Uncontrolled Organ Donation after Cardiac Death

By Casey Carr, MD, and Torben Becker, MD, PhD

A 55-year-old man collapses while driver’s license is obtained in order to performing land care at home and contact next of kin — and he is found to is found to be in cardiac arrest. He have opted in to be an organ donor. receives advanced cardiac life support in the prehospital setting, and when he does not obtain a spontaneous return of circulation, he is transported to the nearest emergency department. Despite further prolonged attempts at resuscitation, his initial rhythm of Is there a mechanism for this patient to donate his organs? Are there differences in approach in countries outside of the United States? What are the ethical considerations of this approach? ventricular fibrillation devolves into The supply for organs for deceased asystole, no cardiac motion is noted on donor transplantation has hit a plateau bedside ultrasound, and his end tidal in the United States despite substantial CO2 is consistently less than 10 mm efforts to increase organ donation Hg. His time of death is declared. His rates over the past 10 years. While organ donation after brain death (DBD) remains the most common form of organ donation, nonstandard forms of donation, such as donation after cardiac death (DCD) have been explored in response to this organ shortage. DCD can be categorized as controlled or uncontrolled. Controlled DCD (cDCD) occurs in the hospitalized setting after planned withdrawal of care. Donation in this setting accounts for less than 10% of all U.S. organ donations. Uncontrolled DCD (uDCD) occurs after unexpected cardiac death, frequently outside of the hospital. While the Institute of Medicine

“The supply for organs for deceased donor transplantation has hit a plateau in the United States despite substantial efforts to increase organ donation rates over the past 10 years. While organ donation after brain death (DBD) remains the most common form of organ donation, nonstandard forms of donation, such as donation after cardiac death (DCD) have been explored in response to this organ shortage.”

has recommended uDCD as a promising and ethically acceptable method of transplantation, adoption of this model in the United States remains incredibly rare.

France and Spain have the most robust programs of this kind, where uDCD account for a significant number of deceased donor transplants and has been practiced since the 1980s. From 2005-2015, Spain had over 1,000 cases of uDCD transplantations. Both of these countries have specific legislation pertaining to uDCD. These legal texts include revisions related to the criteria for death, limitations to preservation, and requirements for consent. Additionally, national guidelines and protocols have been issued that deal with both the ethical and technical aspects of uDCD.

Both Spain and France have an opt out policy regarding organ donation, both controlled and uncontrolled. In these countries, obtaining consent from family is focused on checking for any expressed opposition towards donation. Family consent during uDCD occurs during different points in time, varying between countries and local policy — at times as soon as death is declared or when reperfusion techniques are started. No organ procurement takes place until family provides consent, regardless of where in the uDCD process the conversation occurs. In both France and Spain, there is a strong emphasis on physician involvement in emergency medical services (EMS), which may explain the expansion of these programs in these countries.

The procedure of uDCD consists of determination of death, donor referral, donor transfer, organ preservation, and organ procurement. Consent and authorization for organ donation can take place any time during this process, depending on country and local policy.

Current estimates by the Institute of Medicine (IOM) would have uDCD increase organ donation by 22,000 per year in the United States. These estimates were based on the yearly incidence of out-of-hospital cardiac arrest and experience with organ transplantation after uDCD outside the U.S.; however, there are significant ethical concerns. While the majority of Americans would support rapid organ recovery after out-of-hospital cardiac arrest, most would prefer family consent prior to any preservation procedure, and many feel that uDCD would decrease trust in the medical community. One significant ethical challenge is the definition of the irreversibility of cardiac arrest. While outof-hospital cardiac arrest outcomes are poor, there may be a conflict of interest among clinicians declaring death prior to exhausting all advanced cardiac arrest therapies when uDCD is an option. The cessation of advanced cardiac arrest treatment must be entirely independent of consideration of organ donation. Some authors contend that even in the setting of impartial cessation of CPR, the presence of uDCD protocols may create doubt in the impartiality of health care providers on abandoning CPR.

Another concern is the performance of preservation techniques after cardiac death but before obtaining family consent. In countries with the most successful programs, chest compressions and mechanical ventilation are continued, even after cardiac arrest is declared irreversible. In addition, some preservation techniques are significantly invasive — from placing pleural tubes to initiating ECMO (extracorporeal membrane oxygenation). Patient’s families may be rightfully concerned that their deceased loved one may be exposed to these additional procedures before consent is obtained. In populations where community trust in the medical community is low, these concerns would be understandably heightened.

Currently, there are no ongoing uDCD programs in the U.S. There have been pilot projects, such as in New York City from 2010 to 2011. While reception by families was positive, there were frequent protocol violations and ultimately no organs were ever recovered. Patients with end organ failure who rely on organ transplantation continue to grow in number, and every year more patients die while waiting. Organ donations have plateaued and uDCD is a potential option for change. Emergency physicians are on the front lines in response to cardiac arrest. Given this pivotal position, emergency physicians need to have an understanding of uDCD protocols and practices and are uniquely positioned to contribute to ongoing research and policy development.

ABOUT THE AUTHORS

Dr. Carr is a second-year emergency medicine-critical care medicine fellow at the University of Florida.

Dr. Becker is an assistant professor, chief of the division of critical care medicine and the director of prehospital research in the department of emergency medicine at the University of Florida College of Medicine.