Donation after Circulatory Death (DCD)

Reviewed and revised 13 July 2015

OVERVIEW

  • Donation after Circulatory Death (DCD) refers to organ donation taking place once circulatory arrest has occurred following treatment withdrawal
  • Advantages of DCD:
    •  provides further donation opportunities for people who wish to be organ donors after their death
    • provides an ethically acceptable means of increasing the availability of deceased donor organs
  • Quality end of life care for a potential organ donor remains the priority and must not be compromised by the donation process

ORGAN SPECIFIC ISSUES

  • kidneys: higher incidence of delayed graft function with DCD kidneys but similar graft survival
  • liver: lower patient and graft survival at 1 year
  • pancreatic: similar to brain death donation
  • lung: similar to brain death donation

WARM ISCHAEMIC TIME

  • time from withdrawal of treatment -> cold perfusion
  • the most important phase occurs when SBP < 60mmHg
  • liver: < 30 min
  • kidney and pancreas: < 60 min
  • lung: < 90 min

PRECONDITIONS

  • ventilated patient from whom treatment is to be withdrawn (e.g. severe irreversible brain injury, severe cardiac or respiratory failure, ventilator dependent quadriplegia)
  • death likely to occur within a time following treatment withdrawal that permits organ retrieval for transplantation (normally < 60-90 min, determined by whether the patient will breathe post-extubation)
  • medical suitability as per TSANZ criteria (see Contraindications to Solid Organ Donation)

PREPARATION

  • contact with transplant co-ordinator to see whether possible
  • consent obtained from family (must be informed that withdrawal of care will now take a longer time for planning and testing)
  • may required permission from Coroner
  • blood taken for serological testing and tissue typing
  • permission obtained for the administration of drugs (heparin) and procedures (bronchoscopy, femoral vessel cannulation for preservation solution infusion) to facilitate organ preservation (this can’t be done in NSW for medico-legal reasons)
  • mobilization of transplant team (must not participate in withdrawal or determine death)
  • preoperative assessment

PROCESS

  • documentation of reasons for treatment withdrawal
    -> complete ‘Authority for Organ and Tissue Removal’ form
  • anxiolytics and analgesics can be administered until the moment of death
  • treatment withdrawal (in ICU/OT) -> extubation/ cessation of ventilation

The Definition of Death

  • immobility
  • apnoea
  • absent skin perfusion
  • absence of circulation (no arterial pulsatility for 2 min)
  • don’t monitor ECG
  • re-intubation to prevent aspiration is permissible
  • documentation of death (time and date) by intensivist
  • family can be present until death
  • organ retrieval then must take place in a timely manner to minimise warm ischaemia time
  • if warm ischaemia time exceeded then tissue donation may still be appropriate
  • if organs not suitable for transplantation due to prolonged warm ischaemia time, care of patient will continue in ICU

POST-DONATION TIME

  • patient transferred back to ICU/mortuary (whatever the family prefer)

PREPARATION FOR POSSIBILITY OF UNSUCCESSFUL ORGAN DONATION

  • medically inappropriate
  • warm ischaemia time exceeded
  • may still donate tissue once death has taken place

POSSIBILITY OF CONSENT WITHDRAWAL

  • may occur at any time during the process

References and Links

Journal articles

  • Manara AR, Murphy PG, O’Callaghan G. Donation after circulatory death. Br J Anaesth. 2012;108 Suppl 1:i108-21. [pubmed] [free full text]

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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