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Donation After Cardiac Death: Practical Issues and Ethical Dilemmas

"A national conference on organ donation after cardiac death (DCD) was convened in Philadelphia, Pennsylvania, on April 7-8, 2005, with the goals of sharing DCD experience and garnering a consensus on the medical and ethical propriety of organ donation after cardiac death. Conference participants represented a broad spectrum of health care professionals, including transplant specialists, critical care intensivists, neuroscientists and ethicists. Six working groups were assembled to deliberate on specific DCD issues and fulfill the conference objectives: 1) to define cardiopulmonary criteria for the determination of death, 2) to establish predictive criteria for circulatory arrest within one hour of withdrawal of donor life support, 3) to establish protocols for DCD organ recovery (kidney, liver, pancreas and lung) and transplantation, 4) to develop strategies to initiate and increase DCD in donation service areas, 5) to discuss the allocation of DCD organs for transplantation and 6) to examine perceptions of DCD held by the media and the public."

"As a representative of the ASA Committee on Transplant Anesthesia with 20 years of experience as a liver transplant anesthesiologist and a recognized expert in donor management, I was invited to serve as a member of the Executive Committee and participate in Group 3, led by Tony D’Alessandro, M.D., and Bob Gaston, M.D. A complete summary of the discussion, findings, recommendations and list of participants in each group has been published (Am J Transplantation. 2006; 6:281-291).

Given that DCD is an evolving science in the field of transplant medicine, anesthesiologists should be positive, knowledgeable and informed of the major practical and ethical issues surrounding DCD and organ retrieval.

Practical Issues
Most anesthesiologists are confused about their role in DCD and have legitimate concerns regarding participation. Typically withdrawal of intensive care support and extubation of these donors occurs in the operating room (O.R.), followed by an observation period of up to two hours during which time the criteria for cardiac death must be met (absence of responsiveness, heart sounds, pulse and respiratory effort). After circulatory cessation and a waiting period that varies (at least two minutes of observation, with more than five minutes not recommended), declaration of death is then made by a physician who is not a member of the surgical or anesthetic care team. The transplant surgeons will then initiate cold flushing of the organs with preservation solution and proceed with the donor operation. As the lungs require re-inflation before retrieval, the anesthesiologist may be asked by the surgical team to re-intubate the donor or to provide patient care during a bronchoscopy, which is necessary to assess suitability of the lungs for donation prior to withdrawal of support. It is important that anesthesiologists are familiar with their institutional DCD protocol and the following key points:

• The care of DCD patients should not be transferred to anesthesiologists in the O.R. for withdrawal of life support. Provision of quality end-of-life care for patients and their families is the absolute priority of care and must not be compromised by the donation process. Managing withdrawal of nonbeneficial treatments is not within the expertise or practice of all anesthesiologists, and as such, continuity of care for patients presenting for DCD optimally should be provided by the donor patient’s own physician.

• Determination of death is made using cardiopulmonary criterion (for DCD), which does not require evidence of irreversible brain injury (for donation after brain death, or DBD).

• We should be respectful of the wishes of donor patients, their families and their physicians when they are in the O.R. setting.

• Anesthesiologists should have an active role in the formation of DCD protocols within their own hospitals for the provision of ethical terminal care for living donors and their families.

Increasing the donor pool is crucial for providing a sufficient number of organs to accommodate the more than 90,000 patients currently wait-listed for transplantation in the United States. As such the U.S. Department of Health and Human Services recently initiated the Organ Donation Breakthrough Collaborative in a strategic attempt to establish organ donation best practices and implement highly effective organ donation systems nationwide. Since 2002 the total number of deceased donors has increased from 6,190 to 7,152 (2004) as a result of an increase in the total number of brain-dead donors and an acceleration in DCD organ recovery.

Prior to 1999, there were 345 DCD, of which more than 98 percent were kidney donors. From 1999-2004, the total number of DCD increased to 1,224, with the most dramatic increase from 270 cases in 2003 to 391 cases in 2004 (Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients Annual Report 2005). DCD now accounts for more than 5 percent of all deceased organ donors. Approximately 79 percent of all intra-abdominal organs recovered from DCD donors are transplanted, which compares favorably with non-DCD (89 percent). Current data show equivalency in graft and patient survivals of DCD and DBD primary kidney transplants despite higher delayed graft function rates in DCD organs. The risk of graft failure for DCD livers is higher compared with non-DCD livers (relative risk, 1.85).

Ethical Dilemmas Resolved
Efforts to increase organ donation have been met with resistance from anesthesiologists who are concerned about being coerced into morally, legally and professionally compromising situations. The major ethical issues in DCD organ donation and procurement are held in the balance between the doctrines of beneficence (doing good for the patient and society as a whole) and nonmaleficence (do no harm). This national conference overwhelmingly affirmed the ethical propriety of DCD as not violating the dead-donor rule in that the retrieval of organs for transplantation does not cause the death of a donor. A prospective organ donor’s death may now be determined by either cardiopulmonary (DCD) or neurologic criteria (DBD). Based on a cardiopulmonary criterion, DCD donor death occurs when respiration and circulation have ceased and cardiopulmonary function will not resume spontaneously.

Protocols for DCD organ recovery routinely include the prerecovery administration of anticoagulants, vasodilators and drugs designed to minimize ischemia-reperfusion injury. The issue that remains unresolved concerns timing of administration. In addition it is mandatory that drug therapy must not hasten the death of the donor unless there is a direct benefit to the patient (double effect). An example of this would be administration of opiates for pain relief, which has the inherent risk of respiratory depression. Rapid core cooling of perfusable organs is essential to limit the warm ischemic insult, but informed consent of the patient or family is necessary for any premortem cannulation of large arteries and veins or other interventions (i.e., extracorporeal membrane oxygenation or chest incision for open cardiac massage). As the risk of graft failure is greater for DCD livers, recipients will be asked if they are willing to accept DCD liver offers. Obtaining final consent for transplant should include a discussion of transplantation of organs from donors with varying degrees of risk of failure versus the mortality risk of waiting for the next available ideal donor.

The National Conference on Donation After Cardiac Death affirmed DCD as an ethically acceptable practice of end-of-life care capable of increasing the number of deceased-donor organs available for successful transplantation. The public message to be conveyed is that DCD honors donor wishes in the continuum of quality end-of-life care, it can provide comfort and support to donor families, and it saves lives."

American Society of Anesthesiologists (ASA)
Kerri M. Robertson, M.D., F.R.C.P. (C), is Associate Clinical Professor, Chief of General, Vascular, High-Risk, Trauma, Transplant and Surgical Critical Care Medicine, Chief of Transplant Services, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

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