University of Colorado Hospital Policy and Procedure
Donation After CirculatoryCardiac Death
Related Policies and Procedures: Organ and Tissue Donation Consent for Medical Care and Procedures Advance Directives Determination of Death by Neurologic Criteria (Brain Death) Mechanical entilation! Management and "iberation Decion Ma#ing Ca$acity (DMC) %nd of "ife Care Approved by: Professional Practice& Policy and Procedure Committee O' Committee %thics Committee Medical Board %ffective! ()*+ Current! ,)-- Description: The $ur$ose of this $olicy is to outline the $rocedure in .hich human organs are recovered for the $ur$ose of trans$lantation after the declaration of death according to cardio$ulmonary criteria/ Accountability: A multidisci$linary team of health care $roviders from 0niversity of Colorado 1os$ital is accountable to the needs of the 1os$ital and recommendations of The 2nstitute of Medicine/ Definitions: CirculatoryCardiac Death: (Per 0niform Declaration of Death Act& -,3-4)! The cessation of circulation and res$iration/ 5urther defined by the Nationalo Consensus on Donation after Cardiac death for monitoringby monitoring of death by confirming -) a $ulse of 6ero via arterial catheter or do$$ler &4) that the $atient is a$neic& and +) the $atient is unres$onsive to verbal stimuli for a $eriod of t.o to five minutes before $ronouncement of death/ Donation after circulatorycardiac death (DCD): A $rocedure that entails the recovery of organs after cessation of circulation.here organs are surgically removed follo.ing $ronouncement of death based on irreversible cessation of circulatory and res$iratory function in $atients .ho have not met brain death criteria and decisions are made to forego further life7 $rolonging treatments// Decision Makin Capacity (DMC): The individual has the ability to $rovide informed consent to or refusal of medical treatment/ c4(*o-- Page - of -, Donation After CirculatoryCardiac Death Healthcare Decision Maker! -) A $atient .ho retains DMC& or 4) tThe $erson authori6ed to ma#e medical treatment decisions on behalf of an adult $atient .ho does not have DMC/ This may include an agent under a Durable Medical Po.er of Attorney& family or $ro8y/ A 1ealthcare Decision Ma#er .ho meets the criteria set forth in 9ection 2A belo. is authori6ed to ma#e an anatomical gift/ !ran Procure"ent !rani#ation (!P!): non7$rofit organi6ation that is res$onsible for the evaluation and $rocurement of deceased donor organs for organ trans$lantation (i/e/ Donor Alliance)/ $able of Contents %& Deter"ination of the Healthcare Decision "aker '''''' '''' '&& ( %%& Discussion of Care ( %%%& Potential DCD Donor )valuation ''''''''' '''''' '' *+ %,& Consent-Approval'''''''''''''' '''''' '''' + ( ,& .ithdra/al of 0ife 1ustainin M edical $reat"ent-1upport ' '''' + *2 ,%& Pronounce"ent of Death ''''''''''''''''' '''' + 2 ,%%& !ran Recovery''''''''''''''''''''' '''' 2 + ,%%%& 3inancial Considerations'''''''''''''''&&& &&&&&&&&&&&&&&& &&&&&&2+ %4& References''''''''''''''''''''' ''''&&& &&&&&&2*5 4& Appendi6 A: Donation after Circulatory Death Procedural 3lo/ Chart '&& 7 5 4%& Appendi6 8: DCD Procedure Chart''''''''''''''' 9*:: &7* :; Appendi6 C: DCD 1u""ary 1tate"ent'''''''''''''&:;*:7 Policies: %& Determination of the 1ealthcare Decision Ma#er for donation of anatomical gift/ (C'9 :-47 +(7-*( and C'9 -47+(7-*; ) The 1ealthcare Decision Ma#er re$resentative for the $ur$ose of ma#ing an anatomical gift is the $erson designated in the follo.ing order of $riority! A& Th e donor& if the donor has DMC and is an adult or is a minor and is emanci$ated/ 8& An agent a$$ointed in a medical durable $o.er of attorney signed by the $atient $ursuant to C/'/9/ : -;7-(7;*</ ) unless the $o.er of attorney for health care or other record $rohibits the agent from ma#ing an anatomical gift/=(C'9 -47+(7-*() C& A court7a$$ointed guardian or conservator for the $atient& unless other.ise limited by the court order a$$ointing the guardian or conservator/ C/'/9/ : -;7-(7+-;/ D& The 0C1 Advance Directive (yello.) >or#sheet& 9ection -& 1ealth Care Decision Ma#er ias noted in the 1ealth Care Directive section in the electronic medical record/ or $ro8y to ma#e anatomical gift)organ donations and signed by the $atient&& s$ecifically giving the 1ealthcare Decision Ma#er $ermission to authori6e an anatomical gift/ %%& Discussion of Care! c4(*o-- Page 4 of -, Donation After CirculatoryCardiac Death A/ The discussion is had .ith the $atient& and)or health care decision ma#er& and health care team to discuss goals and values to customi6e the care $lan/ B/ The 1eath Care Decision Ma#er or $hysician initiates the discussion to .ithdra. life7 sustaining treatment/ C/ The decision is made by the 1eathcare1ealthcare Decision Ma#er and the Attending Physician to transition the $atient to end7of7life care/ The DN' is com$leted in the %M' and co7 signed by the Attending Physician .ithin 4( hours/ %%%& Potential DCD Donor %valuation! 9uitable Candidate 9election! The decision is made by the 1ealthcare Decision Ma#er and the Attending Physician to transition the $atient to end7of7life care/ The DNA' order($ur$le) form is com$leted in the %M' and co7& signed by the Attending Physician .ithin 4( hours/ and $laced on the $atient?s chart/ A/ The Donor 2nformation "ine (+*+7+4-7**<*) is notified as soon as the 1eathcare1ealthcare Decision Ma#er begins to consider .ithdra. of life sustaining treatment/ B/ The assessment for DCD candidate suitability should be conducted in collaboration .ith Donor Alliance and the $atient?s $rimary health care team/ Donor Alliance determination of donor suitability may include consultation from the Donor Alliance Medical Director and Trans$lant Center teams that may be considering donor organs for trans$lantation/ C/ A $atient (-* years old to usually <; years& ho.ever each case is evaluated individually) .ho has a non7recoverable and irreversible neurological in@ury or chronic terminal illness resulting in ventilator de$endency but not fulfilling brain death criteria may be a suitable candidate for DCD/ D/ 2n assessment of the $atient ensure that there .ill be no $rogression of the $atient to meeting the neurological criteria for death/ %/ A $atient .ith chronic terminal illness or end stage disease severe neurological im$airment .ho retains DMC and is on life su$$ort may choose to be evaluated by Donor Alliance for DCD/ 5/ Donor Alliance should affirm on assessment (A$$endi8es D and %) that there is a reasonable chance of cardiac death .ithin the time frame that allo.s for organ donationone hour of the .ithdra.al of life sustaining treatment/su$$ort The 1ealthcare Decision Ma#er or $hysician initiates the discussion to .ithdra. life7 sustaining treatment/ su$$ort/ The Donor 2nformation "ine (+*+7+4-7**<*) is notified as soon as the 1ealthcare Decision Ma#er begins to consider .ithdra.al of life sustaining treatment/su$$ort/ The assessment for DCD candidate suitability should be conducted in collaboration .ith the local Donor Alliance and the $atientAs $rimary health care team/ Donor Alliance determination of donor suitability may include consultation from the Donor Alliance Medical Director and Trans$lant Center teams that may be considering donor organs for trans$lantation/ c4(*o-- Page + of -, Donation After CirculatoryCardiac Death An assessment should be made as to .hether death is li#ely to occur (after the .ithdra.al of life7sustaining measures) .ithin - hour follo.ing .ithdra.al of life sustaining treatment/ %,& Consent)A$$roval A/ Donor Alliance fully informs the 1ealthcare Decision Ma#er authori6ed to ma#e an anatomical gift of $rocedures or drug administration for the $ur$oses of organ donation (e/g/ he$arin& regitine& femoral line $lacement& lym$h node e8cision& %CMO& and bronchosco$y)/ No donation7or related medications shall be administered or donation related $rocedures may be $erformed .ithout consent/ Donor Alliance must receive authori6ation from the health care decision ma#er for any $rocedures or drugs administration to $re$are the $atient for DCD recovery/ B/ Conditions involving $otential DCD donor being medically treated)su$$orted in a conscious medical state shall reBuire that the OPO confirms the health care team has assessed the $atient?s com$etency and ca$acity to ma#e .ithdra.al and other medical decisions/ C/ Clearance from medical e8aminer)coroner must be obtained .hen a$$licable/ D/ There should be a $lan for $atient care if death does not occur .ithin the established timeframe after the .ithdra.al of life sustaining medical treatment/measures/ This $lan should include logistics and $rovisions for continued end of life care& including immediate notification of the family)1ealthcare Decision Ma#er/ ,& >ithdra.al of "ife 9ustaining Medical TreatmentMeasures) Patient Management A/ Paralytics must be discontinued and allo.ed to clear& if $ossible& $rior to .ithdra.al of life sustaining treatment& as evidenced by train of four of ()(/su$$ort/ (Per 0C1 %nd7of C "ife $olicy)/ B/ A timeout is reBuired $rior to the initiation of the .ithdra.al of life sustaining measures/ The intent of the timeout is to verify $atient identification& roles and the res$ective roles and res$onsibilities of the $atient care team& Donor Alliance staff& and organ recovery team $ersonnel/ Prior to .ithdra.al of life sustaining medical treatment a timeout is reBuired to confirm! a/ Patient identification b/ The $rocess for .ithdra.ing life7sustaining treatment or ventilated su$$ort/ c/ 'oles and res$onsibilities of the $rimary $atient care team& the OPO team& and the organ recovery team/ d/ The hos$itals $lan for continued $atient care in the event that the $atient does not become a donor and a$$ro$riate communication .ith the health care decision ma#er/ C/ No recovery $ersonnel maymember of the trans$lant team shall be $resent for the .ithdra.al of life sustaining medical treatment/measures/ D/ No member of the organ recovery team or Donor Alliance staff may guide or $artici$ate in the guidance or administration of $alliativeadminister $alliative care& or the declaration declare of death/ %/ 5amily members and other interested $arties& as a$$roved by the 1ealth C c are Decision Ma#er& .ill be given the o$$ortunity to be $resent in the O' during .ithdra.al of life sustaining treatmentcare and during the $eriod bet.een .ithdra.al of su$$ortcare and circulatorycardiac death/ c4(*o-- Page ( of -, Donation After CirculatoryCardiac Death 5/ >ithdra.al of life sustaining measures (e/g/ %TT removal& termination of blood $ressure su$$ort medications) are removed in the o$erating room as $er the attached algorithm D/ 2f a$$licable& $lacement of femoral cannulas and administration of $harmacologic agents (e/g/ regitine7& he$arin) for the sole $ur$ose of donor organ function must be detailed and a$$roved by the 1ealthcare Decision Ma#er authori6ed to ma#e an anatomical gift in the consent $rocess/ ,%& Pronouncement of Death A/ The $atient care team member that is authori6ed to declare death must not be a member of the Donor Alliance or organ recovery team/ B/ The method of declaring cardiac death must com$ly in all res$ects .ith the legal definition of death by an irreversible cessation of circulatory and res$iratory functions for t.o to five minutes before the $ronouncement of death ,%%& Organ 'ecovery A/ There .ill be a time limit of no longer than ; minutes and no less than t.o minutes bet.een cessation of circulation and the $ronouncement of death/ Organ recovery may be initiated immediately on $ronouncement of death/ ,%%%& 5inancial Considerations A/ Donor Alliance $olicy shall ensure that no donation related charges are $assed to the donor family/ Procedures! 9ee A$$endiciesA$$endices! A$$endi8 A7 DCD Procedure 5lo. Diagram= A$$endi8 B7 DCD Procedure Chart= A$$endi8 C7 DCD 9ummary 9tatement= A$$endi8es D and % Donor Alliance Assessment Tools 'eferences! -/ Deita MA& 9nyder E/ Develo$ment of the 0niversity of Pittsburgh Medical Center Policy for the care of terminally ill $atients .ho may become organ donors after death follo.ing removal of life su$$ort/ Fennedy 2nstitute of %thics Eournal -,,+=+!--+74, ("O% +222) 4/ %d.ards E/ Mulvania P/ Ma8imi6ing Organ Donation O$$ortunities Through Donation After Cardiac Death/ Critical Care Nurse& vol 4</ no4/&4**< ("O% ;) +/ McMahan E/ The meta$hysics of death/ Bioethics -,,;=,!,-7-4< ("O% <2) (/ 9ills P/& Blair 1A/& Donation after Cardiac Death! "essons "earned/ Eournal of Trauma Nursing& vol -(& no -& 4**G ("O% ;) ;/ Dries& C/& et al / An Official American Thoracic 9ociety)2nternational 9ociety for 1eart and "ung Trans$lantation)9ociety of Critical Care Medicine)Association of Organ and Procurement Organi6ations)0nited Net.or# of Organ 9haring 9tatement!%thical and Policy Considerations in Organ Donation after Circulatory Determination of Death/ Am E 'es$ir Crit Care Med& ol -33& 2ss -& $$ -*+7-*,& 4*-+ ("O% 3222)/ c4(*o-- Page ; of -, Donation After CirculatoryCardiac Death </ 'eich& D/E/& et al / A9T9 'ecommended Practice Duidelines for Controlled Donation after Cardiac Death Organ Procurement and Trans$lantation/ American Eournal of Trans$lantation 4**,= ,! 4**(74*-- ("O% G22)/ G/ Dare& A/E/& Bartlett& A/9/& 5raser& E/5/& Critical Care of the Potential Organ Donor / Curr Neurol Neurosci 'e$ 4*-4 -4!(;<7(<;/ ("O% ;)/ 3/ Bastami& 9/& Matthes& O/& Frones& T/& Biller7Andorno& N/ 9ystematic 'evie. of Attitudes To.ard Donation after Cardiac Death Among 1eathcare Providers and the Deneral Public/ ,/ Manara& A/'/&Mur$hy& P/D/& O ?Callaghan& D/ Donation after circulatory death/ British Eournal of Anaesthesia 4*-4& -*3! -*37-4-/ ("O% G22)/ -*/ Cam$bell& M/"/(4*--) American Association of Critical Care Nurses! Procedure Manual for Critical Care/ Procedure -+G/ 9t/ "ouis& MO! 9aunders!%lsevier/ --/ C'9 An a tomical Dift Act& Colorado 'evised 9tatues/ 4*G 7+7( (4**G)/ o -4/ 9heath& FN/& et/ al/ Autoresuscitation af ter asystole in $atients being considered for organ donation/ Crit Care Med 4*-4 vol/ (*& -;37-<-/ ("O% <)/ c4(*o-- c4(*o-- Page < of -, Donation After CirculatoryCardiac Death Attach"ent Appendi6 A c4(*o-- Page G of -, Donation After CirculatoryCardiac Death A ppendi6 ttach"ent 8 DCD Procedure Chart 1$)P < Description 0ocation =ey Personnel =ey Points >1upportive care for patients and fa"ilies ; Decision to .ithdra. life7 sustaining treatment 2C0 2C0 team 9$iritualPastoral Care Decision to .ithdra. life sustaining treatmentsu$$ort M09T be inde$endent (and $recede) the DCD $rocess 2nvolvement of #ey $ersonnel $er family D?AR (purple for") "ust be co"pleted@andco"pleted@ and sined by Attendin Physician in the )MR and on chart 2m$lement 2C0 %O" order7set H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 team H 5amily su$$ort through 9$iritualPastoral Care& 2C0 team& social .or# I others (as needed) : Notification of Donor 2nformation "ine ($otential donor) 2C0 2C0 nursing staff Donor Alliance Donor Alliance .ill assess eligibility of a $otential donor (initial assessment should not include contact .ith the $atient or family)/ H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 team H 5amily su$$ort through 9$iritualPastoral Care& 2C0 team& social .or# I others (as needed) ( Donor Alliance 5amily 9u$$ort Coordinator collaboratively .ith 0C1 staff or Designated 'eBuestor offers family organ donation o$tion 2C0 Designated 'eBuestor(s)! Donor Alliance Pastoral Care 1os$ital Manager Decedent Affairs Organ reBuest M09T be $erformed through a Donor Alliance 5amily 9u$$ort Coordinator collaboratively .ith 0C1 staff or Designated 'eBuestor only Organ reBuest must occur through face to face contact/ 2f the family does not s$ea# %nglish& a Bualified inter$reter must be available for accurate translation 2nformed consent $rocess! donor families must understand and agree to all ste$s of the DCD $rocess including acce$tance of the follo.ing! -/ An a$$ro8imate time minimum of <7 3 hours $rior to .ithdra.al of life sustaining treatment is needed to allo. for necessary organ recovery $re$arations/ 4/ The 2C0 team .ill remain at the $atientAs bedside throuhout the /ithdra/al of life sustainin treat"entsupport process& $he H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 team H 5amily su$$ort through Pastoral Care9$iritual Care& Donor Alliance (5amily 9u$$ort Team) I)7 2C0 team and social .or#) others (if $resent) c4(*o-- Page 3 of -, Donation After CirculatoryCardiac Death fa"ily "ay be present in the !R durin end*of*life care /ith sureon approval and if the fa"ily so /ishes& +/ Arterial cannulation may be $erformed $rior to the $atientAs death in the O'/ "ocal anesthesia .ill be used to ensure $atient comfort/ (/ Administration of $harmacologic agents (e/g/ he$arin) for the sole $ur$ose of donor organ function must be detailed in the consent $rocess and ordered on a case by case basis /hen ordered by Donor Alliance-Pri"ary $ea" MD& $he fa"ily "ay be present in the !R durin end*of*life care /ith sureon approval and if the fa"ily so /ishes& Donor Alliance Representative offers fa"ily the choice of acco"panyin fa"ily "e"ber-patient to !R for re"oval of life sustainin treat"entsupport until declaration of death@ and notifies !R of fa"ily choice 'eassure family of $atient comfort and su$$ort throughout the DCD $rocess/ 5amilies should be reminded that the $atient might not al.ays die after .ithdra.al of life7su$$ort/ 'eassure families that their loved one .ould then be returned to the 2C0 for continued su$$ortive care if death does not occur one hour follo.ing the .ithdra.al of life sustaining medical treatment/su$$ort/ 5amilies should also be given the o$tion to see the body of their loved one follo.ing surgery (47( hrs $ost7death) +A 5amily does NOT elect donation! Document decision and $rovide su$$ort 2C0 9$iritualPastoral Care Donor Alliance 2C0 team Provide continued su$$ort for $atient and family= address further Buestions) concerns Donor Alliance documents decision including reason for no donation H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 team H 5amily su$$ort through 9$iritualPastoral Care& 2C0 team& social .or# I others (as needed) c4(*o-- Page , of -, Donation After CirculatoryCardiac Death +8 5amily elects donation! Notify 1os$ital manager& Decedent Affairs 7 begin mobili6a7 tionmobili6ation 2C0 Donor Alliance 1os$ital Manager Decedent Affairs 9$iritualPastoral Care 2C0 team Donor Alliance begins donor management)$lacement $rocess 1os$ital manager .ill ensure a$$ro$riate 2C0 staff allocated and mobili6ed Decedent Affairs .ill initiate $a$er.or# ) .ith family Ongoing su$$ort of family of family H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 team H 5amily su$$ort through Pastoral Care9$iritual Care& Donor Alliance& 2C0 team& social .or# I others (as needed) +C !R staff initiates contact /ith %CU staff and patient fa"ily 2C0 2C0 O' !R nurse contacts %CU nurse and "akes arrane"ents to co"e to the unit and "eet the patient and fa"ily- !R nurse prepares !R for patient and fa"ily& 2 5amily& Donor Alliance and staff $re$arations com$lete! Trans$ort $atient to O' Trans$ort 2C0 resident MD 2C0 nurse I 'T 0C1 trans$ort Donor Alliance Trans$ort should occur after! -/ The family is ready and decision made by 2C0)O' staff)$hysicians) if family .ill accom$any $atient to the O' or remain in the 2C0 for the .ithdra.al of life sustaining treatmentsu$$ort 4/ Donor Alliance has com$leted $re7 recovery $rocess +/ Necessary $re$arations by the O' and 'ecovery teams are com$lete (/ Necessary 2C0 coverage has been secured 2C0 resident MD& 'T and nurse then $roceed .ith the $atient to the O' and continue $atient su$$ort H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 resident MD& nurse and 'T H 5amily su$$ort through Pastoral Care9$iritual Care& Donor Alliance and 2C0 nursing staff I others (as needed) 5 Patient $re$aration for organ recovery O' O' 9taff 2C0 resident MD 2C0 nurse Donor Alliance 2C0 resident MD and nurse continue $atient su$$ort .ith guidance from O' staff and Donor Alliance (see above section 4) O' nursing staff $re$s and dra$es $atient Cannulation may be $erformed under the guidance of Donor Alliance/ H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 resident MD& nurse and 'T H 5amily su$$ort through 9$iritualPastoral Care& Donor Alliance and 2C0 nursing staff I others (as needed) c4(*o-- Page -* of -, Donation After CirculatoryCardiac Death 7 >ithdra.al of life7sustaining treatment O' 2C0 resident MD 2C0 nurse and 'T Donor Alliance >ithdra.al of life sustaining treatment should adhere to 0C1 %nd7of7"ife Duidelines and %CU )!0 order*set@ includin discontinuation and clearance@ if possible@ ofclearance@ of paralytics prior to discontinuation of "echanical ventilator& 2C0 resident and nurse remain $resent throughout the .ithdra.al $rocess to the time of death or the $atientAs return to the 2C0/ 'T e8tubates $atient $er $olicy H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 resident MD& nurse and 'T H 5amily su$$ort through 9$iritualPastoral Care& Donor Alliance and 2C0 nursing staff I others (as needed) 9A Patient does NOT die! 'eturn $atient to 2C0 and continue $atient and family su$$ort Trans$ort 2C0 resident MD 2C0 nurse Donor Alliance 0C1 trans$ort 2f $atient does not die .ithin ON% hour& or .ithin the allotted time s$ecified by the OPO for organ viability& the 2C0 nurse .ill notify 2C0 charge nurse that the $atient is returning to the 2C0 or designated bed/ 2C0 charge nurse )Donor Alliance notifies family that $atient is alive and is returning .ith the 2C0 team H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 resident MD and nurse H 5amily su$$ort through 9$iritualPastoral Care& Donor Alliance& 2C0 team and social .or# 98 Patient dies! Proceed .ith organ recovery O' 2C0 resident MD 2C0 nurse Donor Alliance 'ecovery team Anesthesiologist Patient must have cessation of circulation for (*5 "inutes before pronounce"ent of death& 'esident MD declares J documents death based on the 2nstitute of MedicineAs criteria! Confir" a pulse of #ero by arterial catheter or Doppler sinal if arterial line not already in place Confirm that the $atient is a$neic Confirm that $atient is unres$onsive to verbal stimuli The incision for organ recovery may occur immediately after $ronouncement of death/ Donor Alliance coordinates recovery transition 2C0 nurse notifies 2C0 charge nurse of death Donor Alliance 5amily 9u$$ort Coordinator)Organ 'ecovery Coordinator notifies family of death 'ecovery team $roceeds .ith organ recovery 2C0 team returns to the 2C0 7 2C0 resident MD notifies Coroner of death Decedent affairs com$letes death $ac#et H Attention to $ost7 mortem cultural) religious rituals (.here a$$licable) 7 O' team H 5amily su$$ort through 9$iritualPastoral Care& Donor Alliance& 2C0 nursing staff I)7 others at family reBuest c4(*o-- Page -- of -, Donation After CirculatoryCardiac Death AA 5amily does NOT .ant to vie. body $ost7 recovery! Move body to morgue Trans$ort Donor Alliance 0C1 trans$ort 9$iritualPastoral Care >hether the family .ants to vie. the body after death or recovery of organs should be established at the time of the donation decision H Attention to $ost7 mortem cultural) religious rituals (.here a$$licable) 7 1os$ital staff H 5amily su$$ort through 9$iritualPastoral Care I)7 others at family reBuest A8 5amily .ants to vie. body $ost7 recovery! Move body to PAC0 or designated vie.ing room Trans$ort 0C1 trans$ort trans$ort 9$iritualPastoral Care
%f a PACU space@ preferably the PACU isolation@ is not available@ the Hospital Manaer /ill arrane for trans$ort to an available room .ithin hos$ital and notify the 2C0 nursing staff !R nurses /ill perfor" the post "orte" care on the DCD patient Donor Alliance 5amily 9u$$ort Coordinator)9$iritualPastoral Care accom$anies family to recovery) vie.ing room (or $er family reBuest) Post recovery needs of family .ill be su$$orted H Attention to $ost7 mortem cultural) religious rituals (.here a$$licable) 7 1os$ital staff H 5amily su$$ort through 9$iritualPastoral Care I)7 others at family reBuest %CU tea" K Primary attending and resident MDs& $rimary 2C0 nurse and 'es$iratory Thera$ist ('T) Recovery tea" K Donor Alliance& recovery surgeons& O' nurses and su$$ort staff > Additional $atient& family or staff su$$ort is available at all times through the Palliative Care Consult 9ervice and)or the %thics Consult 9ervice Appendi6 C Donation After Cardiac Death 7 9ummary 9tatement The donation of vital organs and tissues from $atients declared dead using cardiac criteria has been in $ractice since the ince$tion of trans$lantation/ Criteria for the declaration of brain death .ere introduced into clinical $ractice in -,34 and .ere $referred to donation from $atients declared dead by cardiac criteria because .arm ischemic time .as minimi6ed/ Both ty$es of donation are in current use in the country/ Currently only one third of $atients listed for trans$lantation .ill ever receive an organ trans$lant (.../unos/org)/ 2n res$onse to this critical organ shortage ne. strategies in donation have been $laced into clinical $ractice/ 2n 4**4& living donation com$rised nearly one half of all organs recovered& .hile there is increased national activity in donation after cardiac death (DCD)L (.../unos/org)/ c4(*o-- Page -4 of -, Donation After CirculatoryCardiac Death 1eart& lung& liver and #idneys have been successfully recovered from DCD/ 2t is antici$ated that DCD .ill decrease time on the .aiting list and reduce the current -GM .aiting list death rate/ Donation after cardiac death also $rovides a comforting o$tion for families .ho other.ise could not $artici$ate in the donation $rocess/ Donation after cardiac death has been re7evaluated by the %thics Committees at the 2nstitute of Medicine (National Academy Press& -,,G)& 0nited Net.or# of Organ 9haring (0NO9&.../0NO9/org) and locally by Donor Alliance/ 2t is no. acce$ted as an o$tion in organ donation .ithout legal or ethical barriers/
Near Donor 'ecovered Number of Donors (includes DCD) Number of DCD Number of OPO?s .ith at least one DCD -,,+ (&3<- (4 -+ -,,( ;&*,< ;G 44 -,,; ;&+<* <( 44 -,,< ;&(-G G- 4- -,,G ;&(GG G3 -, -,,3 ;&G,3 G( -< -,,, ;&344 3( 4* 4*** ;&,3< --G +* 4**-(Ean7Nov) ;&<-- -(4 +( LDonation After Cardiac Death is the terminology used by 0NO9 and the D119/ Additional terminology included Non 1eart Beating Donors (N1BD) and Asystolic Organ Donors (AOD) BACFD'O0ND! 2n -,;(& the first successful trans$lant of a #idney .as $erformed bet.een identical t.ins/ 9ubseBuently liver (-,<+) and heart (-,<G) follo.ed along .ith lung& $ancreas& intestine and combinations of organs/ %arly trans$lant $rograms obtained organs from living or cadaveric donors/ Prior to -,<3 all cadaveric organs .ere obtained from $atients .ho .ere declared dead according to cardio$ulmonary criteria/ The conce$t of death .as broadened by the re$ort from the Ad 1oc Committee of the 1arvard Medical 9chool (-,<3) on neurologic criteria for brain death/ The definition of death .as modified to include irreversible loss of .hole brain function including brain stem in addition to irreversible cessation of cardio$ulmonary function/ By -,34 Obrain7deathP .as legally acce$ted by every state as a means to declare death/ Because organs from brain7dead donors .ere more li#ely to be viable at the time of recovery& there .as a shift of $reference to $rocurement and use of organs from brain7dead donors/ 1o.ever& the $ractice of DCD has continued uninterru$ted at various sites throughout the nation to the $resent/ That only one third of $atients currently .aiting for organs .ill ever receive trans$lantation has rene.ed the interest in DCD as a means of reducing the organ shortage/ c4(*o-- Page -+ of -, Donation After CirculatoryCardiac Death >hile the 0niversity of >isconsin at Madison has al.ays had an active DCD $rogram& the Pittsburgh OPolicy for the Management of Terminally 2ll Patients >ho May Become Organ DonorP in -,,; .as emblematic of a return to the utili6ation of former resources/ Current evidence sho.ing good organ function follo.ing trans$lantation of organs recovered from DCD donors su$$orts the revitali6ation of DCD $ractices to meet the needs of $atients .aiting for organ trans$lantation (.../unos/org)/ T1% MOD%'N DONO' A5T%' CA'D2AC D%AT1 ! The 2nstitute of Medicine (2OM) convened a grou$ of senior e8$erts .ho .ere not directly involved in organ $rocurement or trans$lantation to analy6e and re$ort on Donation After Cardiac Death/ The investigators met on Euly +*& -,,G to hear evidence from invited $rofessionals re$resenting trans$lantation& organ $rocurement& bioethics& donors& reci$ients and the federal government/ The recommendations of this distinguished committee .ere re$orted in the -,,G re$ort ONon71eart7Beating Organ Trans$lantation= Medical and %thical 2ssues in ProcurementP (National Academy Press -,,G)/ An u$dated re$ort .as issued in -,,, by the 2OM/ This brief syno$sis contains definitions and recommendations $rovided by the 2OM/ Donation After Cardiac Death occurs .hen organs are recovered from a donor .ho is declared dead follo.ing irreversible cessation of circulatory and res$iratory function (0niform Determination of Death Act& -4 0niform "a.s Annotated +4* Q-,,* 9u$$l/R/ A more acce$ting societal vie. of the .ithdra.al of life su$$ort lends $rovision to the $ractice of DCD by im$roving organ viability through controlling the time of death/ The resulting shortened time bet.een absence of circulation and removal or organs should enhance organ survival/ Patients or a $ro8y decision7ma#er may decide to .ithdra. life su$$ort& if $atients are com$etent .ith an intolerable Buality of life or incom$etent but not brain dead& usually due to severe brain in@ury .ith an e8tremely $oor $rognosis as to survival or functional status (Council on 9cientific Affairs and Council on %thical and Eudicial Affairs of the American Medical Association& -,,*= President?s Commission -,3+)/ The decision to .ithdra. life su$$ort must be based u$on the nature of the $atient?s illness& advanced directives and family consent/ Only once these issues have been resolved can a $atient be considered a candidate for DCD/ To $rotect against any conflict of interest& discussions and actions regarding the .ithdra.al of life su$$ort must be se$arated from those concerning organ donation/ Most institutions use t.o teams to accom$lish this tas#/ The medical care team usually deals .ith issues regarding .ithdra.al of life su$$ort& .hile a trained and designated agent of the institution and agent of the Organ Procurement Organi6ation must $erform discussions about donation/ P'%MO'T%M CANN0"AT2ON AND M%D2CAT2ON9 ! Over half of the current national $rotocols for the care of DCD $atients allo. insertion of a femoral arterial catheter before .ithdra.al of life su$$ort once informed consent is obtained from the $ro8y)decision7ma#er/ The catheter is used to infuse $reservation solution immediately follo.ing the declaration of death/ The catheter and infusion of $reservation fluid is of benefit to the $otential reci$ient by reducing .arm ischemic time/ There is no #no.n benefit to the donor/ c4(*o-- Page -( of -, Donation After CirculatoryCardiac Death The use of $remortem he$arin and $hentolamine to $reserve organ function has generated controversy since they may hasten death in some $atients/ The 2OM recogni6es the $rinci$al of double effect .hereby an intervention that $reserves donor organ function may have an unintended adverse effect of hastening death/ This $rinci$al is inherent in the $rocess of .ithdra.ing life su$$ort that in it hastens death/ Because not all interventions .ill elicit the same effect in all $atients& The 2nstitute of Medicine (National Academy Press -,,,) recommends that decisions regarding the use of these medications be made inde$endently in each case by the trans$lant team in con@unction .ith the medical care team and family consent/ The 2OM sti$ulates& ho.ever& that $hysicians must not administer medications that .ill hasten death by e8acerbating an underlying condition such as the use of he$arin in stro#e victims/ 2n contrast there is a consensus that the use of medications to $rovide comfort for dying $atients must not be .ithheld/ The $ractice of comfort care in DCD donors should not differ from that given to other $atients undergoing .ithdra.al of life su$$ort/ D%C"A'AT2ON O5 D%AT1 ! The National Consensus Conference on DCD held in Philadel$hia in 4**; recommends that death is determined using circulatory criteria/ This meets the criteria set forth in the 0niform Declaration of Death Act (0DDA)/ Cessation of circulation should be detected by the absence of an arterial .aveform during continuous arterial vascular monitoring/ Alternatively& cessation of circulation can be detected by the absence of Do$$ler im$ulse .hen measured over a large artery/ The time bet.een cessation of circulation and the declaration of death should be no less than 4 minutes and no longer than ; minutes/ The 0niversity of Pittsburgh uses a t.o7minute interval/ The National Consensus Conferences $resented data to su$$ort the use of a 4 minute .ait bet.een the cessation of circulation and the declaration of death/ They recommend ho.ever& that additional data is collected to assess the incidence of autoresuscitation/ 2t is therefore $ossible that the 47; minute recommendation could be shortened in the future/ 5AM2"2%9 ! The Bill of 'ights for Donor 5amilies em$hasi6es the need for all 2nstitutions to $rovide designated and trained health care givers .ho can $rovide information and e8$lanations of donor $rocedures to family members/ 5ollo.7u$ .ith donor families is strongly recommended by the Bill/ >ithout the su$$ort of donor families trans$lantation .ould come to a virtual standstill and the ho$e of $otential reci$ients .ould be dim/ >e can all enhance donor activity by $roviding comfort and res$ect to donor families/ M2992ON O5 T1% COMM2TT%% ON DONAT2ON A5T%' CA'D2AC D%AT1 AT 0C1! The Medical Board of 0niversity 1os$ital a$$ointed members of the 1ealth 9cience Center to serve on a Committee to develo$ a .or#ing $rotocol for the im$lementation and management of Donation after Cardiac Death (DCD)/ All members .ere $rovided .ith literature from the 2nstitute of Medicine& 0nited Net.or# of Organ 9haring and Donor Alliance sho.ing that DCD is a .ell7established ty$e of organ donation that has been rigorously evaluated by 2nstitutes that re$resent the national and local heath interests/ There are no national or local legal or ethical c4(*o-- Page -; of -, Donation After CirculatoryCardiac Death barriers to use of DCD/ ConseBuently the Committee on DCD is charged .ith develo$ing $olicies that govern)guide the im$lementation and management of a DCD $rogram at the 0niversity of Colorado 1ealth 9ciences Center/ The elements of the $olicy reflect the needs of 0niversity 1os$ital but abide by the essential guidelines set forth by the 2nstitute of Medicine/ To that effect the Committee outlined seven areas that reBuire s$ecial attention in $olicy develo$ment/ A subcommittee .as assigned to each s$ecial area of interest/ %ach subcommittee re$orted its $rogress and $oints of resolution/ The seven s$ecial interest issues .ere assigned to si8 subcommittees/ c4(*o-- Page -< of -, Donation After CirculatoryCardiac Death c4(*o-- Page -G of -, Donation After CirculatoryCardiac Death %8$iration li#elihood .ithin <* and -4* minutes .ill be determined by information from this instrument $lus body mass inde8/ DCD tool score .ith additional $oints for BM2 Probability of e8$iration .ithin <* minutes M Probability of e8$iration .ithin -4* minutes M -* 3 4< -- -+ +( -4 4* (4 -+ 43 ;- -( +3 ;, -; ;* <3 -< <4 G; -G G4 3- -3 3- 3< -, 3G ,* 4* ,4 ,4 4- ,; ,; 44 ,G ,< 4+ ,3 ,G BM2 indicates body mass inde8= DCD& donation after cardiac death Appendi6 )
DCD Assess"ent %nstruction .orksheet Criteria Assined Points Pt& 1core Spontaneous Respirations after 10 min. 'ate S-4 - 'ate T-4 + T S4** cc - T T4** cc + N25 T4* + N25 S4* - No Spontaneous Respirations , Vasopressors/Inotropes No aso$ressors)2notro$es - c4(*o-- Page -3 of -, Donation After CirculatoryCardiac Death 9ingle aso$ressors)2notro$es 4 Multi$le aso$ressors)2notro$es + Patient Age *7+* - +-7;* 4 ;- I + Intubation %ndotracheal Tube + Tracheostomy - Oxygenation After 10 minutes O4 9at S,*M - O4 9at 3*73,M 4 O4 9at TG,M + BMI T4* - 4*74, 4 S+* + 5inal 9core Time from %8tubation to %8$iration c4(*o-- Page -, of -,
8 Soc - Sec.rep - Ser. 248, Medicare&medicaid Gu 34,508 Carraway Methodist Medical Center v. Margaret M. Heckler, Secretary of Health and Human Services, 753 F.2d 1006, 11th Cir. (1985)
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