Donation After Cardiac Death

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Donation After Cardiac Death

• Dr. William Meyer
• Neurosurgeon
• Kern Medical Center

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History and Facts

• Prior to the acceptance of the brain death
  criteria in the mid-1970s, all organ donations
  were performed after cessation of cardiopulmonary
  function (NHBD).
• In 1999, 68 of Donation After Cardiac Death
  (DCD) cases were accomplished across the United
  States.
• In 2006, 322 DCD cases were accomplished.

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History and Facts (contd)

• More than 97,000 people are on the waiting list
  for an organ transplant
• 17 - 20 people die waiting every daynew name
  added to the list approximately every 15 minutes
• Organ recovery following cardio-pulmonary death
  can positively impact the shortage of
  transplantable organs

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Fundamentally

• The family should make the decision to withdraw
  life support independent of, and prior to, any
  discussion regarding organ donation.

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Criteria

• The patient has a non recoverable illness or
  injury and has suffered neurologic devastation.
• The family, in conjunction with the medical
  staff, has decided to withdraw life support.
• Death will likely occur within one hour of
  withdrawal of life support.

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Potential DCD Donor

• Patients with severe neurological injury
• Intracranial hemorrhage, stroke, anoxia, trauma
• Patients without neurological injury
• Degenerative neuromuscular diseases
• End-stage cardiopulmonary diseases
• Do not meet the criteria for brain death
• No chance for survival off the ventilator
• Family elects to deescalate care or withdraw
  support (DNRs)

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OneLegacy Clinical Triggers

• Meets one of the following
• Irreversible Brain injury
• End stage musculoskeletal disease
• High spinal cord injury
• Ventilator dependent
• Family has made patient DNR or plans to withdraw
  all life support
• Family inquired or initiated discussion about
  organ donation

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Process

• Refer the patient to OneLegacy.
• A coordinator will come on site and evaluate the
  patient to determine suitability.
• In conjunction with the health care team, the
  family will be informed of the patients
  suitability.
• If suitable, the family will be fully informed
  about all procedures relating to the
  pronouncement of death and the organ recovery
  process by OneLegacy.

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Patient Management

• The patient will continue to be supported
  hemodynamically and on a ventilator until
  withdrawal of support.
• Standard comfort measures will be given at the
  discretion of the attending physician or their
  designee.
• OneLegacy will provide parameters for donor
  management and lab studies to be approved by the
  attending physician or their designee.

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Withdrawal of Support

• A OneLegacy DCD consent form will be signed by
  the next-of-kin. The original copy will remain in
  the patients chart.
• Removal of life support usually takes place in
  the O.R.
• Organ recovery occurs 5 minutes after asystole/
  pronouncement of death

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Pronouncement of Death

• The adult patient will be pronounced dead after 5
  minutes of asystole or 5 minutes of ventricular
  fibrillation measured by electrical activity and
  arterial pulse monitoring.
• Death will be pronounced by a physician or
  designated nursing staff.
• The physician certifying death may not be
  involved in the recovery or transplantation of
  the organs.
• The physician will record the date and time of
  death in the medical record and, if applicable,
  complete the death certificate.

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What Happens if the Patient does not Expire?

• Occurs in approximately 5-10 of DCD cases
• If the patient does not arrest within a time
  deemed suitable by the organ recovery team, the
  patient will be returned to a prearranged room
  and provided with comfort measures.
• OneLegacy will be responsible for the costs
  relating to the evaluation and recovery of organs
  regardless of whether the organs are recovered.

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OPO Performance 2003-2004DCD Donors

• 
  2003 2004
• OPOs without DCD donors 27
  16
• OPOs with at least 1 DCD donor 32
  42
• OPOs with gt 5 DCD donors 12
  20
• Total number of DCD donors 264 (4.1)
  395 (5.5)

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Impact of DCD upon DBD

• 16 DSAs accounting for 80 of DCD donation in
  2004 increased DCD, SCD, and ECD donor recovery
• from 2003 to 2004
• 49.3 increase for DCD
• 9.4 increase for SCD
• 3.8 increase for ECD
• Donation rate increased from 50 to 53.9
• In 2004, non-DCD recovery positively associated
  with DCD recovery among the 59 DSAs.

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Organ Transplant Breakthrough Collaborative
GoalsOrgans Transplanted per Donor

• Standard Criteria Donors 4.3
• DCD Donors 2.75
• ECD Donors 2.5
• Total
  3.75
• At Least 10 of all Donors Are DCD

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OPO Performance 2004DCD Donors

• Gift of Life 47 (12.1)
• NEOB 38 (19.5)
• Gift of Hope 36 (12.1)
• Life Center 33 (19.0)
• Midwest 28 (18.2)
• UW 27 (20.3)
• Lifequest 18 (16.7)
• Michigan 14 (5.1)
• Core 14 (9.3)
• Washington 12 (10.0)

• Finger Lakes 11 (20.8)
• TRC 10 (9.9)
• Mid America 8 (7.1)
• LOPA 8 (5.0)
• Carolina 7 (5.1)
• Golden State 7 (15.2)
• One Legacy 7 (2.0)
• Iowa 6 (15.4)
• New Jersey 6 (3.85)
• New York 6 (2.3)

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Important Facts to Remember

• The family should make the decision to withdraw
  life support independent of the decision to
  donate organs.
• This procedure should not be viewed as a way to
  circumvent brain death criteria but as a means to
  provide families with an additional option of
  donation that complies with the patient or
  authorized family directives.
• The Institute of Medicines evaluation of the
  ethics of DCD stated that the procedure should
  be considered a reasonable source of organ
  donors.

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References

• California Health and Safety Code, sections
  7150-7156.5, 7180-7184.5 and 7188-7195.
• Medical and Ethical Issues in Procurement
  Division of Health Care Services, 1997 (IOM).
• Conditions of Participation for Hospitals, Part
  482, Federal Register, 1998.
• Gift of Life Sample Hospital Policy and
  Procedure Non Heart-Beating Organ Donation
• University of Pittsburgh Medical Center
  Presbyterian Hospital Policy and Procedure Manual
  Non-Heart Beating Organ Donation