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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.
What is Circulatory Death?
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
What is the Dead Donor Rule?
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.
The Uniform Determination of Death Act
The National Conference of Commissioners on Uniform State Laws in 1980 formulated the Uniform Determination of Death Act (UDDA) that states:
“An individual is dead who has sustained either
A determination of death must be made in accordance with accepted medical standards.” 6
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.
How is irreversibility defined?
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.
Cessation of circulatory and respiratory functions is recognized by an appropriate clinical examination that reveals the absence of responsiveness, heart sounds, pulse and respiratory efforts.
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.
What are the requirements for consideration of DCD?
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.
In contrast, a potential DCD donor is still completing the dying process but has not yet been declared dead. Thus, quality end-of-life care remains the absolute priority and must not be compromised by the donation process. Patients have the right to and should be provided those medications that prevent and alleviate pain and suffering (“comfort care”), but no medication should be prescribed or administered with the express intention of hastening death.
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.
Principles for Institutional Development of DCD Guidelines
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.
The main principles for institutional DCD guidelines include the following:
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.
Model Elements for Controlled* Donation after Circulatory Death Policy
*Maastricht Classification: Definition of Controlled DCD Donor
DCD donors are grouped by the Maastricht classification (1995; amended 2000)10:
Controlled DCD donors would include those outlined in classification III of the Maastricht criteria and categories I, II, IV, and V are termed uncontrolled.11
The Anesthesiologist’s Role with DCD and Policy
It is important that anesthesiologists become involved with the development of their institutional DCD protocol and be familiar with their protocol including the following:
Respect for the Potential DCD Donor, DCD Donor, and Families
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.
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