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Understanding Organ Donation After Cardiac Death _DCD_

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					Understanding Organ Donation
After Cardiac Death (DCD)
A Resource Guide for Healthcare Professionals
2
           Introduction

           Organ and tissue donation offers families a glimmer of hope
           and comfort at a time when all seems lost. It also provides
           families the opportunity to honour a loved one’s wish to donate.
           Organ transplantation has evolved from an experimental
           treatment to the treatment of choice for thousands of Ontarians
           who await the gift of life. Transplantation offers recipients
           whose lives were severely restricted by their illness, or next
           to death, a dramatic improvement in health and well-being.
           Unfortunately the supply of solid organs for transplantation has
           not met the demand and has, despite best efforts, remained
           relatively unchanged over the past decade. Historically organ
           donation has only occurred after brain death and only a small
           percentage of all hospital deaths result from a determination of
           neurological death (brain death). Some estimates are as small as
           1.5-3%. Reliance on organ donation after brain death severely
           limits the availability of organs for transplant. The numbers tell
           the story:

                                    A Historical Overview of Donation and Transplantation Activity

                          2500


                                      Actual Donors   Transplants   Waiting List

                          2000
           Total Number




                          1500




                          1000




                           500




                             0
                             1994      1995   1996    1997   1998    1999     2000   2001   2002   2003   2004
                                                                    Years




UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals             3
    DCD: A Short History

    Formerly called Non-Heart-Beating Organ Donation (NHBD),
    organ donation after cardiac death (DCD) has been an end-of-
    life option for patients and families for more than thirty years in
    the USA and Europe. Prior to the introduction of the concept of
    brain death and its ensuing laws, DCD was the way in which all
    organs were recovered.

    Initially DCD had its limitations such as poor organ function
    for recipients. Donation after brain death (deceased donation)
    offered better outcomes. As a result DCD fell by the wayside
    and donation after brain death became the preferred method
    of organ recovery.

    The ongoing shortage of organs for transplantation has
    created a renewed interest in organ donation after cardiac
    death. Improved medications and surgical techniques have
    dramatically improved the outcomes for recipients of DCD
    donated organs. These advances combined with the severe
    shortage of organs for transplant make organ donation
    after cardiac death another option for patients and families
    interested in giving the gift of life.




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           DCD: A Short Description

           Organ donation after cardiac death is an option for families
           of patients who have decided to withdraw life support after a
           physician has determined that there is no long- term prognosis
           for recovery, and for those patients who do not meet the
           criteria for neurological death. After the decision has been
           made that the patient has no chance of survival and the family
           has decided to withdraw life support, the family is offered the
           option of organ donation after cardiac death. The option of
           donating organs after cardiac death should be offered prior to
           the withdrawal of life support but only after the decision to
           withdraw life support has been made.




UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals   5
    Hospital Staff – Your Role in DCD

    Trillium Gift of Life Network (TGLN) will assist hospitals in
    providing the option of DCD to families while ensuring the
    process works for all those involved.

    Physician:
    • Makes major decisions about patient care
    • Works to preserve life before decision made to withdraw care
    • Serves as family advocate and may offer the option of DCD
    • Declares patient’s death by cardio-circulatory criteria


    Nurse:
    • Provides on-going care to families throughout the patient’s
      hospital stay
    • Coordinates clinical management of patients and provides
      support for family
    • May make the referral call to Trillium Gift Of Life Network
      about potential DCD donor
    • May initiate DCD conversation after discussion with the
      healthcare team and Trillium Gift Of Life Network


    Pastoral Care and Social Worker:
    • Meets spiritual, religious and other non-clinical needs of
      patient and family
    • Serves as family advocate in collaboration with medical and
      nursing staff
    • May provide DCD information in response to family requests




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           The DCD Process: Ten Steps To Saving Lives

           The DCD process is no more difficult or complex than organ
           donation after brain death. The wishes and needs of the
           family are paramount and always the focus of the team
           during this emotionally charged time. Families make the
           decision to help others at a time of great personal loss.
           Sensitivity, openness and the ability to actively listen can
           all help in making the DCD process as positive as possible
           under the circumstances.

           Step One: End-of-Life Decision
           For the patient on life support, the family is informed about
           the serious nature of their loved one’s injury and their poor
           prognosis. After all medical options have been exhausted,
           families are consulted regarding the withdrawal of life sustaining
           treatment. The decision to withdraw life support is made by
           the family and the medical team. Participants may include the
           attending physician, bedside nurse, clergy, a representative
           from social work and extended family members. The option
           of organ donation after cardiac death poses no difference
           in the decision to withdraw life support than cases where
           support is withdrawn and donation was not an option.


           Step Two: Offering The Option
           After TGLN has been contacted, a decision will be made to
           determine if the patient is a potential DCD donor. Once this
           decision has been made, a designated person (either an Organ
           & Tissue Donation Coordinator, their designate, or a hospital
           assigned person) will offer the family the option of donation.
           The person providing the option will have specific training
           on how to sensitively conduct a donation conversation. This
           conversation will take place in a quiet area away from the
           patient’s bedside where the family will not be distracted
           by external stimuli. The family is given full and complete
           information regarding the option of DCD so that they can
           make a decision that is right for them and their loved one.




UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals   7
    The DCD Process: Ten Steps (continued)

    Step Three: Consent
    If the family consents to organ donation the next of kin or
    legal substitute completes the organ donor consent form
    in compliance with the Trillium Gift Of Life Network Act.
    In addition, TGLN staff, or designated hospital staff, obtain
    written consent for several specific actions:
    • Organ donation after cardiac death
    • Pre-mortem treatment for the purpose of organ donation
      after cardiac death
    This may include medication and preparation for the insertion
    of cannulas to ensure optimal organ outcome.
    To ensure timely surgical recovery of consented organs and
    optimal graft function, it may be necessary to insert a small
    cannula in the groin where organ flush solutions will be
    administered after death has been pronounced and the
    five minute waiting time post asystole has been observed.
    Anticoagulants may be administered prior to death while
    the heart continues to beat to avoid clotting and ensure
    circulation and perfusion to all organs.


    Step Four: Evaluation
    The TGLN coordinator, in collaboration with the healthcare
    team, will coordinate the donation process. This will include
    a respiratory drive assessment, organ function assessment,
    and a complete and thorough medical and social history to
    ensure transplant suitability. Further suitability testing may
    ensue as a result of the social/medical questionnaire. The
    TGLN representative will schedule the OR time and arrange
    the arrival of the necessary surgical recovery teams.
    The TGLN representative will discuss with the family the
    possibility that their loved one will not expire within the
    timeframe needed for donation to ensure optimum outcomes
    for transplant recipients. If this situation occurs the patient
    will be returned to an appropriate area of the hospital where
    comfort measures can be provided and family members can
    be present.




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           Step Five: Coordination and Decision Making
           TGLN staff and the medical staff at your hospital will consult
           with the family regarding timing of withdrawal. This decision
           will be made prior to the arrival of the surgical team.
           Withdrawal of life support may occur in the ICU, the OR or
           another area close to the OR.
           Withdrawal of life support is usually done by the physician who
           has been in charge of the patient’s care, but may be done by
           other physicians depending on your specific hospital policy.


           Step Six: Preparing for Surgery
           When the surgical recovery team arrives at the hospital they
           will consult with the healthcare team. The recovery team will
           be available to answer any questions or address any concerns
           the staff may have. They will get an update on the status of the
           patient and review the consent form and confirm blood type.


           Step Seven: Final Good-Byes
           Trillium Gift of Life Network recognizes that this is an
           emotionally charged time for family members. Family members
           will be afforded every opportunity to have their last moments
           with their loved one be as memorable and personal as possible.
           The TGLN representative will be available at this time to offer
           support and tend to the needs and final wishes of family
           members.




UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals   9
     The DCD Process: Ten Steps (continued)

     Step Eight: Withdrawal of Life Support
     If withdrawal of life support is to take place in the operating
     room the patient will now be transferred, supported on a
     ventilator and monitored by medical staff. If support is to be
     withdrawn in the ICU, the medical team will withdraw life
     support. A physician not involved with the transplantation
     process will pronounce death. A second physician is required
     by the TGLN Act to confirm death for donation to occur. In
     addition, a physician will confirm the absence of spontaneous
     respiration and absence of a pulse pressure for a period of five
     minutes.
     It is important to note that in all settings where life support is
     withdrawn, patient comfort measures are of utmost concern.
     The attending physician may administer analgesia based on
     clinical judgment. The same end-of-life care is given to the
     patient regardless of whether support is withdrawn in the
     ICU or OR and if organ donation had not been an option. In
     some instances the family may be present in the OR for the
     withdrawal of life support depending on individual hospital
     policy.


     Step Nine: Organ Recovery
     After the declaration of death and the five-minute absence
     of spontaneous respiration and absence of pulse pressure is
     documented, surgical recovery of organs begins. (Research has
     shown that a patient’s heart will not resume beating beyond
     two minutes after declaration of cardiac death.)
     If the patient does not expire within the timeframe needed for
     organ recovery (120 minutes), the patient will be transferred
     to a designated area as outlined in step four.


     Step Ten: Saving More Lives
     The organs that are recovered are allocated according to an
     agreed upon provincial algorithm which gives waiting recipients
     a second chance at life.




10
           Benefits of Organ Donation After Cardiac Death

           Organ donation after cardiac death provides the family
           of patients who do not meet the criteria for donation after
           neurological death (deceased donation) the option of
           honouring a loved one’s wish.
           Recipients are not the only ones that benefit from organ
           donation. Because of the recipient’s second chance at life
           their family is able to enjoy more quality time together.
           Organs from DCD donors are proven to have similar
           outcomes as those from deceased donors.




UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals   11
     Frequently Asked Questions

     Organ donation can raise a variety of question and concerns
     not only for families of potential donors but also for those
     who care for them. Research has shown that organ donation
     after cardiac death raises some specific concerns, such as:


     1. Who are the two physicians that pronounce death?

     The attending physicians such as a neurologist, neurosurgeon,
     anesthetist or intensivist are all able to declare death. The
     physicians that declare death will have no affiliation with a
     transplant program.



     2. Will the family be able to be with their loved one at
        the end of life?

     Depending upon the hospital protocol this may be an option
     for families. If withdrawal of life support occurs in the ICU the
     family may be present to witness asystole. In some institutions
     it may even be possible for family members to be in the OR
     when death is declared. It is important to note that family
     members will be informed of the need to leave their loved
     one’s side once death has been declared so that the recovery
     surgery may proceed.


     3. Is the patient really dead when organ recovery occurs?

     Organs are never recovered from a patient until they have had
     two (2) confirmations of death by two different physicians who
     have no association with a transplant program. TGLN will then
     wait an additional five minutes prior to the start of surgical
     recovery of organs to ensure auto resuscitation does not occur.




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           4. Does the patient feel pain during organ recovery?


           No. After someone dies they no longer feel pain. Organ
           donation after cardiac death only occurs after a patient
           is declared dead.



           5. Are medical professionals doing harm?


           Patients considered for DCD have suffered an injury or illness
           that has rendered them dependent on life support with no
           hope of recovery. DCD is not offered as an option to families
           until a decision to withdraw life support has been made in
           consultation with the medical team. DCD is an option for
           families at end-of-life where their loved one does not meet
           the criteria for deceased donation but who are interested in
           donating the gift of life.



           6. Is there a conflict of interest for the Organ Procurement
              Organization (TGLN)?

           TGLN will only be contacted when death is imminent or after
           the decision to withdraw life support has been made by the
           family and physician. The role of TGLN is to educate and
           support hospital staff, ensure every family is offered the option
           of donation according to the Trillium Gift of Life Network Act,
           and to honor the wishes of patients and their families.




UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals   13
     Trillium Gift of Life Network gratefully acknowledges the
     work of the University of Wisconsin Hospitals and Clinics
     Organ Procurement Organization, and for their sharing of
     both expertise and resources.




     References:

     Organ Donation After Cardiac Death: Saving More Lives.
     The University of Wisconsin Hospitals and Clinics Organ
     Procurement Organization, 600 Highland Avenue, Madison, WI




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UNDERSTANDING ORGAN DONATION AFTER CARDIAC DEATH (DCD) A Resource Guide for Healthcare Professionals   15
      For more information:

  Trillium Gift of Life Network
155 University Avenue, Suite 1440
   Toronto, Ontario M5H 3B7




 Toronto Region: 416-363-4438
   Toll Free: 1-877-363-8456
  Email: info@giftoflife.on.ca




          Printed in Canada, 2005

				
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