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 $atients being considered for organ
donation/ Crit Care Med 4*-4 vol/ (*& -;37-<-/ ("O% <)/
c4(*o--
c4(*o-- Page < of -,
Donation After CirculatoryCardiac Death
Attach"ent Appendi6 A
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Donation After CirculatoryCardiac Death
A ppendi6 ttach"ent 8
DCD Procedure Chart
1$)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$$ort
through Pastoral
Care9$iritual Care&
Donor Alliance and
2C0 nursing staff I
others (as needed)
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Donation After CirculatoryCardiac Death
5
Patient
$re$aration for
organ recovery
O'
O' 9taff
2C0 resident MD
2C0 nurse
Donor Alliance
2C0 resident MD and nurse glove and
go.n for sterile field and continue
$atient su$$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 -,