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D onation After C irculatory D eath

D onation After C irculatory D eath. Dawn Seery, D.BE, MA,RN Director of Healthcare Ethics Seton Family of Hospitals For Ethics Champions Series October 8, 2014. Explore the concept of Donation after Circulatory Death Reflect on the ethical tensions associated with DCD

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D onation After C irculatory D eath

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  1. Donation After Circulatory Death Dawn Seery, D.BE, MA,RN Director of Healthcare Ethics Seton Family of Hospitals For Ethics Champions Series October 8, 2014

  2. Explore the concept of Donation after Circulatory Death • Reflect on the ethical tensions associated with DCD • 3) Review recommended DCD elements of practice Objectives

  3. Why emphasize DCD? • Aging society with chronic illness and marginal organs • Hospitals reporting DCD as >30% of donor base • Goal of maximum capacity = • Maximize the number of donors and transplants by identifying donor potential

  4. 123,720 16,883 8,275 920 DCD 1105 DCD 268 DCD 645 DCD Supply andDemand http://optn.transplant.hrsa.gov Figures as of 10/03/2014

  5. About DCD: • The first organ transplants from deceased donors were DCD • Donation processes changed after Harvard Brain death criteria - Brain death = “heart beating donor” 3)“DCD” has changed over time: • Non-Heart Beating Donor; Asystolic donor • Donation after cardiac death • Donation after circulatory death • DCD could increase supply of transplantable organs by 20%; UNOS goal of 10% DCD 5) TJC mandates that even if hospitals do not perform DCD, their policies must address it.

  6. Donation after Circulatory Death: Organ procurement from a person declared death after the planned withdrawal of life-sustaining medical treatment and the irreversible cessation of circulatory and respiratory functions. Conceptual and ethical issues: • Does DCD violate Dead Donor rule? • How much time must elapse? • How shall conflicts of interest be managed?

  7. In order to procure organs from a person, the person must be dead. Definition of Death- 1)“An individual who has sustained either 1) irreversible cessation of circulatory and respiratory functions, or 2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. (Uniform Determination of Death Act, 12 uniform laws annotated 589 (West 1993 and West Suppl. 1997) or 2) In accordance with state regulation and hospital policy; consistent with medical and legal standards Dead Donor Rule

  8. Concerns : 1)Increasing attention to DCD may shift emphasis away from doing what is best for a dying patient to the utility of procurement 2) Determining that death has occurred: • Circulation will not be restored – permanently ceased; will not auto-resuscitate • Brain function will not be restored • Waiting period after asystole prior to declaration – how long to ensure all cessation of circulatory and brain activity?

  9. The dead donor rule does not preclude discussion of or consent to donation prior to death. • New class of potential donors: vent dependent with irreversible condition • Separate the withdrawal decision from the donation decision: • Timing of discussion • By whom?

  10. First Person Consent for DCD: • Consistent with autonomy expressed in Patient Self-Determination Act of 1990. • OPO and hospital have legal obligation to honor the patient’s advance directive that may include organ donation. • The OPO and the hospital should cooperate to ensure that the patient who may decide to forgo life-sustaining medical treatment receives the information required to make an informed decision. • Specific procedural safeguards are needed for conscious vent-dependent patients.

  11. How much time until “Dead” • Whether death has occurred may be empirically unverifiable; is brain death slower than cardiac death? • Imminently dying can be difficult to define • Potential for spontaneous auto-resuscitation • Some DCD protocols shorten the time to declaration • Goal: limit hypoperfusion during waiting time • Disclosure of premortem interventions • Disclosure of specified time period for death

  12. Managing Conflicts of Interest • Consent process • Separation/decoupling • No involvement of OPO or transplant team in decision to withdraw • Premortem interventions to improve organ viability should not harm the donor • Informed consent • Concurrent palliative care, including sedation and analgesia • Code status should be clearly established • OPO and transplant team should not be involved in the declaration of death. • Individual physicians should be allowed to opt out.

  13. Organ donation saves lives • Pool of recipients has grown more quickly than pool of donors • DCD maximizes a scarce resource • Donation requires fully informed consent and provides protection for the donor • DCD may honor patient/family wish • Family may find comfort in donation • Donation nurtures altruism Arguments in support of DCD

  14. Arguments Opposing DCD • DCD manipulates definition of death • Is it two, five or ten minutes? • Permanent and irreversible: when? • Autoresuscitation has not been studied in infants and children. • The underlying medical condition explains why patient is vent dependent but is not the cause of death. • Patients declared dead under DCD programs are imminently dying but not yet dead. • The practice of organ donation may conflict with clinicians’ primary obligation to take care of patient – to serve their medical interests, not to use them to serve the interests of others.

  15. Arguments Opposing • Do No Harm • DCD procedures may not be in the patient’s best interest. • Potential of failed donation • Patient is transferred to a nursing unit to die • Families experience additional distress • Pressure to succeed • Strain on resources • Violates individual conscience and integrity of the professionals

  16. Unsettled Matters: • Substituted judgment difficult: Designated donor on drivers license – binding? • Should families be told of the ethical debate regarding irreversible, permanent cessation? • Is a plan for post donation attempt clearly in place if patient does not die after withdrawal?

  17. Current DCD Policy Requirements: • OPO must have written agreement with hospitals that participate in DCD recovery; • Hospitals must have DCD protocols that define roles and responsibilities of OPO and of transplant centers for evaluation and management of potential donor • Suitable candidate for DCD: • Patients with disease that results in necessary life-sustaining medical treatment/support with ventilator, dependence including those with spinal cord injuries, pulmonary diseases and neurologic diseases • Required plan for “patient care in the event that death does not occur within the established time period after withdrawal.” • Required time out prior to ensure that surgical recovery team does not influence withdrawal of life sustaining medical treatment/support.

  18. Guiding Principles • The offer of organ donation should be a routine part of advance care planning for end of life. • Once the decision to forgo life-sustaining medical treatment is made, then a discussion about donation is appropriate. Explicit informed consent is necessary and a comprehensive post-donation plan must be in place. • The ethical imperative is to enable the most successful outcome for that patient at that time in that place.

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