Part 3 - Adult Basic and Advanced Life Support - 2020 American Heart Association Guidelines For Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (001-222)
Part 3 - Adult Basic and Advanced Life Support - 2020 American Heart Association Guidelines For Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (001-050)
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)
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$lantation after the declaration of death according to circulatorycardio$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 death due to 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/ 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 c4(*o-- Page - of -, Donation After CirculatoryCardiac Death 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 Medical $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'&&75 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& The 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! A/ The discussion is had bet.een.ith the $atient& and)or health care decision ma#er& .ith the attending $hysician and health care team to discuss goals and values to customi6e the care $lan/ c4(*o-- Page 4 of -, Donation After CirculatoryCardiac Death B/ The 1eath Care Decision Ma#er or attending $hysician initiates the discussesion to .ithdra.al of life7sustaining 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 $rogression of the $atient to neurological criteria for death is unli#ely/ %/ 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 ofafter 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$$ort/ The assessment for DCD candidate suitability should be conducted in collaboration .ith the local Donor Alliance and the $atientAs $rimary health care team/ Donor Alliance determination of donor suitability may include consultation from the Donor Alliance Medical Director and Trans$lant Center teams that may be considering donor organs for trans$lantation/ An assessment should be made as to .hether death is li#ely to occur (after the .ithdra.al of life7sustaining measures) .ithin - hour follo.ing .ithdra.al of life sustaining treatment/ %,& Consent)A$$roval c4(*o-- Page + of -, Donation After CirculatoryCardiac Death 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 and)or a $hysician 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$$orted in a conscious medical state shall reBuire that the OPO confirms the health care team has assessed the $atient?s mental com$etency and ca$acity to ma#e medical decisions including .ithdra.al of life sustaining treatment/ C/ Clearance from medical e8aminer)coroner must be obtained .hen a$$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 Ccare 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/ 5/ >ithdra.al of life sustaining measures (e/g/ %ndotrachealTT 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 c4(*o-- Page ( of -, Donation After CirculatoryCardiac Death a$$roved by the 1ealthcare Decision Ma#er authori6ed to ma#e an anatomical gift in the consent $rocess/ ,%& Pronouncement of Death A/ The $atient care team member $hysician that is authori6ed to declare death must not be a member of the Donor Alliance or organ recovery team/ B/ The method of declaring cardiac death must com$ly in all res$ects .ith the legal definition of death by an irreversible cessation of circulatory and res$iratory functions for t.o to five minutes before the $ronouncement of death ,%%& Organ 'ecovery A/ There .ill be a time limit of no longer than ; minutes and no less than t.o minutes bet.een cessation of circulation and the $ronouncement of death/ Organ recovery may be initiated immediately on $ronouncement of death/ ,%%%& 5inancial Considerations A/ Donor Alliance $olicy shall ensure that no donation related charges are $assed to the donor family/ Procedures! 9ee A$$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$$ortunities Through Donation After Cardiac Death/ Critical Care Nurse& vol 4</ no4/&4**< ("O% 3) +/ McMahan E/ The meta$hysics of death/ Bioethics -,,;=,!,-7-4< ("O% 32) (/ 9ills P/& Blair 1A/& Donation after Cardiac Death! "essons "earned/ Eournal of Trauma Nursing& vol -(& no -& 4**G ("O% 3) ;/ Dries& C/& et al/ An Official American Thoracic 9ociety)2nternational 9ociety for 1eart and "ung Trans$lantation)9ociety of Critical Care Medicine)Association of Organ and Procurement Organi6ations)0nited Net.or# of Organ 9haring 9tatement!%thical and Policy Considerations in Organ Donation after Circulatory Determination of Death/ Am E 'es$ir Crit Care Med& ol -33& 2ss -& $$ -*+7-*,& 4*-+ ("O% 3222)/ </ '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)/ c4(*o-- Page ; of -, Donation After CirculatoryCardiac Death 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/ Crit Care Med 4*-+= (-! 3,G7,*;/ ("O% ;)/ ,/ 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 Anatomical Dift Act& Colorado 'evised 9tatues/ 4*G7+7( (4**G)/o -4/ 9heath& FN/& et/ al/ Autoresuscitation after 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$$ort M09T be inde$endent (and $recede) the DCD $rocess 2nvolvement of #ey $ersonnel $er family D?AR (purple for") "ust be co"pleted@andco"pleted@ and sined by Attendin Physician in the "edical record)MR and on chart 2m$lement 2C0 %O" order7set H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 team H 5amily su$$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$$ort Coordinator collaboratively .ith 0C1 staff or Designated 'eBuestor only Organ reBuest must occur through face to face contact/ 2f the family does not s$ea# %nglish& a Bualified inter$reter must be available for accurate translation %nfor"ed consent process! the health care decision ma#er and)or donor families must understand and agree to all ste$s of the DCD $rocess including acce$tance of the follo.ing! -/ An a$$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 throughout the .ithdra.al of life sustaining 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& for hemodynamic monitoring& is recommended to bemay be $erformed $rior to the DCD $rocess/ $atientAs death in the O'/ "ocal anesthesia .ill be used to ensure $atient comfort/ 2f this is not $ossible or acce$table to the health care decision ma#er& a Do$ller .ill be used to monitor blood $ressure/ (/ Administration of $harmacologic agents (e/g/ he$arin& vasodilators) 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 the physician&Donor Alliance-Pri"ary $ea" MD& The family may be $resent in the O' during end7of7life care .ith surgeon a$$roval and if the family so .ishes/ Donor Alliance 'e$resentative offers family the choice of accom$anying family member)$atient to O' for removal of life sustaining treatmentsu$$ort until declaration of death& and notifies O' of family choice/ At time of death family is escorted from the O' in a timely manner to avoid undue duress and assure se$aration of declaration of death and the $rocurement $rocess/ 'eassure family of $atient comfort and su$$ort throughout the DCD $rocess/ 5amilies should be reminded that the $atient might not al.ays die in an acce$table time frame for organ donation after .ithdra.al of life7su$$ort/ 'eassure families that their loved one .ould then be returned to the 2C0 in this circumstance/ for continued su$$ortive care if death does not occur one hour follo.ing the .ithdra.al of life su$$ort/ 5amilies should also be given the o$tion to see the body of their loved one follo.ing surgery (47( hrs $ost7death) c4(*o-- Page , of -, Donation After CirculatoryCardiac Death +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$$ort through 9$iritualPastoral Care& 2C0 team& social .or# I others (as needed) +8 5amily elects donation! Notify 1os$ital manager& Decedent Affairs 7 begin mobili6a7 tionmobili6ation 2C0 Donor Alliance 1os$ital Manager Decedent Affairs 9$iritualPastoral Care 2C0 team Donor Alliance begins donor management)$lacement $rocess 1os$ital manager .ill ensure a$$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 O' staff initiates contact .ith 2C0 staff and $atient family 2C0 2C0 O' O' nurse contacts 2C0 nurse and ma#es arrangements to come to the unit and meet the $atient and family) O' nurse $re$ares O' for $atient and family/ 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& consent is signed& and decision made by 2C0)O' staff)$hysicians) if family .ill accom$any $atient to the O' or remain in the 2C0 during 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$$ort through Pastoral Care9$iritual Care& Donor Alliance and 2C0 nursing staff I others (as needed) c4(*o-- Page -* of -, Donation After CirculatoryCardiac Death 5 Patient $re$aration for organ recovery O' O' 9taff 2C0 resident MD 2C0 nurse Donor Alliance 2C0 resident MD and nurse glove and go.n for sterile field and continue $atient su$$ort 2C0 resident MD and nurse continue $atient su$$ort .ith guidance from O' staff and Donor Alliance (see above section 4) O' nursing staff $re$ares $atient for organ recovery$re$s and dra$es $atient Primary team MD $erforms arterial cannulation if not already done and the health care decision ma#er consents/ Or uses a Do$ller for measuring arterial im$ulse/ Cannulation may be $erformed under the guidance of Donor Alliance/ H Patient sym$tom management $er 0C1 %nd7of7"ife Duidelines 7 2C0 resident MD& nurse and 'T H 5amily su$$ort through 9$iritualPastoral Care& Donor Alliance and 2C0 nursing staff I others (as needed) 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 $atient does not die .ithin one ON% hour& or .ithin the allotted time s$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$$ort through 9$iritualPastoral Care& Donor Alliance& 2C0 team and social .or# Patient dies! Proceed .ith organ recovery O' 2C0 resident MD 2C0 nurse Donor Alliance 'ecovery team Anesthesiologist Patient must have cessation of circulation for ( *5 "inutes before pronounce"ent of death& 'esident MD2n accordance .ith state la.& a $hysician declares J documents death based on the 2nstitute of MedicineAs criteria! -) Confirm a $ulse of 6ero by arterial catheter or Do$$ler 4)Confirm that the $atient is a$neic +) Confirm that the $atient is H Attention to $ost7 mortem cultural) religious rituals (.here a$$licable) 7 O' team H 5amily su$$ort through 9$iritualPastoral Care& Donor Alliance& 2C0 nursing staff I)7 others at family reBuest c4(*o-- Page -- of -, Donation After CirculatoryCardiac Death 98 unres$onsive to verbal stimuli 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$$ort Coordinator)Organ 'ecovery Coordinator notifies family of death 'ecovery team $roceeds .ith organ recovery 2C0 team returns to the 2C0 7 2C0 resident MD notifies Coroner of death Decedent affairs com$letes death $ac#et AA 5amily does NOT .ant to vie. body $ost7 recovery! Move body to morgue Trans$ort Donor Alliance 0C1 trans$ort 9$iritualPastoral Care >hether the family .ants to vie. the body after death or recovery of organs should be established at the time of the donation decision H Attention to $ost7 mortem cultural) religious rituals (.here a$$licable) 7 1os$ital staff H 5amily su$$ort through 9$iritualPastoral Care I)7 others at family reBuest A8 5amily .ants to vie. body $ost7 recovery! Move body to PAC0 or designated vie.ing room Trans$ort 0C1 trans$ort trans$ort 9$iritualPastoral Care
%f a PACU space@ preferably the PACU isolation@ is not available@$ the 1os$ital Manager .ill arrange for trans$ort to an available room .ithin hos$ital and notify the 2C0 nursing staff O' nurses .ill $erform the $ost mortem care on the DCD $atient Donor Alliance 5amily 9u$$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$$ort through 9$iritualPastoral Care I)7 others at family reBuest %CU tea" K Primary attending and resident MDs& $rimary 2C0 nurse and 'es$iratory Thera$ist ('T) c4(*o-- Page -4 of -, Donation After CirculatoryCardiac Death Recovery tea" K Donor Alliance& recovery surgeons& O' nurses and su$$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)/ 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 +( c4(*o-- Page -+ of -, Donation After CirculatoryCardiac Death 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/ >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/ c4(*o-- Page -( of -, Donation After CirculatoryCardiac Death 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$$ort once informed consent is obtained from the $ro8y)decision7ma#er/ The catheter is used to infuse $reservation solution immediately follo.ing the declaration of death/ The catheter and infusion of $reservation fluid is of benefit to the $otential reci$ient by reducing .arm ischemic time/ There is no #no.n benefit to the donor/ The use of $remortem he$arin and $hentolamine to $reserve organ function has generated controversy since they may hasten death in some $atients/ The 2OM recogni6es the $rinci$al of double effect .hereby an intervention that $reserves donor organ function may have an unintended adverse effect of hastening death/ This $rinci$al is inherent in the $rocess of .ithdra.ing life su$$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$$ort the use of a 4 minute c4(*o-- Page -; of -, Donation After CirculatoryCardiac Death .ait bet.een the cessation of circulation and the declaration of death/ They recommend ho.ever& that additional data is collected to assess the incidence of autoresuscitation/ 2t is therefore $ossible that the 47; minute recommendation could be shortened in the future/ 5AM2"2%9 ! The Bill of 'ights for Donor 5amilies em$hasi6es the need for all 2nstitutions to $rovide designated and trained health care givers .ho can $rovide information and e8$lanations of donor $rocedures to family members/ 5ollo.7u$ .ith donor families is strongly recommended by the Bill/ >ithout the su$$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$resent the national and local heath interests/ There are no national or local legal or ethical barriers to use of DCD/ ConseBuently the Committee on DCD is charged .ith develo$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 with additional points for BMI Probability of expiration within 60 minutes % Probability of expiration within 10 minutes % 10 ! 6 11 1" "# 1 0 # 1" ! $1 1# "! $% 1$ $0 6! 16 6 &$ 1& & !1 1! !1 !6 1% !& %0 0 % % 1 %$ %$ %& %6 " %! %& BMI indicates body mass index' DCD( donation after cardiac death Appendi6 )
DCD Assessment Instruction Worksheet Criteria Assigned Points Pt. Score Spontaneous Respirations after 10 min. )ate *1 1 )ate +1 " ,- *00 cc 1 ,- +00 cc " .I/ +0 " .I/ *0 1 No Spontaneous Respirations % Vasopressors/Inotropes .o -asopressors0Inotropes 1 c4(*o-- Page -3 of -, Donation After CirculatoryCardiac Death 1in2le -asopressors0Inotropes Multiple -asopressors0Inotropes " Patient Age 03"0 1 "13$0 $1 4 " Intubation 5ndotracheal ,ube " ,racheostomy 1 Oxygenation After 10 minutes 6 1at *%0% 1 6 1at !03!%% 6 1at +&%% " BMI +0 1 03% *"0 " /inal 1core ,ime from 5xtubation to 5xpiration c4(*o-- Page -, of -,
Part 3 - Adult Basic and Advanced Life Support - 2020 American Heart Association Guidelines For Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (001-222)
Part 3 - Adult Basic and Advanced Life Support - 2020 American Heart Association Guidelines For Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (001-050)
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)