Organ Donation Opportunities for Action (2006) / Chapter Skim
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5 Expanding The Population of Potential
5 Expanding The Population of Potential
Pages 127-174
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From page 127... ...
deaths, those with circulatory determination of death. Because most Americans support organ donation and many have designated their consent for donation by signing their driver's license or a donor card or by joining a donor registry, it is important to identify ways in which these individuals can have the opportunity to be organ donors after they die.
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From page 128... ...
Because uncontrolled DCDD has not been fully explored, the chapter provides an estimate of the potential number of donors as well as outlining major challenges in moving forward in this area. An additional group of potential donors are those with age or medical characteristics outside of the standard criteria for organ donation.
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From page 129... ...
Many cardiac arrests occur in the home and at other sites outside of the hospital setting. As a result, a number of factors (such as the duration of time before emergency care is provided and the availability of healthcare professionals and medical equipment)
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. In situations involving unanticipated or uncontrolled deaths, there may be many more unknowns; healthcare professionals may arrive after the patient has collapsed and the length of time with hypotension, cardiovascular shock, or cardiac dysrhythmia may be unknown.
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. It is important to note that in the early days of transplantation, DCDD protocols were frequently used, and in some organ procurement organizations (OPOs)
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For cases of cardiac arrest in uncontrolled circumstances, there is not time to plan in advance to maintain organ viability, but certain organ preservation measures can be implemented after death is declared. The outcomes of controlled DCDD transplantation have been found to be similar to those for DNDD transplantation for most organs.
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. Although implementation of uncontrolled DCDD protocols and programs is recognized as an opportunity to greatly increase the number of potential organ donors (especially kidney donors)
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. That report's recommendations focused on controlled DCDD and suggested that attention be given to greater consistency in DCDD policies and better support for patients and their families, sustaining the integrity of organ procurement efforts, and maintaining public confidence in the organ transplantation system (Box 5-3)
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From page 135... ...
Recommendation 2: The decision to withdraw life-sustaining treatment should be made independently of and prior to any staff-initiated discussion of organ and tis sue donation. Recommendation 3: As recommended in the 1997 IOM report, statistically valid observational studies of patients after the cessation of cardiopulmonary function need to be undertaken by appropriate experts.
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From page 136... ...
It will be important to focus on the systems changes at the hospital and the OPO levels and will also require that the public and healthcare professionals be engaged in discussions about the complexities of DCDD. Learning from Past Experience and International Models Several European countries have developed and have used the infrastructures of both the emergency medical services and the transplantation services to provide optimal emergency care and to be available as needed to
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From page 137... ...
. Furthermore, in the early 1990s efforts were made in Washington, D.C., to develop a program for uncontrolled DCDD.
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From page 138... ...
The program illustrates the potential for communities to come together to support organ donation efforts; the challenges in financing this program, however, led to its discontinuation and point out the necessity of sustained funding sources for such efforts to be fully developed and implemented. Furthermore, there needs to be a broader appreciation of the impact that DCDD could have in terms of the numbers of lives that could be saved as well as the healthcare cost savings that could be achieved by reducing the numbers of people receiving dialysis.
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. The criteria used to identify potential organ donors include no evidence of drug dependency or death by physical violence, and the onset of external cardiac massage and mechanical ventilation within 15 minutes of cardiac arrest.
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. Unique features that facilitate uncontrolled DCDD in Madrid include the use of intensive care ambulances that are staffed by a prehospital physician and nurse who deliver patient care in the field (Alvarez et al., 2002)
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. As might be anticipated, among this relatively small number of DCDD donors, only about 6 percent were the result of uncontrolled DCDD, and most of these were Maastricht Category IV donors (Table 5-2)
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142 3 22 366 391 2004 6,751 7,150 5.5 17 17 236 270 2003 6,178 6,457 4.2 22 13 154 189 2002 5,994 6,190 3.1 7 6798 11 151 169 2001 5,905 6,080 2.8 10 8 19 100 118 deaths. 2000 5,848 5,985 2.0 IV 4 64 19 87 37 1999 5,700 5,824 1.5 Category 3 48 75 52 1998 5,666 5,793 1.3 Maastricht 32 were 60 78 46 1997 5,354 5,478 1.4 DCDDs 49 181 71 63 donors.
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GENERAL ETHICAL CONSIDERATIONS When the IOM committees examined DCDD in both 1997 and 2000, they acknowledged that DCDD raises numerous potential ethical issues, and they presented both general ethical principles and specific rules to guide DCDD. The present IOM committee concurs with the general ethical principles established in the 1997 IOM report, and these have subsequently been embraced by both U.S.
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Therefore, although a complete analysis of the ethical issues surrounding DCDD is beyond the scope of this report, this committee believes that it is worth examining why three IOM committees and at least two international consensus conferences have all concluded that both controlled and uncontrolled DCDD can proceed in an ethical manner yet so little has changed in clinical practice. 3Although U.S.
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Although DCDD has been controversial in some circles, a consensus is emerging that controlled DCDD can proceed in accordance with widely shared ethical commitments.
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. Second, all controlled DCDD donors have "do not resuscitate" orders in place; organ recovery occurs only when an independent decision is made to discontinue all life-sustaining treatments.
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Withdrawal of Treatment The medical and ethical literature on controlled DCDD rarely discusses the fact that donation follows the withdrawal of mechanical ventilatory support. Yet, surveys indicate that among the general public the acceptability of DCDD is directly tied to the acceptability of withdrawing artificial ventilation (Keenan et al., 2002; DuBois and Schmidt, 2003)
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. This suggests that such confusion can have a detrimental effect on the implementation of DCDD protocols and on the healthcare professionals themselves.
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, it bears stating that under no circumstances should financial incentives for organ donation be offered to families who need to make decisions regarding the continuation or discontinuation of life-sustaining treatments. Family Interests and Consent As the 2000 IOM report emphasized in its fourth recommendation, DCDD "should focus on the patient and the family." Specifically, DCDD should · follow patient and family wishes as closely as possible; · meet family needs for information, support, and follow-up; · recognize and respect the patient's and the family's social, economic, and racial or ethnic diversity; and · follow clear mechanisms for identifying and covering all organ procurement costs.
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DCDD. Nevertheless, most of their recommendations addressed only controlled DCDD, and the 2000 report included only one uncontrolled DCDD protocol, the Washington Hospital Center's Protocol for the Rapid Organ Recovery Program (Appendix F)
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Myth: Organs removed by using DCDD protocols do not work well for transplanta tion. Fact: Most organs removed by using a DCDD protocol work as well or nearly as well as other donated organs.
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Fact: Uncontrolled DCDD protocols can be used for a significantly broader popu lation of potential donors than any other protocols. those who suffer unexpected cardiopulmonary arrest are enormously varied.
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· Transplant centers that proceed with uncontrolled DCDD should do so only after a publicly created protocol that specifies resuscitative guidelines with concrete protections is developed. Appendix F provides the protocol developed by the Washington Hospital Center for uncontrolled DCDD.
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(Either way, it is incumbent upon hospitals and physicians to develop the necessary protocols in accord with ethical principles bearing on respect for the remains of the deceased, to be transparent, and to consult relevant communities.) REEXAMINATION OF UNCONTROLLED DCDD Uncontrolled DCDD typically involves individuals who have collapsed suddenly out of hospital and arrive in the emergency department without spontaneous vital signs after having received CPR from emergency medical services (EMS)
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data set (Lombardi et al., 1994) should provide a conservative estimate of the number of potential uncontrolled DCDD donors who meet the Modified Madrid Criteria.
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In addition to the current focus on increasing the number of controlled DCDD donors, the committee believes that the possibility of uncontrolled DCDD should be fully explored to see if this might be realistic, particularly in urban areas with extensive trauma and emergency care systems. It is important to acknowledge the challenges and the level of effort that will be needed to ensure that DCDD is a feasible option.
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An informed public can make the assessments that are needed to provide input into the planning and development of DCDD protocols. As with the development of the Washington Hospital Center's uncontrolled DCDD program (described earlier)
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· Mentor and evaluate. Current variations among hospitals and OPOs in the number of DCDD cases need to be addressed through mentoring programs and other efforts by the Organ Donation Breakthrough Collaboratives and professional organizations, which should encourage the development of DCDD programs.
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Economic Considerations Careful consideration must be given to the economic impact of emphasizing uncontrolled DCDD. There are potential savings in the value of the organs procured.
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Demonstration projects would allow and enable exploration of the challenges and opportunities for uncontrolled DCDD and should be evaluated carefully. If deemed successful, donation programs focused on uncontrolled DCDD should be scaled up and disseminated to other cities and regions.
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are being used. Various investigators have assessed the efficacies of organs from pediatric deceased donors; organs from donors with abnormal renal function, prolonged ischemia times, diabetes, and hypertension; organs with vascular or other anatomic abnormalities; or organs retrieved from living unrelated donors and DCDD donors (IOM, 1997; Rudich et al., 2002; Tan et al., 2004)
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162 ORGAN DONATION: OPPORTUNITIES FOR ACTION TABLE 5-5 UNOS Definition of Expanded-Criteria Kidney Donors Donor Age Categories (years) Donor Condition <10 1039 4049 5059 60 CVA + HTN + Creat > 1.5 X X CVA + HTN X X CVA + Creat > 1.5 X X HTN + Creat > 1.5 X X CVA X HTN X Creat > 1.5 X None of the above X NOTE: X = expanded-criteria donor; CVA = cerebral vascular accident was the cause of death; HTN = history of hypertension at any time; Creat > 1.5 = creatinine level of >1.5 milligrams per deciliter.
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From page 163... ...
Therefore, the recommendations for the use of expanded-criteria organs for these patients are less clearly established. Much remains to be learned about the defining characteristics of ideal potential donors, donated organs, and potential recipients so that expanded-criteria allocation and utilization policies can become more evidence based.
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. For example, therapeutic use of inotropic drugs, donor age, and the presence of moderate to severe hepatic steatosis independently influence the severity of liver preservation injury and the duration of stay in the intensive care unit for liver transplant recipients (Briceno et al., 2002)
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This study confirms the need to establish and update guidelines to include all current and prospective variables that might influence donor selection, graft function, and patient and graft survival. Ethical Considerations for Expanded-Criteria Organ Donation The use of expanded-criteria organs raises a number of ethical issues.
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These categories of organ quality and designations for organ screening will evolve with new knowledge about graft survival. Organ Quality Much remains to be learned about the spectrum of organ variability, particularly for organs other than kidneys, and there is a need to develop the quantitative measures that can inform patients and clinicians.
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From page 167... ...
This activity should complement current ongoing efforts to expand the number of controlled DCDD and DNDD donors and should be accompanied by thorough research on the nature and extent of impediments to the implementation of DCDD protocols and on the effects of efforts to remove them.
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The U.S. Department of Health and Human Services, states, and local entities should encourage and fund demonstration projects to determine the feasibility of increasing the rates of uncontrolled DCDD in cities with established and extensive trauma centers and emergency response systems.
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2006. Report of a national conference on donation after cardiac death.
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American Journal of Respiratory and Critical Care Medicine 160(1)
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Journal of Critical Care 17(1)
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A position paper by the Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine. Critical Care Medicine 29(9)
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2003. Estimating the number of potential organ donors in the United States.
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