Donation after Cardiac Death

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Donation after Cardiac Death

• Ari J Cohen, M.D., FRSCS, FACS
• Liver Transplant Surgeon
• Surgical Director, Kidney Transplant Program
• Director of Transplant Research
• Ochsner Clinic
• New Orleans, Louisiana, USA

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Definitions

• Brain Dead Donor
• Organ procurement follows death by neurological
  criteria, even though the heart continues to beat
  through ventilatory support
• Donation after Cardiac Death Donor (DCD)
• Also referred to as a controlled
  non-heart-beating donation (NHBD)
• Organ procurement follows a death that occurs
  after a planned withdrawal of life-support.

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DCD HistoryIn the Beginning

• Transplantation emerged in the 1950s and early
  1960s
• Kidney Recovery 1951
• Liver Recovery 1963
• Heart Recovery - 1967
• Source of organs for these transplants?
• Patients were dead under cardiopulmonary criteria
• Organs were recovered after the heart stopped

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Why institute a DCD policy?

• Expand donor pool (may increase organs available
  by 20Lewis and Valerius, 1999)
• Offers families option of organ donation in cases
  where brain death criteria is not met
• Over 1,800 people in Louisiana waiting for a
  life-saving organ
• Over 101,000 people nationally waiting for a
  life-saving organ

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Consider populations

• Key populations for potential donors
• Head injury
• Unstable trauma patients
• Stroke
• Brain hemorrhage
• Cardiac arrest

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Donation after Cardiac Death (DCD) Contemporary
Issues

• Practice constitutes active euthanasia?
• Prohibitive conflict of interest for
  professionals and institutions?
• Adequate social support for dying patients and
  families?
• Whether unethical and illegal practice is
  preventable?

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Institute of Medicine (IOM)Executive Summary

• DCD donors are a medically and ethically
  acceptable source of organs
• Written protocols approved locally and open to
  the public
• Case by case decision to administer
  anticoagulants and vasodilators
• Pre-mortem consent for any cannulation

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Institute of Medicine (IOM)Executive Summary

• Separate the responsibilities of attending
  physician from transplant/procurement physicians
• Determination of death after 5 minutes without
  monitored arterial pulse
• Families should be fully informed and offered
  option of attending life support withdrawal
• Donors and families should not suffer financial
  penalties

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IOM Committee on DCD II2000

• Recommendation 1 All OPOs should explore the
  option of non-heart-beating organ
  transplantation.
• Recommendation 2 The decision to withdraw
  life-sustaining treatment should be made prior to
  any discussion of organ and tissue donation.

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IOM Committee on DCD II2000

• Recommendation 3 Observational studies of
  patients after the cessation of cardiopulmonary
  function need to be undertaken.
• Recommendation 4 Non-heart-beating organ and
  tissue donation should focus on the patient and
  the family.
• Recommendation 5 Develop a voluntary consensus
  on non-heart-beating donation practices.

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IOM Committee on DCD II2000

• Recommendation 6 Adequate resources are required
  to cover costs of outreach, education and any
  increased costs associated with non-heart-beating
  organ and tissue recovery.
• Recommendation 7 Research should be undertaken
  to evaluate the impact of non-heart-beating
  donation on families, care providers, and the
  public.

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Society of Critical Care Medicine Recommendations

• Decision to withdraw therapy should be made
  before and independent of any decision to donate
• Organ procurement must not cause death and death
  must precede procurement
• Death must be certified by using standardized,
  objective and auditable criteria following state
  law and no patient may be certified by MD who
  participates in procurement/transplantation
• Care is first and foremost directed towards the
  dying patient
• Medications that alleviate pain and suffering are
  permissible

CCM 2001 291826-1830
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Key Barriers to Increasing DCD

• Earlier recognition of futility ? withdrawal of
  support ? removes potential DCD donors from donor
  pool
• Perceived needs of the transplant recipient/team
  surpass the needs of the critically ill patient
• Failure to include donation into Living Wills and
  Advanced Health Care Directives

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Key Barriers to Increasing DCD

• Pragmatic slippery slopes
• Manipulation of timing of death
• Defining irreversible of cardiopulmonary arrest
• Criteria for DCD
• Potential conflicts of interest

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Clinical Guidelines

• Patient evaluation
• Organ evaluation
• At least one full set of labs
• Vital signs
• Urine output
• Arterial blood gases
• Serological testing
• HLA typing

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Clinical Guidelines

• Patient criteria
• Age 36 weeks gestation- 70 year of age
• Medical/Social History
• Probability of cardiac arrest
• LOPA with attending physician permission will
  assess patients dependency on the ventilator
  (negative inspiratory force NIF)
• vasopressor support
• Length of time on ventilator

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Clinical Guidelines

• Blood type
• Patient height and weight
• BMI
• Labs
• SGOT, SGPT, PT/PTT,
• Direct Bili, Total bili
• BUN/creatinine
• ABGS

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Clinical GuidelinesNeurological assessment

• Spontaneous respiration
• Absent cough
• Absent gag
• Pupillary response
• Corneal response
• Sedatives?

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Consent Process

• Performed by Family Support Team
• Hospital Surgical Consent Form
• Discontinuation of life support
• Extubation with no reintubation
• Arterial line placement
• Lab work, blood draw
• Surgical preparation of body (shave, prep, and
  drape)
• Patient may not cardiac arrest in allotted time

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Consent Process

• Hospital Surgical Consent Form
• Removal of liver, kidneys, pancreas, spleen,
  lungs, and lymph nodes
• Biopsy of kidneys and liver
• Cannula placement
• Medication administration
• Heparin
• Mannitol and lasix
• Comfort measures

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Family Provisions

• Family Support
• Pastoral Care, Social Services, Nursing staff,
  Physician staff
• Family Understanding
• Family understands poor prognosis
• Should patient not arrest after 60 minutes
• Returned to ICU or floor
• Will not be placed back on ventilator

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DCD procedure

• Withdrawal of life support
• Performed in operating room
• Conduct team meeting prior to withdrawal of life
  support
• Hospital staff
• Recovery staff
• Patient will be prepped and draped
• Hospital staff physician will coordinate and
  perform removal of life support (extubation)
• Recovery/transplant team cannot be involved in
  declaration

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DCD procedure

• Determination of death
• Vital signs every minute once ventilator is
  discontinued (BP, HR, O2 sat)
• Cardiac arrest must occur within 60 minutes after
  removal of life support
• Patient must have a non-survivable cardiac rhythm
  for 5 minutes prior to recovery
• Documentation of cardiac death by two separate
  physicians as defined in LSA-R.S. 9111

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Operating Room

• Full OR team
• Anesthesia optional
• Ventilator is disconnected in operating room
• Family may be present if allowed by hospital.
• Attending or consulted MD must be present for
  declaration
• Coordination of Organ Recovery
• Recovery team

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Organs Recovered for Transplant
Liver and Pancreas
Lungs
Kidneys
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Questions?