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Considerations in Developing a Policy for Organ Donation After Cardiac Death
By James E. McFeely, MD, Medical Director Critical Care Units, Alta Bates Summit Medical Center, Berkeley, CA, is Associate Editor for Critical Care Alert.
Dr. McFeely reports no financial relationship to this field of study.
There continues to be a huge discrepancy between the number of individuals on the national waiting list for vital organ transplant and the number of donor organs available. Every day in the United States approximately 17 people die while waiting for an organ transplant. Every 13 minutes someone is added to the national waiting list, which currently includes more than 100,000 individuals.1 To increase the success rate in obtaining donor organs, stakeholders such as Medicare and the Joint Commission now require hospitals to closely collaborate with their regional organ procurement organization and, more recently, have required hospitals to develop policies relating to potential donation following cardiac death (DCD).2
Since the early days of transplantation, an ethical, social, and legal consensus has emerged supporting the right of patients or their surrogates to choose to donate organs. Similarly there is broad consensus that patients and surrogates can request withdrawal of life-support technology when the burdens of therapy outweigh the benefits. In practice, this consensus has been accompanied by a general agreement on the definition of brain death and the acceptability of using organs from these cases for transplantation purposes.
Under pressure from the ever-growing gap between the number of candidates on waiting lists and the number of organs available, there are increasing efforts to identify sources beyond the limited pool of brain-dead donors. One such source is patients who have died a "controlled" cardiac death following withdrawal of life support.3 Organs obtained through this method are of much higher quality than those available through uncontrolled cardiac death and approach the utility of organs from brain-dead donors.
Arguments For and Against the Use of DCD
There are a number of arguments supporting the use of DCD. First, it respects the rights of patients and their families to choose organ donation after withdrawal of life-sustaining therapies; it honors their wishes and offers the opportunity to create meaning out of a great loss without the need to wait for brain death for potential donation. Second, society benefits from an increased organ donor supply to respond to the needs of potential recipients. Moreover, within the transplant community there is broad consensus about the appropriateness of DCD and the viability of organs obtained in this manner.4 Finally, many argue that DCD does not represent new ethical ground, but is a logical extrapolation of established rights and the broad consensus mentioned above.5,6 Specifically, the patient's right to have life support withdrawn, when combined with the right to donate organs, equates to the right to have the opportunity for DCD.
Critics of DCD, however, challenge this logic as overly simplistic. They argue that the process of donation after cardiac death actually changes the moral landscape of the clinical scene and therefore requires careful reconsideration rather than reliance on pre-existing norms established prior to development of current models for DCD.
Arguments against DCD include that it creates a significant conflict of interest within the treatment team, given that the best interests of the organ donor may conflict with the best medical care for optimal organ transplant success. This, in turn, may result in decreased trust between the caregivers and patients and their families.
Another conflict may arise for those engaged in the withdrawal of life support: They may face conflicting responsibilities to the patient having life support withdrawn and to those awaiting transplanted organs.7 Moreover, some argue that as long as there is a lack of broad social consensus and understanding within the larger community regarding the appropriateness of DCD, allowing for such transplants may in fact lead to an overall decrease in donation rates due to a lack of trust in the motivations of the health care system. Finally, some consider DCD a violation of the "do no harm" moral paradigm, as the donation process itself provides no direct health benefit to the donor. Many caregivers, including physicians, continue to find DCD difficult to accept intellectually and ethically.1
Major medical societies, including the Institute of Medicine and Society of Critical Care Medicine, have made general recommendations supporting DCD, and in some regions approximately 20% of transplanted organs are obtained through this pathway. Some institutions have decided not to implement DCD procedures after an internal review of the ethical issues involved.
Issues for Institutions to Consider in Implementing DCD
If an institution decides to support DCD, a number of clear policies should be put in place to minimize conflict of interest and maximize successful transplantation of organs.4,8 These policies will need to comply with any state or local regulations that might be relevant relating to consent, withdrawal of care, or determination of death. Of utmost importance is that the attending physician's primary responsibility remain with the patient and that decisions be determined by the comfort and well-being of the patient, with only secondary consideration given to effects on the potentially donated organs.
Informed consent for the procedure is mandatory and should come from a trained requestor rather than from a member of the primary treatment team. The California Transplant Donor Network, for example, provides trained requestors for this purpose; those institutions that wish to use internal staff should be required to provide mandatory annual training to maintain competency with this skill. Once consent has been obtained, control of treatment decisions regarding the potential donor should remain with the attending physician, while input may be solicited from the transplant team. Decisions should continue to be primarily driven by the comfort of the patient.
The policy should also specify procedures surrounding the withdrawal of life support. Hospitals should be prepared to facilitate requests from the family to be with the patient at the time of death. The family should also receive psychosocial support, along with preparation for what they will see and what will be needed of them (for example, they will need to leave the room shortly after death to facilitate organ donation). The policy should state where the life-sustaining therapies will be withdrawn (most likely the operating room) and that the withdrawal of life-sustaining therapies should be performed by the patient's treatment team, not the transplant team. Specific standardized criteria for determination of death should be predefined and utilized. The definition of death for both organ donors and hospital patients should utilize the same criteria within a single institution. A predefined waiting period should be observed prior to declaration of death and transfer of care to the procurement team. Inasmuch as auto-resuscitation has not been reported after 2 minutes, a minimum 2-minute waiting period seems appropriate in order not to unnecessarily increase warm ischemia time.4 This minimum waiting time may also be subject to state or local regulations (for example, see reference 9). Objective evidence proving the standard criteria for death have been satisfied should be documented and kept in the medical record. Once the patient has been declared dead, care of the corpse should be turned over to the organ procurement team.
Each institution should take a measured approach to the issue of DCD and make an appropriate decision regarding participation based on the laws, ethical norms, and societal view within its local community. The concept of DCD and its ethical implementation will require input from many stake holders, including community members, clergy, hospital staff, and critical care physicians.