ischemia time can compromise graft survival, it seems critical to simplify protocols and implement measures to reduce its duration, as well as to effectively preserve the lungs before recovery. The procedure of topical lung cooling is simple, cheap, and associated with appropriate outcomes. The value of ex situ MP as a tool to evaluate the viability of uDCD lungs and to repair ischemically damaged tissue is still to be validated.
In the most successful uDCD programs, cardiac compression and mechanical ventilation are resumed following the determination of death. In the cDCD setting, death by circulatory criteria is defined by the permanent (will not return), not by the irreversible (cannot return), cessation of circulation, that will lead to the irreversible loss of brain functions.75 After 5 minutes of the circulatory arrest that follows the withdrawal of life-sustaining therapies, cases of autoresuscitation have not been described.73 Death can be determined in this setting as long as circulation is not artificially restored to the brain. If NRP is initiated after the determination of death in cDCD, the aorta must be blocked with a balloon or by surgical clamping or vessel ligation to avoid reperfusion of the brain.5 The question is if these same criteria are applicable to the uDCD setting. As the protocols have been designed, potential uDCD donors are exposed to at least 2 no-flow periods (that of the CA and that of the no-touch period) and to prolonged periods of low-flow.18 In the Spanish experience, the median time between the CA and the determination of death is 90 minutes. This intense and prolonged ischemic injury to the brain has led to the assumption that brain death has developed at the moment CPR for preservation purposes is resumed. Still, more evidence is needed to understand the process by which no-flow and low-flow periods lead to the irreversible cessation of neurological functions.
The development of a successful uDCD program requires a well-designed logistical plan to allow for the efficient activation of the uDCD pathway once the donation opportunity has been identified. The key is to fulfill the logistical and legal requirements to reduce warm ischemic injury to the organs that will be subject to transplantation.
Although there are differences between programs, the activation of the uDCD protocol is decided based on the exchange of information between the EMS and the donor coordinator at the hospital. Therefore, it is mandatory to define clear inclusion criteria (Table 2) to facilitate the decision-making process.
The implementation of uDCD does not entail the need for additional resources on the EMS side, since these are the same as those required for aCPR. However, the use of mechanical compression devices is highly recommended to maintain an optimal chest compression during a prolonged period of time (usually >1 h) and with continuous movements in the ambulance during the transfer of the potential donor.82
The determination of death and the cannulation of vessels for organ preservation purposes can be performed in the emergency department, the intensive care unit, or the operating room. As warm ischemia time needs to be reduced as much as possible, it is desirable that the entire procedure takes place in the same unit.21
In order to minimize the duration of cold ischemia, it is advisable that organs are allocated locally and only shared with other centers in the event that no suitable recipients are identified on the local waiting lists.20 In such cases, fast-track allocation schemes should be used to make the organ offers to centers that have previously expressed interest in using uDCD organs for transplantation.
uDCD is a complex procedure from a logistical point of view and can only be developed under an appropriate regulatory framework that deals with the ethical challenges that it poses. uDCD can significantly contribute to increase transplantation activities and leads to acceptable posttransplant outcomes, that can improve if modifiable and well-identified factors are controlled. Making uDCD possible after an unsuccessfully resuscitated CA not only improves patient access to transplantation therapies, but it also provides more patients with the unique opportunity to donate organs upon their death, if donation is consistent with their wishes and values.
This statement has been developed as a result of collaboration between the American Society of Anesthesiologists (ASA) Committees on Transplant Anesthesia, Critical Care Medicine, and Ethics. The Society of Critical Care Anesthesiologists supports this statement.
While the concept of organ donation after circulatory death (DCD) has previously generated controversy and concern, clearly written policies aided the development of standardized practice, resolved uncertainties and continue to be required by the Center for Medicare and Medicaid Services (CMS) and the Joint Commission. DCD contributed almost 9% of organs transplanted in 2015.1 As such, the original statement from the Institute of Medicine (1997) has held true in that DCD is “a medically effective, and ethically acceptable approach to reducing the gap that exists now and will exist in the future between the demand for and the available supply of organs for transplantation”.2
The document is intended to serve as an educational guide and template for donation after circulatory death organ recovery and transplantation policies that should be customized by any department or institution choosing to use it. Changes in technology and practice require that such policies and procedures undergo periodic review and revision by clinicians, administration and legal representatives.
The practice of DCD involves the continuum of quality end-of-life care for patients and their families, and withdrawal of treatments that are no longer beneficial or may extend suffering. Optimally, patients presenting for organ donation after circulatory death should receive care from their primary care/critical care attending physician or their designee who has established rapport with the patient, family, and/or agent. “Agent” means an individual authorized to make healthcare decisions on the patient’s behalf by a power of attorney for health care or authorized to make an anatomical gift on the patient’s behalf by any other record signed by the patient.
Institutions should develop a protocol for the provision of end-of-life care by appropriately skilled physicians. Withdrawal of life support is not within the expertise of practice of all anesthesiologists, and is not a common aspect of anesthesia practice within the operating room.
However, anesthesiologists are the natural leaders and facilitators in that environment and should be knowledgeable and informed of the major practical and ethical issues surrounding DCD and organ retrieval. Consequently, anesthesiologists should be involved in the development of protocols within their own hospitals for provision of ethical terminal care for organ donor patients and their families, informed by guidelines developed by the Institute of Medicine and the United Network for Organ Sharing (UNOS)3,4. Anesthesiologists should be respectful of the wishes of donor patients, their families, and their primary care physicians when they are in the operating room setting, but no physician should be required to administer care to these patients.
The President’s Commission on Death Determination supports two separate, but complementary sets of criteria. One is based on irreversible absence of circulation and respiration (Donation after Circulatory Death – DCD), and the other is based on irreversible absence of whole brain function (Donation after Death declared by Neurologic Criteria - DDNC).5 Either is satisfactory for the determination of death before organ donation, and both are supported in law.6
According to the dead donor rule, a patient should not be killed for or by the donation of their organs, and complete single organs should only be procured from dead people. Single lungs, kidneys and lobes of a liver may be donated by living donors in strictly regulated circumstances.
This definition was approved by the American Medical Association in 1980 and by the American Bar Association in 1981. All states within the United States of America adhere to the UDDA or some modification of that.
Irreversibility is recognized by persistent cessation of function during an appropriate period of observation. Based on cardiopulmonary criterion, death occurs when respiration and circulation have ceased and cardiopulmonary function will not resume spontaneously. This meaning of “irreversibility” also has been called the “permanent” cessation of respiration and circulation.
Electrocardiographic (ECG) silence is not required for the determination of death, as it may persist beyond the absence of circulatory activity (pulselessness) which is the criterion for declaring death.
In applying the circulatory criterion of death in circumstances other than DCD, clinical examination alone may be sufficient to determine cessation of circulatory and respiratory functions. However, the urgent time constraints of DCD may require more definitive proof of cessation of these functions by the use of confirmatory tests. Confirmatory tests (e.g. intra-arterial monitoring or Doppler study) should be performed in accordance with the hospital protocol to assure the family and hospital professional staff that the patient is dead.
There is an obligatory period of observation to determine that such circulatory activity will not spontaneously recur, and that subsequently death may be declared. In the context of DCD, guidelines require waiting for longer than two minutes but for no more than five minutes of absent circulatory function before pronouncing the patient dead.
This 2 to 5 minute time interval takes into consideration that there is no literature to support “auto-resuscitation” of the heart following two minutes of circulatory arrest, while observing an end-point of five minutes minimizes warm ischemic damage to perfusable organs. This is in accordance with recommendations from the Institute of Medicine3, the American College of Critical Care Medicine7, the Society of Critical Care Medicine7, and the Canadian Council on Organ Donation8.
Most patients considered for DCD will have been in the intensive care unit (ICU) and are dependent on ventilatory and circulatory support. Many, but not all of these patients, will be neurologically devastated but do not meet the requirements for death declared by neurologic criteria.
Ethically and legally, a patient deemed a potential DCD candidate is not equivalent to a patient declared dead by neurologic criteria – those latter are by definition not conscious or alive and cannot suffer. UNOS guidelines for maintaining perfusion of organs in such patients are well established.
A decision to allow death to occur by forgoing or withdrawing further life-sustaining therapies will have been made in accordance with the wishes of the patient and/or agent (as defined above). This must happen prior to and independent of any discussions about DCD.
The local organ procurement organization (OPO) will have been notified of the patient’s critical state in keeping with CMS Conditions of Participation (§482.45 A-0370, A-0371) prior to discussions of withdrawal of life-sustaining treatments. The OPO cannot thereafter approach patients and/or agents until after the decision to withdraw supportive treatments has been made.
When a consensual decision has been made to withdraw life support, the opportunity for DCD should be available to honor a donor's wishes in every donor service area of the United States. As of January 1, 2007, it is a Joint Commission requirement for hospitals to have and implement a DCD policy with direction from the regional Organ Procurement Organization (OPO) 9.
Donor care and end-of-life decisions are paramount and determined by the primary care attending physician/critical care attending physician and patient or their agent and potentially the hospital ethics committee.
All decisions and actions taken following the decision to consider a patient for DCD should preserve the legal limits of patient autonomy, which refers to the capability and right of patients to control the course of their own medical treatment and participate in the treatment decision-making process through informed consent.
Donor designation is a documented, legally binding commitment by an individual to make an anatomical gift and, just like a will or testament, it can only be revoked by that individual. Presence on the donor registry therefore informs the clinical team and OPO of the desired disposition of organs after death, but does not in itself constitute an authority to affect the mode or manner of dying. It does, however, emphasize and reinforce the imperative towards timely and appropriate communication between clinicians and the OPO.
The decision for withdrawal of treatments must be made before and separate from any discussion and decision to donate organs; one of the ethical axioms of organ donation necessitates adherence to the dead donor rule.
The patient’s primary care /critical care attending physician or their designee is best suited to withdraw life-sustaining treatments, prevent potential suffering throughout this process and should be welcomed into the operating room. The patient’s attending critical care physician/primary care physician or designee should declare and record the time of death. In order to avoid potential conflict of priorities, the physicians caring for a donor should not be involved in any of the donation, organ procurement or transplantation procedures. In order to avoid potential conflict of interest, it would be optimal that participation of the primary care/critical care attending physician or designee in withdrawal of life-sustaining treatments should be avoided if that critical care physician is anticipated to participate in the “planned” care of the recipient.
Determination of death is made by cardiopulmonary criteria. The period of circulatory cessation and the monitoring modality that confirms death is institution specific. Declaration of death should be legally binding according to state requirements.
If the anesthesiologist is not involved in any procurement (including post-mortem intubation) or transplant procedures, they may by prior arrangement and mutual agreement substitute for the primary care/critical care attending physician in the declaration of death and patient management.
Protocols for DCD organ recovery may include the pre-recovery administration of anticoagulants, vasodilators, antioxidants and drugs designed to minimize ischemia- reperfusion injury and preserve vascular endothelium. The optimal timing of administration of these drugs during the DCD process is not known.
The administration of heparin at the time of withdrawal of life-sustaining treatment is the current standard of care. The long-term survival of the transplanted organs may be at risk if thrombi impede circulation to the organ after reperfusion. Most transplant centers specify the timing of heparin administration in DCD, and omission of heparin may hinder the distribution of recovered organs. The use of heparin is considered controversial on the basis of theoretical concerns that it may hasten the death of the donor by causing intracranial hemorrhage or worsening active bleeding. Nevertheless, there are presently no reported cases to suggest that the administration of heparin causes sufficient bleeding after withdrawal of treatment to hasten death of the donor.
Rapid postmortem core cooling of perfusable organs with preservation solutions is essential to limit the warm ischemic insult. Informed consent of the patient or agent is necessary for any premortem cannulation of large arteries and veins or any other medical interventions to support the organs for donation prior to death.
A patient who has a non-recoverable and irreversible neurological injury resulting in ventilator dependency but not fulfilling the definition for death declared by neurologic criteria may be a suitable candidate for DCD.
The decision to withdraw life-sustaining measures must be made by the patient, care team, legal next of kin, or agent and documented in the patient’s chart. This must occur prior to any discussion of organ donation.
If queried, the healthcare team may direct questions regarding organ donation to OPO personnel or designated requestor, who will obtain consent for the donation thereby reinforcing in practice the separation between the role of the primary care team and the OPO.
An assessment should be made as to whether death is likely to occur (after the withdrawal of life-sustaining treatments) within a time frame that allows for organ donation (usually 60 to 120 minutes).
Authorization for organ donation is obtained from the appropriate person or entity according to jurisdictional policy after the decision to withdraw life-sustaining treatments is obtained. A Do Not Resuscitate (DNR) order is entered into the patient’s chart.
Location (intensive care unit, operating room, or other) for the process of withdrawal of life-supporting treatments should be determined after discussion and agreement with the donor’s family or agent.
There should be a plan for patient care and immediate family support if death does not occur within the established timeframe after the withdrawal of life-sustaining treatments which precludes the planned organ procurement. This plan should include logistics and provisions for continued end-of-life care and be discussed with the family and/or agent, who should be educated as to the possibility of non-donation and subsequent management.
End-of-life care is the responsibility of the patient’s primary care/critical care attending physician or their designee. Patients have the right to and should be provided medications that prevent and alleviate pain and suffering (comfort care). Patients may require anticipatory dosing with analgesics, sedatives and/or amnestics prior to considered extubation and may require additional medication administered as necessary, titrated to the observed level of distress. Any medication must be given according to need and with the goal of alleviating any pain and suffering, not with the intention of hastening the dying process.
the OPO should have discussed their requirements for reintubation and have made arrangements for patients who are known to have difficult airways with the attending anesthesiologist overseeing the operating room, well in advance of withdrawal of life-sustaining treatments. Alternatively, the OPO may provide an individual to perform this function (as per institutional DCD protocol). Whosoever performs the reintubation of the patient’s trachea should not be involved in the declaration of death.
If indicated and consent is obtained, a bronchoscopy may be performed prior to withdrawal of support and extubation to determine suitability of the lungs for donation. At some centers, bronchoscopy may be performed after declaration of death. Recommendations for ventilator settings and FiO2 prior to withdrawal may be specified by the attending physician overseeing end-of life care. Ventilation after death will be dictated by OPO protocol.
There must be a determination of the location and process for withdrawal of life- sustaining treatments as a component of the patient’s care. Considerable resources are required to provide optimum end-of-life patient care to implement a DCD protocol in the operating room. In addition, the organ procurement surgery requires multiple personnel and healthcare resources. Communication between the OPO and all others involved in the DCD process and management of the operating room is essential for the success and optimal timing of implementing the DCD process.
The patient’s primary care/critical care attending physician or their designee with expertise in the withdrawal of life support agrees to participate in the withdrawal of life support, and will not be involved in organ retrieval or the intraoperative care of the recipients of this patient’s donated organs.
Depending on institutional policy, if informed consent is obtained for pre- mortem isolation or cannulation of femoral vessels, these procedures are usually performed prior to the patient entering the operating room. The surgical procurement team must exit the operating room prior to the family entering. After death, the family must be escorted out of the operating room before the surgical procurement teams enter the room. Families should be told that they will be rapidly escorted out after death for purposes of preserving the donated organs. A member of staff should be identified in advance with the responsibility of escorting the family out of the operating room to an appropriate location. The surgical procurement team must not be present in the operating room during withdrawal of care. After any indicated and consented placement of premortem cannulae, the surgical procurement or transplant teams should have no contact with the patient until after the primary care/critical care attending physician or their designee has declared the patient dead and the written documentation has been completed.
In the event that death has not occurred within one hour after termination of life- sustaining treatments, the patient should be reassessed. A decision is then made to either extend the waiting period for an additional hour or cease the donation process in which case the medical team transports the patient from the operating room to a predetermined location and continues care of the patient. The member of staff tasked with escorting the family should accompany them back to that location.
Once there is a declaration of death, an incision to recover organs should be performed immediately. The transplant surgeons will initiate perfusion of the organs with cold preservation solution and proceed with the donor operation.
Continuity of care for patients presenting for DCD should optimally be provided by the donor patient’s own primary care/critical care attending physician or their designee. The responsibility for withdrawal of life support of the DCD patient also belongs to this individual and should never be transferred to anyone other than a qualified physician who has a preexisting treating relationship with the patient and expertise in end-of-life care. Provision of quality end-of-life care for DCD patients and their families is the absolute priority and must not be compromised by the donation process. Managing the withdrawal of life- sustaining treatments may not be within the expertise or practice of all anesthesiologists. For DCD, determination of death is made using cardiopulmonary criteria and does not require evidence of irreversible cessation of function of the whole brain (the criteria for DDNC).
While anesthesiologists staffing operating rooms should not be required to participate in withdrawal of care or declaration of death, they may be asked to reintubate and ventilate lungs to support and facilitate the DCD process. A role in reintubation would also preclude their involvement in antemortem procedures supporting the donation process, which should normally occur in the ICU prior to transfer to the operating room. Consequently, all anesthesiologists are strongly encouraged to be familiar with the DCD protocols particular to their institution, to determine appropriate methods for management of medical personnel and donor families, as well as timing, communication, and arrangements for care outside the operating room if needed.
While anesthesiologists staffing operating rooms should not be required to participate in withdrawal of care or declaration of death, they may be asked to reintubate and ventilate lungs to support and facilitate the DCD process. A role in reintubation would also preclude their involvement in antemortem procedures supporting the donation process, which should normally occur in the ICU prior to transfer to the operating room. Consequently, all
The death of a patient and donation of their organs should be recognized as a gift that a patient and/or their families are offering to others. All personnel should be respectful of the wishes and privacy of the donor patients and their families, and all those involved in the donation and transplantation process. All should strive to facilitate the donation and transplantation process, mindful of their responsibilities, particular expertise, potential conflicts of interest, and according to the guidelines listed above, institutional policies, and state and federal laws.
Organ Procurement and Transplantation Network Bylaws. United Network for Organ Sharing. Under contract to the Model Elements for Controlled DCD Recovery Protocols, ATTACHMENT III TO APPENDIX B OF THE OPTN BYLAWS. Accessible at
We all know what death means. And for most of us, that means our heart and brain stop functioning. But, sometimes the brain dies and the heart continues to beat only with the support of mechanical ventilators in the intensive care unit. You can rely on us to help you understand the process differences between brain death (BD) and donation after circulatory death (DCD) – both which can provide potential healing through organ, eye and tissue donation.
Circulatory death is the irreversible cessation of all circulatory and respiratory function. Circulation and oxygenation stops. Ventilated patient has not deteriorated to brain death. This may still be an opportunity for organ donation for patients/families when brain death has not occurred.
Organ transplantation improves the quality of life and increases the life expectancy of patients with end-stage organ failure. The demand for transplantation is likely to continue to increase, given an ageing population, an increase in the prevalence of renal failure, and advances in transplant technology, immunosuppression, and intensive care.1 Donation after circulatory death (DCD) describes the retrieval of organs for the purposes of transplantation that follows death confirmed using circulatory criteria, and contrasts in many important respects within the modern-day standard model for deceased donation, namely donation after the confirmation of death using neurological criteria [i.e. donation after brain death (DBD)]. Although many of the original kidney transplant programmes started using organs retrieved from asystolic donors (indeed the first heart transplanted by Christiaan Barnard was retrieved from a DCD donor), many of these donors were in a state that would today be recognized as one of brain death. Consequently, the time taken for cessation of the circulation after withdrawal of cardiorespiratory support was predictable and short. Nevertheless, the professional acceptance of the concept of brain death that followed the declaration of the Ad Hoc Committee of Harvard Medical School in 19682 and publication of criteria for the diagnosis of brain death,3,4 together with the better outcomes from using organs retrieved from cadavers with a heart beat, resulted in most of the early DCD programmes coming to an end.
Uncontrolled DCD presents a different set of challenges. By its very nature, warm ischaemic injury is already established at the time that the potential for donation is recognized, and measures to arrest its progression must be instituted in parallel to the assessment of donation potential, mobilization of a retrieval service, and approaching the family for permission to proceed. For logistical reasons, uncontrolled DCD is usually restricted to kidney-only retrieval within or close to transplant centres where a retrieval team is readily available.
Organs from controlled DCD donors are exposed to a greater duration of warm ischaemia than those from comparable DBD donors. Furthermore, while this is at its most profound between the onset of asystole and establishing organ cold perfusion, it begins during the preceding phase of cardiorespiratory collapse. A better measure of ischaemic injury is therefore the so-called functional warm ischaemia time, which is considered to begin when the patient's systolic arterial pressure decreases below 50 mm Hg, the arterial oxygen saturation decreases below 70%, or both and which ends with cold perfusion.34 Ischaemic injury increases the risks of primary graft failure, delayed graft function, and other ischaemic complications (e.g. biliary structures), and is a considerable concern to retrieval and implantation teams. As a consequence, retrieval teams may be cautious in accepting organs from older potential DCD donors or those with co-morbidities such as diabetes mellitus, hypertension, and peripheral vascular disease that may amplify such ischaemic damage. Similarly, organ retrieval may not occur if the time interval from withdrawal of treatment (or onset of functional warm ischaemia) to asystole is prolonged, with the current UK criteria for DCD organ retrieval being given in Table 2.34 Furthermore, retrieval and transplantation teams will continue to advocate a variety of interventions that might prevent or reverse ischaemic injury.35 These include
May be limited to 20 min in sub-optimal donors. Outcomes from DCD liver transplantation are acceptable, but there is greater postoperative morbidity and a higher incidence of graft failure and biliary complications compared with DBD grafts
It is elements of these strategies, together with issues around the withdrawal of life-sustaining treatment and identifying the potential for DCD, that give rise to many of the professional and ethical objections to the practice of DCD.
Treatment withdrawal is delayed until a retrieval team has travelled to the donating hospital and made their necessary preparations in theatre. It is vital that those responsible for organ allocation and retrieval do all they can to minimize these delays, recognizing the needs of the donor and their family at this time. This is particularly important in circumstances when it is proposed to delay withdrawal until the recipients of particularly vulnerable organs (e.g. liver, pancreas, and lung) have been identified and admitted to the transplant centre.
Withdrawal of treatment within the operating theatre complex reduces ischaemic injury by avoiding the need to transfer a patient from a critical care area after the diagnosis of death. However, while the interests of the patient as an organ donor might be best served by treatment withdrawal within the theatre complex, there are concerns that this might compromise other aspects of end-of-life care.42 Units planning for withdrawal in operating theatre must have systems in place to ensure that a patient's right to comfort, dignity, and privacy is guaranteed and that this care is delivered by appropriately trained and experienced healthcare professionals such as members of the ICU/ED team.34 Specifically, transferring the care of a dying patient to theatre staff, who may be untrained and inexperienced in end-of-life management, is unacceptable.42 Similarly, it is vital that unlimited access for close family, friends, and those meeting the religious or spiritual needs of the patient is ensured. It is also important that the medical professional responsible for confirming death is suitably experienced and readily available, and that a plan for the subsequent care of the patient should be available should donation not take place. In Australia, withdrawal of cardiorespiratory support is almost always undertaken in ICU as it is considered death in the operating theatre is a rare and difficult event for staff. Such an approach ensures that if cessation of the circulation does not occur in a time frame compatible with donation, further disruption to the family and patient is avoided and distress minimized. Members of the transplant team, including donor transplant coordinators, must not be involved in any aspect of the end-of-life care of the potential DCD patient.
Currently, in the UK, retrieval teams mobilized for potential DCD donations ‘stand down’ on 40% of occasions. An accurate and reliable scoring system relevant to local practice which helped predict the likelihood of death within a given time period would be welcome. Reducing the number of ‘stood down’ donations would avoid family distress,43 reduce the burden on hard-pressed ICU staff, and also enable more efficient use of scarce retrieval capacity. Factors associated with early circulatory collapse after treatment withdrawal include a younger age, non-triggered modes of artificial ventilation, high , the use of inotropes, and a low arterial pH.41 Two predictive tools, the University of Wisconsin44 and the UNOS scoring systems,45 are available from North America, but neither has been fully validated for UK or Australian practice. In the USA, more than 50% of patients meeting more than one of the UNOS criteria die within an hour of withdrawing life support treatment.46
The criteria used to justify the decision to stand-down organ retrieval, need to be robust, outcome-based, and subject to continual review in order to ensure that suitable donors are not lost. Although more than 90% of the patients who become DCD donors in the UK die within 2 h of withdrawal of treatment (Table 4), data from the UK Potential Donor Audit indicate that successful retrieval has occurred even after 4 h in circumstances where the functional warm ischaemic time has been acceptable. One centre has demonstrated that increasing the minimum waiting time from 1 to 4 h after withdrawal of treatment, the number of DCD kidney retrieved was increased by 30%, without compromising transplant outcome.47 In contrast, in Australia, retrieval is not pursued if the patient does not die within 90 min of the withdrawal of cardiorespiratory support. It is vital that retrieval teams work consistently to agreed minimum standards if the confidence of referring units in the process is to be maintained and developed. It is similarly important that the reasons for standing a retrieval team down are clearly and promptly communicated to the referring team.
Potential for DCD and actual DCD donations according to the time elapsed between treatment withdrawal and onset of asystole in the UK from October 2009 to December 2010 (data from the Potential Donor Audit courtesy of NHSBT)
Potential DCD donors usually lack capacity at the time of their final illness, although there are occasions where patients with motor neurone disease, high cervical cord injury, or end-stage respiratory failure have consented themselves for donation after irreversible asystole. This has happened on at least four occasions in Australia. In circumstances where patients lack capacity for decision-making, ICU clinicians in the UK have an overarching obligation to limit treatments to those which offer some overall benefit to their patients. In the past, such assessments have focused heavily upon what might be considered to be in the medical best interests of an individual, an approach that might appear to render interventions to promote deceased donation for the benefit of a third party transplant recipient unethical and even unlawful. However, it is now recognized that what is of ‘overall benefit’ to an individual within the context of their end-of-life care is much broader than this12,13 and should include an assessment of factors such as their emotional, cultural, family, and religious interests and also the patient's medical condition. These interests, including those relating to organ donation, are usually determined by discussions with the patient's family and by consulting an organ donor register in countries that have one. This broader interpretation of best interests has been supported by the courts48,49 and is enshrined in the UK Mental Capacity Act.50 Once it is established that an individual wished to be an organ donor, then certain interventions can be considered to be in their best interests if they facilitate donation and do not cause the person distress or harm.11 Examples of interventions that may or may not represent potential harm are included in Table 5, although it is stressed that such assessments should be made on an individual basis. What might be the correct course of action (and therefore lawful) for one individual might not be for another. Using this approach, obtaining blood samples, maintaining life-sustaining treatment, and altering the time and place of treatment withdrawal may all be considered to be in a patient's best interests if they wished to be an organ donor and they represent no harm, whereas interventions such as systemic heparinization (which might promote the expansion of an intracerebral haematoma), cardiopulmonary resuscitation (CPR), and femoral cannulation that might inflict pain or distress to a patient or their close family and friends or accelerate death are unlikely ever to be in the patient's best interests.11 The Australian ethical framework for organ donation makes a distinction between a decision made by an individual and the one made by surrogate decision makers, and gives greater weight to an expression of individual autonomy.27 This is of particularly relevance to end-of-life care, when the assessment of an individual's best interests extends beyond their wellbeing to attainment of their aspirations and the fulfilment of other desires and wishes.
One of the most debated areas worldwide in the practice of DCD is at what point death can be declared after loss of the circulation and respiration. DCD requires that death is declared at the earliest possible time after circulatory arrest that is scientifically, ethically, and professionally acceptable to minimize warm ischaemic time while ensuring that the dead donor rule is not breached, that is, the patient is not unintentionally killed as a result of donating their organs. Perhaps surprisingly, there has until recently been very little professional guidance on how and when to declare death after loss of the circulation and respiration. This is despite the fact that globally, circulatory criteria are the most commonly used and accepted criteria for determination of death. However, the introduction of DCD programmes and reports of autoresuscitation (spontaneous return of the circulation after circulatory arrest) have brought these criteria into sharp focus and resulted in the publication of many, and not always consistent, national guidelines.17–19,35,51,52 Much controversy surrounds the precise time that needs to elapse after the onset of circulatory arrest before death can be declared. This varies around the world, with some commentators believing that the criteria for the determination of death are being manipulated to facilitate transplantation53 while apparently not breeching the dead donor rule. Indeed, others have suggested that the dead donor rule has resulted in the definition of death being revised inappropriately and should therefore be abandoned, permitting the removal of vital organs while a donor was still alive. They argue that with proper safeguards no patient will die from organ donation who would not otherwise die as a result of the withdrawal of life support.54–57
Many criteria allow death to be confirmed (and therefore organ retrieval to begin) after 5 min of continuous cardiorespiratory arrest. Five minutes of continuous asystole is sufficient to ensure that both consciousness and respiration have ceased and also that the possibility for spontaneous resumption of the circulation has passed. However, the brain may at this time remain to some degree responsive to the artificial restoration of its blood supply, be this as a result of continued CPR,58 the introduction of extra-corporeal circulatory support or as a result of post-mortem interventions that inadvertently provoke the return of ventricular function. It follows that at this time, that is, after 5 min of continuous asystole, irreversibility depends in part upon prohibiting restoration of the cerebral circulation rather than an absolute inability to restore cerebral function. This contrasts with circumstances in which neurological criteria for the determination of death are applied. In these circumstances, the pathology leading to the irreversible loss of consciousness and respiration has been established for several hours before the diagnosis is made.
The challenges in this area are considerable. Irreversibility in such circumstances might be considered to be weaker than when death is confirmed by neurological criteria because here it depends upon intent and pathophysiology.59 Others suggest that the loss of circulation should be described as permanent rather than irreversible,60 and propose that for the purposes of DCD, death should only be recognized when the risk of autoresuscitation has passed, when CPR will not be attempted and when there is an absolute prohibition on interventions that may restore the cerebral circulation being undertaken after the declaration of death. A recent systematic review of autoresuscitation showed that this has only been reported in the context of abandoned CPR and not when invasive treatment is withdrawn.61 There seems to be growing global consensus that a minimum of 5 min of continuously observed and appropriately monitored absence of the circulation, apnoea, and coma will define the point at which death can be diagnosed. The development of such consensus will increase confidence in the way we determine death and prevent a repetition of practices in DCD that have previously aroused much concern and criticism, such as retrieval of a heart from a neonatal DCD donor after only 75 s of loss of the circulation.62 The diagnosis of death is reviewed in detail elsewhere in this issue.63
As noted above, warm ischaemic injury limits the potential for DCD, and it is legitimate for retrieval teams to consider the benefits of reversal of such processes before cold perfusion and how this might be achieved. It is similarly legitimate, and indeed mandatory, for critical care teams to evaluate such proposals within the pathophysiological context of the criteria used to diagnose death. For instance, uncontrolled DCD protocols that allow CPR to continue or being re-instated after the declaration of death in order ‘to decrease warm ischaemia of the kidneys … and to re-establish heart activity before organs were removed’64 might carry some considerable risk. Further to this, a recent study has revealed that three patients in a series of 48 had a return of spontaneous circulation when a mechanical device was used during transfer of potential DCD donors from the community to the transplant centre, one of whom went on to make a good neurological recovery.58
There is now growing consensus that no intervention that might potentially restore cerebral circulation at a time when nervous tissue might be responsive to such restoration should be allowed under any circumstances, given the time-sensitive way in which death is diagnosed in the setting of DCD.34,60 These include both those that might inevitably or inadvertently restore cerebral blood flow (Table 6). Protocols for uncontrolled DCD raise further specific ethical issues regarding post-mortem interventions, including how much information families receive and the acceptability of applying invasive measures to preserve organs before obtaining consent from the family or establishing the patient's wishes. The legal framework for donation in Spain, which is one of presumed consent, is interpreted in practice to support such interventions,65 while in the UK, both the Human Tissue Act66 and the Human Tissue (Scotland) Act67 specifically allow the placement of femoral perfusion cannulae ahead of the family approach.
Complete exclusion of the cerebral circulation must be achieved by clamping of appropriate vessels before perfusion is commenced. Balloon occlusion of the thoracic aorta does not reliably exclude the cerebral circulation and should only be used when perfusion is achieved using non-blood fluid
A DCD programme should only be introduced into a hospital's ICU, ED, or both in a planned fashion and after extensive consultation with all interested parties. The following steps have been suggested as helpful in the implementation.7,8,16,68,69
This should include opinion leaders from the ICU, ED, and transplant teams to influence attitudes and behaviours, ideally those with experience in implementing change or healthcare improvement. They should identify and engage all the key stakeholders that need to be involved in the development of a local protocol and its implementation. They should also identify the potential local barriers and solutions to the development of a DCD programme.
An audit of all deaths in the ICU and ED over a period of time will allow an estimation of the total number of patients who would be suitable for DCD. The criteria for suitability will depend on whether controlled or uncontrolled DCD is to be practiced. The audit is helpful in assessing the workload implications and resources requirements for both the ICU and ED and also the local retrieval teams.
Review of the first few cases allows an opportunity to learn lessons and further improve the DCD programme. Any issues arising can be discussed and resolved locally. This may involve updating the local protocols when necessary to address issues such as management of stand-downs, coroner problems, lack of senior medical support, interventions to maintain cardiorespiratory stability while awaiting the arrival of a retrieval team, and the conflicting demands upon limited theatre capacity.
Single centre and data from the United Network for Organ Sharing (UNOS) report good long-term patient survival and graft survival with DCD liver allografts, and these outcomes have been considered equivalent to those obtained from DBD allografts.71–73 In Spain, good results have been achieved when using cardiopulmonary bypass to reverse ischaemia ahead of cold perfusion.74 The 3 yr survival of recipients of livers from DCDs and DBDs is comparable at 63% and 72%, respectively. However, the incidence of primary graft failure is increased (from 6% to 12%) in recipients of a liver from a DCD; there is also a higher incidence of bile duct complications, which is related to the length of the warm ischaemic time.9,73,75 For these reasons, livers from DBDs remain preferable and very strict criteria for selection of DCD liver donors are used to reduce these complications. Encouraging results have been reported using an experimental model of ex vivo normothermic perfusion of the liver using a modified cardiopulmonary bypass circuit,76 which may further improve outcomes in the future.
As noted above, the world's first human heart allograft was retrieved from an asystolic donor. More recently, and somewhat controversially because of the very short interval from asystole to retrieval,80 a small number of successful paediatric heart transplants have resulted from retrieval from neonatal DCD donors.62 A number of teams around the world continue to explore the possibility of successful adult and paediatric heart transplantation using grafts retrieved from DCD donors,81 mindful of both the apparent contradiction in using a heart graft from a patient whose death has been confirmed on ‘cardiac’ grounds82,83 and perhaps more importantly aware of the genuine risks to the donor should retrieval require restoration of ventricular function and the systemic circulation in vivo before isolation of the cerebral circulation.84 The diagnosis of death applies to that person as a whole, not to their individual organs. There is therefore no ethical inconsistency if the heart is re-started ex vivo and transplanted to a recipient.43
In the UK, currently an average of 3.6 organs are transplanted per DBD donor compared with 2.1 organs after DCD. While the number of organs transplanted from DCD donors may increase in the future, they are unlikely to fully match those transplanted after DBD, either in terms of the number of organs transplanted or their quality. Therefore, the focus of DCD programmes should be to provide the option of deceased donation for patients who will never meet the neurological criteria for the diagnosis of death, rather than an option for clinical staff and families to support donation without the need for lengthy neurological evaluations and subsequent donor optimization. However, many involved in transplantation express the view that DCD programmes do indeed detract from DBD and thereby jeopardize cardiothoracic, and to a lesser extent liver transplant programmes, and point to the falling number of DBD donors in countries with active controlled DCD programmes.
It is increasingly accepted that consideration of organ and tissue donation should be a routine part of end-of-life care in both ICU and ED, with DBD considered in patients meeting the neurological criteria for death and DCD considered in patients after the withdrawal of active treatment. DCD allows families the option to meet the wishes of a dying relative who had previously expressed a wish to become an organ donor but who does not meet the neurological criteria for confirming death. Expansion of DCD schemes has the potential to increase the number of transplantable organs donated by patients dying in ICUs and EDs.
A.R.M. is a Regional Clinical Lead in Organ Donation in the UK, and P.G.M. is the UK National Clinical Lead for Organ Donation. Both receive funding from NHS Blood and Transplant. G.O. is the Australian National Medical Director of Organ and Tissue Donation and Transplantation Authority.
In order to be a deceased organ donor in BC, a person needs to be in an intensive care unit (ICU) and on a ventilator (breathing machine). Donation is only considered after all life-saving methods to save a patient’s life have been tried.
Donation after Circulatory Death (DCD) is an option for organ donation for patients with severe brain injuries once a decision has been made to remove all life-sustaining treatments. When a person's heart permanently stops beating, they have experienced Circulatory Death.
PHSA provides specialized health care services to communities across British Columbia, on the territories of many distinct First Nations. We are grateful to all the First Nations who have cared for and nurtured the lands and waters around us for all time, including the xʷməθkʷəy̓əm (Musqueam), Sḵwx̱wú7mesh Úxwumixw (Squamish Nation), and səl̓ílwətaʔ (Tsleil-Waututh Nation) on whose unceded and ancestral territory our head office is located.