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University of Colorado Hospital Policy

Introduction:
The purpose of this policy is to outline the procedure in which human organs
are recovered for the purpose of transplantation after the declaration of death according to
circulatory criteria.

Scope:
I. A multidisciplinary team of heath care providers



Table of Contents
Policy Details: ................................................................................................................................. 2
I. Determination of the Healthcare Decision maker...2
II. Discussion of Care .2
III. Potential DCD Donor Evaluation. 2
IV. Consent/Approval..3
V. Withdrawal of Life Sustaining Medical Treatment/Support. 3
VI. Pronouncement of Death...3
VII. Organ Recovery...3
VIII. Financial Considerations............................................3
2
Related Policies:.............................................................................................................................. 4
Definitions: ..................................................................................................................................... 4
References: ...................................................................................................................................... 4
Appendix A: Donation after Circulatory Death Procedural Flow Chart6
Appendix B: Donation after Circulatory Death Procedure Chart7-12


Donation After Circulatory Death

Effective Date:

Revised Date: 7/14
Replaces Policy: Donation After Cardiac
Death


Approval Date: 7/14 Policy Owner: Professional Practice, Policy
and Procedure Committeee
Donation After Circulatory Death

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Policy Details:
I. Determination of the Healthcare Decision Maker for donation of anatomical gift. (CRS
12-34-104 and CRS 12-34-105 ).
The Healthcare Decision Maker for the purpose of making an anatomical gift is the person
designated in the following order of priority:
A. The donor, if the donor has decision making capacity (DMC) and is an adult or is a minor
and is emancipated.
B. An agent appointed in a medical durable power of attorney signed by the patient
pursuant to C.R.S. 15-14-506. unless the power of attorney for health care or other
record prohibits the agent from making an anatomical gift.(CRS 12-34-104)
C. A court-appointed guardian or conservator for the patient, unless otherwise limited by
the court order appointing the guardian or conservator.
D. The Health Care Decision Maker as noted in the Health Care Directive section in the
electronic heath record (EHR).

II. Discussion of Care:
A. The discussion is had between the patient, and/or health care decision maker, with the
attending physician and health care team to discuss goals and values to customize the care
plan.
B. The Heath Care Decision Maker or attending physician discusses withdrawal of life-
sustaining treatment.
C. The decision is made by the Healthcare Decision Maker and the Attending Physician to
transition the patient to end-of-life care. The DNR is completed in the EHR and co-signed
by the Attending Physician within 24 hours.

III. Potential DCD Donor Evaluation:
.
A. The Donor Information Line (303-321-0060) is notified as soon as the Healthcare
Decision Maker begins to consider withdrawal of life sustaining treatment, the glascow
coma scale is < or = 5, or the family has questions about donation.
B. The assessment for donation after circulatory death (DCD) candidate suitability should be
conducted in collaboration with Donor Alliance and the patients primary health care
team. Donor Alliance determination of donor suitability may include consultation from
the Donor Alliance Medical Director and Transplant Center teams that may be
considering donor organs for transplantation.
C. A patient who has a non-recoverable and irreversible neurological injury or chronic
terminal illness resulting in ventilator dependency but not fulfilling brain death criteria
may be a suitable candidate for DCD.
D. In assessment of the patient ensure that progression of the patient to neurological criteria
for death is unlikely.
E. A patient with chronic terminal illness or end stage disease who retains DMC and is on
life support may choose to be evaluated by Donor Alliance for DCD.
F. Donor Alliance should affirm on assessment that there is a reasonable chance of death
within the time frame that allows for organ donation after the withdrawal of life
sustaining treatment.

IV. Consent/Approval
A. Donor Alliance and/or a physician must receive authorization from the health care
Donation After Circulatory Death

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decision maker for any procedures or drugs administration to prepare the patient for DCD
recovery.
B. Conditions involving potential DCD donor being medically treated/supported in a
conscious medical state shall require that the Organ Procurement Organization (OPO)
confirms the health care team has assessed the patients mental competency and capacity
to make medical decisions including withdrawal of life sustaining treatment.
C. Clearance from medical examiner/coroner must be obtained when applicable.
D. There should be a plan for patient care if death does not occur within the established
timeframe after the withdrawal of life sustaining medical treatment. This plan should
include logistics and provisions for continued end of life care, including immediate
notification of the family/Healthcare Decision Maker.
V. Withdrawal of Life Sustaining Medical Treatment
A. Paralytics must be discontinued and allowed to clear prior to withdrawal of life
sustaining treatment, as evidenced by train of four of 4/4, a discussion is had with the
physician if 4/4 is unable to be attained.
B. Prior to withdrawal of life sustaining medical treatment a timeout is required to
confirm:
a. Patient identification.
b. The process for withdrawing life-sustaining treatment or ventilated support.
c. Roles and responsibilities of the primary patient care team, the OPO team, and
the organ recovery team.
d. The hospitals plan for continued patient care in the event that the patient does
not become a donor and appropriate communication with the health care
decision maker.
C. No recovery personnel may be present for the withdrawal of life sustaining medical
treatment.
D. No member of the organ recovery team or Donor Alliance staff may guide or administer
palliative care, or declare death.
E. Family members and other interested parties, as approved by the Health Care Decision
Maker, will be given the opportunity to be present in the OR during withdrawal of life
sustaining treatment and during the period between withdrawal of support and circulatory
death.
F. Withdrawal of life sustaining measures (e.g. Endotracheal removal, termination of blood
pressure support medications) are removed in the operating room as per the attached
algorithm.
VI. Pronouncement of Death
A. The patient care team member physician that is authorized to declare death must not be a
member of the Donor Alliance or organ recovery team.
B. The method of declaring death must comply in all respects with the legal definition of
death by an irreversible cessation of circulatory and respiratory functions for two
minutes before the pronouncement of death.
VII. Organ Recovery
A. Organ recovery may be initiated immediately on pronouncement of death.

VIII. Financial Considerations
A. Donor Alliance policy shall ensure that no donation related charges are passed to the
donor family.

Appendices: Appendix A- DCD Procedure Flow Diagram; Appendix B- DCD Procedure Chart
Donation After Circulatory Death

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Related Policies:
Organ and Tissue Donation
Consent for Medical Care and Procedures
Advance Directives
Determination of Death by Neurologic Criteria (Brain Death)
Mechanical Ventilation: Management and Liberation
End of Life Care

Definitions:
Healthcare Professional: Any individual who is licensed and/or qualified to practice a health
care profession (for example, physician, nurse, social worker, clinical psychologist, pharmacist,
PT/OT/ST, or respiratory therapist) and is engaged in the provision of care, treatment, or services
as defined by their job description. (if applicable)

Healthcare Provider: A credentialed or licensed practitioner who has ordering privileges and
prescribing authority. (if applicable)

Circulatory Death: (Per Uniform Declaration of Death Act, 1981): The cessation of circulation
and respiration. Further defined by monitoring of death by confirming 1) a pulse of zero via
arterial catheter or Doppler, 2) that the patient is apneic, and 3) the patient is unresponsive to
verbal stimuli for a period of two minutes before pronouncement of death.

Donation after circulatory death (DCD): A procedure that entails the recovery of organs after
death due to cessation of circulation in patients who have not met brain death criteria and
decisions are made to forego further life-prolonging treatments.

Decision Making Capacity (DMC): The individual has the ability to provide informed consent
to or refusal of medical treatment.

Healthcare Decision Maker: 1) A patient who retains DMC, or 2) the person authorized to
make medical treatment decisions on behalf of an adult patient who does not have DMC. This
may include an agent under a Durable Medical Power of Attorney, family or proxy. A
Healthcare Decision Maker who meets the criteria set forth in Section I below is authorized to
make an anatomical gift.

Organ Procurement Organization (OPO): non-profit organization that is responsible for the
evaluation and procurement of deceased donor organs for organ transplantation (i.e. Donor
Alliance).


References:
1. DeVita MA, Snyder JV. (1993). Development of the University of Pittsburgh Medical
Center Policy for the care of terminally ill patients who may become organ donors after death
following removal of life support. Kennedy Institute of Ethics Journal (3),113-29. (LOE 5)
2. Edwards J. Mulvania P. (2006). Maximizing Organ Donation Opportunities Through
Donation After Cardiac Death. Critical Care Nurse, 26 (2), 101-115. (LOE 8)
3. McMahan J. (1995). The metaphysics of death. Bioethics, 9 (2), 91-126. (LOE 8)
Donation After Circulatory Death

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4. Sills P., Blair HA. (2007). Donation after Cardiac Death: Lessons Learned. Journal of
Trauma Nursing, 14 (1), 47-50. (LOE 8)
5. Gries, C., White, D.B., Truog, R.D., DuBois, J., Cosio, C.C.,Halpern, S.D. (2013). An
Official American Thoracic Society/International Society for Heart and Lung
Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement
Organizations/United Network of Organ Sharing Statement:Ethical and Policy
Considerations in Organ Donation after Circulatory Determination of Death. Am J Respir
Crit Care Med, 188, (1), 103-109. (LOE 8)
6. Reich, D.J., Mulligan, D.C., Abt, P.L., Pruett, T.L., Abecassis, M.M.I.,Klintmalm,
G.B.G. (2009). ASTS Recommended Practice Guidelines for Controlled Donation after
Cardiac Death Organ Procurement and Transplantation. American Journal of
Transplantation , 9, 2004-2011. (LOE 7)
7. Dare, A.J., Bartlett, A.S., Fraser, J.F. (2012). Critical Care of the Potential Organ Donor.
Curr Neurol Neurosci Rep, 12, 456-465. (LOE 5)
8. Bastami, S., Matthes, O., Krones, T., Biller-Andorno, N. (2013). Systematic Review of
Attitudes Toward Donation after Cardiac Death Among Heathcare Providers and the General
Public. Crit Care Med, 41, 897-905. (LOE 1)
9. Manara, A.R.,Murphy, P.G., OCallaghan, G. (2012). Donation after circulatory death.
British Journal of Anaesthesia , 108, 108-121. (LOE 7)
10. Campbell, M.L. (2011). American Association of Critical Care Nurses: Procedure
Manual for Critical Care. Procedure 137. St. Louis, MO: Saunders:Elsevier. (LOE 1)
11. Anatomical Gift Act, Colorado Revised Statues. (2007). 207-3-4. Retrieved from
http://www.colorado.gov (LOE 8)
12. Sheath, KN., Nutter, T., Stein, D.M., Scalea, T.M., Bernat, J. L. (2012).
Autoresuscitation after asystole in patients being considered for organ donation. Crit Care
Med, 40, (1), 158-161. (LOE 6)
13. Proposal to Update and Clarify Language in the DCD Model Elements. (2013). Retrieved
from http://www.unos.org (LOE 8)















Donation After Circulatory Death

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Donation After Circulatory Death

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Appendix B
DCD Procedure Chart

STEP
#
Description Location
Key
Personnel
Key Points
*Supportive
care for
patients and
families


0
Decision to
withdraw life-
sustaining
treatment
ICU
ICU team
Spiritual
Care
Decision to withdraw life sustaining
treatment MUST be independent
(and precede) the DCD process
Involvement of key personnel per
family
DNAR must be completed, and
signed by Attending Physician in
the medical record
Implement ICU EOL order-set
Patient
symptom
management
per UCH End-
of-Life
Guidelines -
ICU team
Family
support
through
Spiritual Care,
ICU team,
social work +
others (as
needed)

1
Notification of
Donor
Information
Line (potential
donor)
ICU
ICU
nursing
staff
Donor
Alliance
Donor Alliance will assess
eligibility of a potential donor
(initial assessment should not
include contact with the patient or
family).
Patient
symptom
management
per UCH End-
of-Life
Guidelines -
ICU team
Family
support
through
Spiritual Care,
ICU team,
social work +
others (as
needed)





2

Donor
Alliance
Family
Support
Coordinator
collaboratively
with UCH
staff
ICU
Designated
Requestor:
Donor
Alliance
Organ request MUST be performed
through a Donor Alliance Family
Support Coordinator collaboratively
with UCH staff only
Organ request must occur through
face to face contact. If the family
does not speak English, a qualified
interpreter must be available for
accurate translation
Informed consent process: the
health care decision maker and/or
donor families must understand and
agree to all steps of the DCD
process including acceptance of the
following:
1. An approximate time of 6-8
hours prior to withdrawal of
life sustaining treatment is
needed to allow for necessary
organ recovery preparations.
Patient
symptom
management
per UCH End-
of-Life
Guidelines -
ICU team
Family
support
through
Spiritual Care,
Donor
Alliance
(Family
Support
Team) +/-
ICU team and
social work/
others (if
present)

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2. The ICU team will remain at
the patient's bedside throughout
the withdrawal of life
sustaining treatment process.
3. Arterial cannulation, for
hemodynamic monitoring, is
recommended to be performed
prior to the DCD process.
Local anesthesia will be used
to ensure patient comfort. If
this is not possible or
acceptable to the health care
decision maker, a Doppler will
be used to monitor blood
pressure.
4. Administration of
pharmacologic agents (e.g.
heparin, vasodilators) for the
sole purpose of donor organ
function must be detailed in the
consent process and ordered
on a case by case basis by the
physician.
The family may be present in the
OR during end-of-life care if the
family so wishes. Donor Alliance
Representative offers family the
choice of accompanying family
member/patient to OR for removal
of life sustaining treatment until
declaration of death, and notifies
OR of family choice. At time of
death family is escorted from the
OR in a timely manner to avoid
undue duress and assure separation
of declaration of death and the
procurement process.
Reassure family of patient comfort
and support throughout the DCD
process.
Families should be reminded that
the patient might not always die in
an acceptable time frame for organ
donation after withdrawal of life-
support. Reassure families that their
loved one would then be returned to
the ICU in this circumstance.
Families should also be given the
option to see the body of their loved
one following surgery (2-4 hrs post-
death)

Donation After Circulatory Death

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3A
Family does
NOT elect
donation:
Document
decision and
provide
support
ICU
Spiritual
Care
Donor
Alliance
ICU team
Provide continued support for
patient and family; address further
questions/ concerns
Donor Alliance documents decision
including reason for no donation
Patient
symptom
management
per UCH End-
of-Life
Guidelines -
ICU team
Family
support
through
Spiritual Care,
ICU team,
social work +
others (as
needed)



3B
Family elects
donation:
Notify
Hospital
manager,
Decedent
Affairs - begin
mobilization
ICU
Donor
Alliance
Hospital
Manager
Decedent
Affairs
Spiritual
Care
ICU team
Donor Alliance begins donor
management/placement process
Hospital manager will ensure
appropriate ICU staff allocated and
mobilized
Decedent Affairs will initiate
paperwork with family
Ongoing support of family
Patient
symptom
management
per UCH End-
of-Life
Guidelines -
ICU team
Family
support
through
Spiritual Care,
Donor
Alliance, ICU
team, social
work + others
(as needed)

3C

OR staff
initiates
contact with
ICU staff and
patient family
ICU
ICU
OR
OR nurse contacts ICU nurse and
makes arrangements to come to the
unit and meet the patient and
family/
OR nurse prepares OR for
patient and family.

Donation After Circulatory Death

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4

Family, Donor
Alliance and
staff
preparations
complete:
Transport
patient to OR
Transport
ICU
resident
MD
ICU nurse
+ RT

Donor
Alliance
Transport should occur after:
1. The family is ready, consent is
signed, and decision made by
ICU/OR staff/physicians/ if
family will accompany patient
to the OR or remain in the ICU
during withdrawal of life
sustaining treatment
2. Donor Alliance has completed
pre-recovery process
3. Necessary preparations by the
OR and Recovery teams are
complete
4. Necessary ICU coverage has
been secured
ICU resident MD, RT and nurse
then proceed with the patient to the
OR and continue patient support
Patient
symptom
management
per UCH End-
of-Life
Guidelines -
ICU resident
MD, nurse
and RT
Family
support
through
Spiritual Care,
Donor
Alliance and
ICU nursing
staff + others
(as needed)


5
Patient
preparation for
organ
recovery
OR
OR Staff
ICU
resident
MD
ICU nurse
Donor
Alliance

ICU resident MD and nurse glove
and gown for sterile field and
continue patient support
OR nursing staff prepares patient
for organ recovery patient
Primary team MD performs arterial
cannulation if not already done and
the health care decision maker
consents. Or uses a Doppler for
measuring arterial impulse.

Patient
symptom
management
per UCH End-
of-Life
Guidelines -
ICU resident
MD, nurse
and RT
Family
support
through
Spiritual Care,
Donor
Alliance and
ICU nursing
staff + others
(as needed)



6

Withdrawal of
life-sustaining
treatment
OR
ICU
resident
MD
ICU nurse
and RT
Donor
Alliance

Withdrawal of life sustaining
treatment should adhere to UCH
End-of-Life Guidelines and ICU
EOL order-set, including
discontinuation and clearance, of
paralytics prior to
discontinuation of mechanical
ventilator.
ICU resident and nurse remain
present throughout the withdrawal
process to the time of death or the
patient's return to the ICU. RT
extubates patient per policy
Patient
symptom
management
per UCH End-
of-Life
Guidelines -
ICU resident
MD, nurse
and RT
Family
support
through
Spiritual Care,
Donor
Alliance and
ICU nursing
staff + others
(as needed)
Donation After Circulatory Death

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7A

Patient does
NOT die:
Return patient
to ICU and
continue
patient and
family support
Transport
ICU
resident
MD
ICU nurse
Donor
Alliance

If patient does not die within one
hour, or within the allotted time
specified by the OPO for organ
viability, the ICU nurse will notify
ICU charge nurse that the patient is
returning to the ICU or designated
bed.
ICU charge nurse /Donor Alliance
notifies family that patient is alive
and is returning with the ICU team
Patient
symptom
management
per UCH End-
of-Life
Guidelines -
ICU resident
MD and nurse
Family
support
through
Spiritual Care,
Donor
Alliance, ICU
team and
social work







7B


Patient dies:
Proceed
with organ
recovery
OR
ICU
resident
MD
ICU
nurse
Donor
Alliance
Recovery
team
Patient must have cessation of
circulation for 2minutes before
pronouncement of death. In
accordance with state law, a
physician declares & documents
death based on the Institute of
Medicine's criteria:

1) Confirm a pulse of zero by
arterial catheter or Doppler
2)Confirm that the patient is
apneic
3) Confirm that the patient is
unresponsive to verbal stimuli
The incision for organ recovery
may occur immediately after
pronouncement of death.
Donor Alliance coordinates
recovery transition
ICU nurse notifies ICU charge
nurse of death
Donor Alliance Family Support
Coordinator/Organ Recovery
Coordinator notifies family of death
Recovery team proceeds with organ
recovery
ICU team returns to the ICU -
ICU resident MD notifies Coroner
of death
Decedent affairs completes death
packet
Attention to
post-mortem
cultural/
religious
rituals (where
applicable) -
OR team
Family
support
through
Spiritual Care,
Donor
Alliance, ICU
nursing staff
+/- others at
family request

8A

Family does
NOT want to
view body
post-recovery:
Move body to
morgue
Transport
Donor
Alliance
UCH
transport
Spiritual
Care

Whether the family wants to view
the body after death or recovery of
organs should be established at the
time of the donation decision
Attention to
post-mortem
cultural/
religious
rituals (where
applicable) -
Hospital staff
Family
support
through
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Spiritual Care
+/- others at
family request


8B
Family wants
to view body
post-recovery:
Move body to
designated
viewing room
Transport
UCH
transport
Spiritual
Care

The Hospital Manager will
arrange for transport to an
available room within hospital
and notify the ICU nursing
staff
OR nurses will perform the post
mortem care on the DCD patient
Donor Alliance Family Support
Coordinator/Spiritual Care
accompanies family to recovery/
viewing room (or per family
request)
Post recovery needs of family will
be supported
Attention to
post-mortem
cultural/
religious
rituals (where
applicable) -
Hospital staff
Family
support
through
Spiritual Care
+/- others at
family request
ICU team = Primary attending and resident MDs, primary ICU nurse and Respiratory
Therapist (RT)
Recovery team = Donor Alliance, recovery surgeons, OR nurses and support staff
* Additional patient, family or staff support is available through the Palliative Care Consult
Service and/or the Ethics Consult Service