5.1 Understanding donation after circulatory death (DCD)
Introduction
This section contains general information about DCD in New Zealand. DCD is only possible in hospitals that have been credentialed for this process.
What is DCD?
DCD is organ donation occurring after death which has been determined by the absence of circulation.
Which patients should be discussed with ODNZ?
- On ventilatory support in ICU, irrespective of diagnosis and age.
- Consensus that intensive therapies will be withdrawn in the near future.
Which organs can be donated?
In New Zealand lungs, liver and kidneys can be donated in a DCD process. There are several factors which determine which organs can be donated by an individual patient and ODNZ, working with the transplant services, will decide this.
What is the process for DCD?
In New Zealand ICUs, death is very often preceded by withdrawal of intensive therapies, either when it is clear that the patient is dying despite all possible therapies or when continuing intensive therapies are not in the patient’s best interests.
Intensive therapies are withdrawn after consensus has been reached between the treating team and the family. DCD is possible in many of these circumstances.
Prior to any conversations with the family about DCD, ODNZ requests that ICUs discuss these patients with the ODNZ medical specialist who, along with the treating intensivist, will determine whether death is likely to occur within a time frame which makes DCD possible. Sometimes during these discussions, it becomes clear that brain death may occur. In these circumstances both DCD and the option of waiting for brain death to occur should be discussed with the family.
It is ethical to have discussions with ODNZ about donation in parallel with discussions with the family about withdrawal of intensive therapies. However, the option of DCD should only be offered to the family after:
- consensus has been reached between the ICU and the family that intensive therapies will be withdrawn
- the family understand that death is very likely to occur
- ODNZ and ICU team determine that DCD is possible.
If the family raises donation before a consensus has been reached that intensive therapies will be withdrawn, this should be acknowledged sensitively and documented in the clinical record. The family should be told that the ICU team will discuss donation with them in the future should it become appropriate.
The consent requirements and assessment of suitability for donation are the same for both DCD and DBD.
In circumstances where the death should be discussed with the coroner, this discussion should be done while the patient is still alive. If the coroner accepts that these circumstances would lead her/him to accept jurisdiction over the death, conditional agreement from the coroner for DCD must be obtained.
Although in law the coroner is not entitled to take jurisdiction over a death that has not yet occurred, it has been accepted by the Chief Coroner that conditional agreement for DCD can be given. The name of the coroner should be documented.
When the family agrees to DCD, the donor coordinator organises all aspects of the donation process in consultation with the ICU staff, OT staff and the transplant teams. The donor coordinator travels with the donor surgical team(s) to the hospital and will meet the family if present.
The location of withdrawal of intensive therapies is determined primarily by whether the family wish to present at the time of withdrawal and death. Withdrawal of intensive therapies in the OT will only take place if no family member wishes to be present at this time. In practice almost all withdrawals take place in the ICU.
In some hospitals where the ICU is a considerable distance from the OT, it may be appropriate for withdrawal of intensive therapies to be facilitated in a location outside of the ICU which still allows family members to be present.
ODNZ requires that a reliable arterial line be present in all circumstances of DCD. Pulse oximetry will also be required.
The use of medication at the end of life
The use of medication to alleviate distress is the responsibility of the ICU staff. Medication should be used in exactly the same manner (no more and no less) that it would be used in these clinical circumstances if DCD was not occurring.
ODNZ supports the use of whatever dose of medication is necessary to alleviate distress for the patient. ODNZ does not support the use of medication in excess of this to hasten death to ensure that DCD takes place, even if the family request this.
It is impossible to accurately predict the time from withdrawal of intensive therapies until death in an individual patient. ODNZ works with the ICU staff to ensure that all realistic possibilities for DCD are recognised, whilst accepting that a proportion of patients will not die within a time frame that makes DCD possible.
Some ICU staff feel that they have failed if organ donation does not take place. ODNZ wishes to reassure staff that success is measured by the integrity of the process and not by the donation outcome.
Determination of death
Death is determined by the intensive care specialist according to the criteria in the ANZICS Statement:
- absent spontaneous movement
- absent breathing
- absent arterial pulsatility of at least five minutes duration confirmed by clinical examination (absent heart sounds and/or central pulse).
Although ANZICS allows cessation of circulation to be determined by electrical asystole, ODNZ requires that a reliable arterial line be present in all circumstances of DCD.
Death, including the time of death, is documented on the Determination of Death Form for DCD. If the patient dies in the ICU or in a room outside the OT, the patient is transferred to the OT within a few minutes of death.
Donor surgery
If lung donation is occurring, an anaesthetist who is part of the thoracic donor surgical team, will re-intubate the trachea to prevent aspiration.
The donor surgical team(s) will not be present with the patient during the period of time from withdrawal of intensive therapies until death is determined.
If death does not occur within a timeframe after withdrawal of intensive therapies which allows for DCD, then DCD is abandoned. If the patient is outside of the ICU they are transferred back to the ICU for ongoing care. Tissue donation can still be facilitated following death.
5.2 Sequence of events in DCD
A patient on ventilatory support in ICU in whom intensive therapies are likely to be withdrawn.
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Family and treating team agree to the withdrawal of intensive therapies.
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ODNZ is contacted to discuss the potential for DCD.
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Blood is taken for the Donor Blood Pack and the donor coordinator arranges transport.
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The agreement of the coroner is obtained when required.
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Donor information is obtained and required documentation is completed.
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Donor coordinator organises the organ donation.
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OT is set up for donor surgery.
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Planning meeting for all staff involved.
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Withdrawal of intensive therapies in ICU, OT or room adjacent to OT.
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Death is determined and documented.
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Donor surgery commences immediately.
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After the surgery is completed the family may wish to spend time with their relative.