Donation after Cardiac Death

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Donation after Cardiac Death

• Anita Charochak, DO
• Diane Silverstein, RN
• St John Providence Hospital
• Southfield

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The waiting list

• Almost 100,000 people waiting for an organ
  transplant in US
• In 2006 29,000 solid organ transplants were done
• 18 people die each day awaiting organ transplant
• Another name is added to the transplant list
  every 12 minutes

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Organ donors transplantations, US, 1988-2006

• NEJM, 2007

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Organ donors

• 4 types of donors
• Living related
• Altruistic
• Donation after brain death
• Donation after cardiac death

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What is donation after cardiac death?

• Process where the ventilator is discontinued,
  then organs are removed by surgeons?
• Natural death occurs and then the heart and lungs
  are restarted so organ procurement may occur?
• Life support is removed with the patient
  receiving comfort measures, waiting for the heart
  and lungs to stop, declaration of death and then
  organ removal?

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DCD

• Not new
• Before 1968 this was primary source for organ
  donation
• Dead donor rule
• Irreversible heart stoppage triggered organ
  procurement

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Donation after cardiac death

• Formerly called non-heart beating donation, NHBD
• Controlled or uncontrolled
• Controlled is family decides to withdraw care if
  a patient has irreversible illness
• Uncontrolled is sudden cardiac death

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Brain death, DBD

• 1970
• Law began to accept the declaration of death on
  the basis of loss of brain function
• Brain death cardiac death both irreversible

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Commonly asked questions

• Are the organs going to be any good?
• How does this process differ from brain death?
• How does the process work?

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Are the organs going to be any good?

• Some organs cannot tolerate low blood flow for
  even a short time
• Heart, intestines
• Weber et al, NEJM, 2002 347248-55
• 15 year follow up, kidney recipients
• 122 DCD recipients 122 DBD recipients
• DCD initially had delayed graft function
• 48 versus 24 in DBD group
• 10 year graft survival 79 DCD 77 DBD

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Brain death, DBD

• Patient is eligible for organ donor status once
  brain brainstem have been irreversibly injured
• Death certificate shows time of brain death, not
  time of cardiac death
• After brain death declaration, body kept
  functioning with help of machines and medications

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How does cardiac death differ from brain death?
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Donation after cardiac death, DCD

• Opportunity for family to consider donation when
  patient does not meet brain death criteria
• End deaths
• on waiting
• list

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DCD

• This is an opportunity for families to make a
  gift of organ donation even if there is no brain
  death
• Honors patients wishes

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Viewpoints

• Institute of Medicine
• DCD donors should be considered a reasonable
  source f organ donors
• Society of Critical Care Medicine
• If, in the process of delivering high-quality
  end-of-life care, organ donation is possible,
  then critical care professionals should help
  enable that outcome. (2002)

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Uniform Determination of Death Act, 1981

• Death caused by irreversible cessation of
  circulatory and respiratory function or entire
  brain including brainstem
• In brain death donation, physician making
  determination of death and physician making
  independent confirmation may not participate in
  removing or transplanting any organs

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Who is a potential DCD donor?

• Patients being kept alive on a ventilator /-
  supportive medications
• Irreversible brain injury
• End-stage neuromuscular disease
• High spinal cord injury
• End-stage cardiopulmonary disease
• Family has decided to withdraw life support
• Need both cessation of cardiopulmonary function
  AND irreversibility

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Is this patient a DCD donor?

• Health care team input
• Will death occur within a certain time period
  after removal of life support?
• There will be times that the transplant team will
  be mobilized, waiting and the patient will
  survive greater than the expected time
• Time is 60 to 90 minutes

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DCD

• Family has made decision to withdraw life support
  independent of decision to donate organs

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DCD personnel

• Donation coordinator
• Physician
• Nurse
• Pastoral care social worker

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? Donation coordinator

• Huddle with care team to review family support
  plan
• Offers donation
• Addresses myths fears
• Provides family with time support during process

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?Physician

• Manages patient
• Works to preserve life before there is a decision
  to withdraw life support
• Serves as advocate for family
• Declares death in OR, or room near OR

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?Nurse

• Provides ongoing care to patient family support
  during medical care phase
• Supports family when decision is made to withdraw
  life support
• Provides nursing care and administers comfort
  medications during the discontinuance of life
  support

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?Pastoral Care Social Worker

• Meets the spiritual, religious other needs of
  the patient family
• Works in collaboration with the team of
  physicians nurses

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Goals of physician

• Grief loss of family is primary concern
• Interventions should be to alleviate pain and
  suffering
• DCD is analogous to ventilator liberation/allow
  natural death
• Both are end of life care
• Focus on patient family
• Both end in death
• Difference is location where the end-of-life care
  takes place

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How does DCD differ from removing life support in
end-of-life care?

• Location
• OR or area next to OR
• Prior to extubation patient given heparin
• Facilitate removal of organs
• Surgical personnel are present in another
  location awaiting cardiac death declaration

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Pronouncement of death

• Occurs when there is cessation of circulation and
  respiration
• Not cessation of electrical activity
• Waiting period used between asystole provision
  of death
• 2 to 5 minutes
• Assure spontaneous circulation doesnt occur

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Institute of Medicine, 2000

• Irreversible cessation of cardiopulmonary
  function
• Will not spontaneously return
• Cannot be restarted with resuscitation
• Resuscitation will not be restarted on morally
  justifiable grounds

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What if death doesnt occur?

• Patient is transported to ICU
• Comfort measures are continued
• Hospitality cart provided for family
• No restriction on visiting hours
• Hospice may be consulted
• Patient may be transferred to a private room,
  away from the business of the ICU
• Never let the family feel you are abandoning them!

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What if death doesnt occur?

• Family may be confused
• Explain
• This does not mean that your family member will
  get better. If means that organ donation was not
  possible
• Best if family is prepared beforehand

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What is the process?

• 6 steps
• End-of-life decision in an appropriate donor
  patient
• Notification of Gift of Life
• Consent obtained
• Approval by Medical Examiner if necessary
• Withdrawal of life-sustaining measures
• Pronouncement of death
• Organ recovery

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Steps 1 to 3

• Donors have non-recoverable and irreversible
  neurologic injury resulting in ventilator
  dependency but not fulfilling brain death
  criteria
• Decision to withdraw care by legal next of kin
  and patients care team
• Documented in chart
• Assessment if death will occur within a time
  frame that allows for organ donation
• Gift of Life has met with the patients family
  and obtained consent
• Clearance from Medical Examiner if needed
• Plans for end of life care if patient does not
  die within established timeframe

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Moving on to removal of life support

• Patient will be transported to a private area
• Final farewell

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Step 4 Withdrawal of life support

• Surgical timeout to verify patient identification
  roles responsibilities of team
• No member of transplant team shall b present
• Gift of Life is present but the hospital care
  team is providing end of life care
• Administration of heparin prior to extubation
• Hospital care team Intensivist or resident,
  nurse, pastoral care
• Respiratory need not be present

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Step 5 Death pronouncement

• Death pronouncement will be by the physician
  providing end of life care
• The physician will document write clearly in the
  chart
• Absence of pulse
• Absence of spontaneous respirations
• I pronounced the patient dead at such time.

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Step 6 Organ recovery

• Patient is transferred to the surgical team

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Checklist for Withdrawal of Life Support leading
to possible Organ Donation (DCD)

• Provide support for family as a team
• Assure privacy and respect for the dying dead
• Move the patient to the OR or adjoining area
• Have medications readily available to alleviate
  pain suffering
• Follow your standard practice
• Write the order for comfort measures, Do not
  resuscitate before you transport patient
• Heparin, 30,000 units available for IVP use prior
  to extubation

• Have the body release form signed before the life
  support withdrawal occurs
• Prepare the family for the possibility that death
  is not predictable
• Organ donation might not occur
• Patient may be transported back to ICU
• Patient may be transferred from ICU
• Have a death certificate available
• May be requested by transplant surgeon

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Checklist

• To be presented at next Organ Tissue donation
  meeting
• Plan is to have checklist on top of form with
  place to write progress note and have team
  members sign

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DCD

• Opportunity for families of patients with severe
  brain injury, who do not meet brain death
  criteria, having decided to pursue withdrawal
  of care, to have the option of donation
• Patients physician will withdrawal life support
  in OR or adjoining room, comfort measures
• If patient dies within established timeframe,
  death is pronounced and patient is transferred to
  transplant team
• Transplant team waits 5 minutes following
  pulselessness before starting organ recovery