organ donation after circulatory death

Nearly 40,000 transplants are performed in the United States every year. Approximately 81% of the transplants (n = 24,982) involve organs from deceased donors, who can donate multiple organs. Nineteen percent (n = 5,986) were made possible by living donors. Transplants continue to increase from organ procurement donation after circulatory death (DCD). DCD is when patients receiving mechanical ventilation with severe neurological damage short of “brain death” can donate organs. After the withdrawal of life support and cessation of circulation, a waiting period of usually 2 to 5 min is required, the patient is then determined to be deceased, and the organs are retrieved. Donation after cardiac death is legal based on the 1981 Uniform Determination of Death Act (UDDA).

“The UDDA states that ‘an individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brainstem is dead.’” Currently, the UDDA is the operative law in most states (38 of 50) in the United States and accounts for 3,000 (9%) of all transplants. Under the dead donor rule, donors must be determined to be dead according to established legal criteria and medical standards before procurement of vital organs for transplant. Current DCD protocols set a time threshold for cardiac death, usually 60 min after withdrawal of life support to meet the criteria for donation, but there is ongoing investigation about extending this time. Studies show that most patients (76%) will die within 60 min; the median time to death is about 20 min. Therefore, waiting indefinitely is not an option. This patient did not die quickly and thus did not meet the criteria for donation. The patient should be returned to the ICU, and end-of-life care should be continued (choice B is correct).

The patient has severe traumatic brain injury with extensive cerebral edema and impending herniation. Laying the patient flat would increase intracranial pressure and cause brain herniation and death within the required time window for DCD. A critical factor in the DCD program is that there is an absence of harm to the donor and valid consent to donation to allow organ donation. Withdrawing means of life support allows the patient to die but does not cause death. Laying the patient flat or administering additional doses of sedation and analgesia in the absence of symptoms would cause the patient harm and hasten death (choices A and C are incorrect).

The UDDA and the dead donor rule limit the number and types of transplants that could occur per year. Some argue that the patient’s death is the imminent outcome and that as long as you have consent from the medical power of attorney, procuring vital organs should be allowed without the declaration of death. Although this approach may lead to an increased number of transplants, it is not within the current legal and ethical boundaries (choice D is incorrect).1234

Footnotes

  1. SEEK Questionnaires ↩

  2. Delmonico FL. The concept of death and deceased organ donation. Int J Organ Transplant Med. 2010;1(1)15-20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4089217/#:~:text=The%20UDDA%20states%20that%20%E2%80%9Can,and%20by%20the%20American%20Bar ↩

  3. Iltis AS, Cherry MJ. Death revisited: rethinking death and the dead donor rule. J Med Philos. 2010;35(3):223-241. PubMed ↩

  4. Wind J, Snoeijs MG, Brugman CA, et al. Prediction of time of death after withdrawal of life-sustaining treatment in potential donors after cardiac death*. Crit Care Med. 2012;40(3):766-769. PubMed ↩