Abstract
Background
Two Types of Organ Donation
1.
2.
Selecting Patients for DCD
Appropriate patients are generally comatose patients for whom a decision has been made to discontinue life-sustaining treatments with the expectation of imminent death. The decision to discontinue life-sustaining treatments is made prior to any discussions of organ donation. Most institutions have policies and procedures which alert the OPO of potential donors. After discussion with their medical director and recipient transplant centers, the OPO determines donor suitability. Trained professionals—usually OPO representatives—approach the family about organ donation, and obtain consent from the appropriate medical decision maker for organ donation. Potential donors are generally between 0 and 60 years of age. Patients should not meet the criteria for death by neurologic criteria (they are candidates for organ donation via brain death protocols). The OPO staff prognosticate whether the patient is sufficiently likely to die within the 60-minute window after cessation of life-prolonging treatments. This estimate is based on physiologic parameters including spontaneous respiratory rate, negative inspiratory force, age, oxygen saturation, level of hemodynamic instability, and body mass index (BMI).
Procedure
1. Families are counseled about what to expect during the discontinuation of life-sustaining treatments and what to expect as the patient receives comfort care. Hospitals may have policies requiring the patient to have a DNR order while awaiting the DCD procedure; in others the decision to resuscitate a patient or not in order to attempt to maintain the patient as a viable organ donor is a negotiated decision. Families should be prepared for the possibility that the patient may not die quickly after the ventilator is withdrawn and that the patient may become an unsuitable donor. This occurs in about 20%–30% of DCD cases nationally. This can cause added emotional trauma to grieving families who may want both a swift and comfortable death for their loved one as well as the opportunity to help others through organ donation. Families should be reassured that the patient will continue to receive careful symptom management until she or he die no matter how long that takes.
2. In order to prevent conflicts of interest, members of the OPO and organ recovery teams should not be involved in the decision to discontinue life-support, or in directing the medical care of the patient prior to the declaration of death. Because of this, intensivists, palliative care physicians, or other clinicians may be asked to direct the care of the dying donor after extubation.
3. Once consent is obtained from a legal surrogate and appropriate teams are ready, discontinuation of life-sustaining treatments begins. Extubation generally occurs in the operating room but may occur in a nearby ICU or recovery area based upon local hospital practice. Many hospital policies allow family members to be present in the operating room until the patient dies.
4. The patient may be given preextubation medications to relieve anticipated distress. These medications, as well as symptom medications given after cessation of life-support, should be given in the exact same way as in non-DCD situations to alleviate signs of pain, labored breathing, and other symptoms (see Fast Facts 33–35).
5. The patient is extubated to room air. Other lines and tubes are discontinued as deemed appropriate to maximize patient comfort. All noncomfort medications are discontinued including vasoactive agents.
6. Declaration of death is based on hospital policy. Usually policies require apnea and 2 to 5 minutes of asystole or pulseless electrical activity. The hospital's DCD policy will outline the exact criteria for declaring cardiac death.
7. Following death pronouncement the patient is taken to the OR, or the organ recovery team enters the OR where the patient died and procurement begins. The organ recovery team never encounters the patient's family during the DCD process.
8. If the patient does not die in a reasonable amount of time as determined by the organ procurement organization, the patient is returned to a location in the hospital for ongoing symptomatic treatment until death occurs. Ongoing emotional and bereavement support should occur for family members throughout the process.