Organ Donation After Circulatory Determination of Death:
Introduction by Dr. Sally Vitali.
Please note that in this video we
will be following the guidelines used
at Boston Children's Hospital.
Some of this information may need
to be modified based on the guidelines and practices
in place in your institution.
This video is part one of a series on the Organ Donation
After Circulatory Determination of Death, or DCDD process,
at Boston Children's Hospital.
My name is Sally Vitali, and I'm a Pediatric Intensivist here
at the hospital.
In this video, I will introduce the concept of DCDD,
and cover the process of referral, patient eligibility,
approach, and consent.
There are two pathways to organ donation
at the end of a patient's life.
The most common pathway since the late 1960s
has been donation after neurologic determination
of death, or donation after brain death.
A more recent option for families
is donation after circulatory determination
of death, or DCDD, which was previously called donation
after cardiac death.
Donation after neurologic determination of death
occurs following the diagnosis of brain death, which is made
using strict clinical criteria.
The patient is declared dead, but remains supported
by a mechanical ventilator and possibly cardiac medications
or ECMO in an intensive care unit.
The family is approached for consent, and if they consent,
arrangements are made for the body
to be taken to the operating room for organ recovery.
In DCDD, a family and the medical team
have made a decision together at the end of a child's life
that life sustaining treatments, including a ventilator,
will be withdrawn.
If the patient is medically eligible and likely
to die within 60 minutes of discontinuing the ventilator,
the family is approached for consent.
If they consent, the medical team and the family
will go with the patient to the operating
room for the withdrawal of the ventilator
and any cardiac support.
If the patient progresses to a pulseless arrest
within 60 minutes of withdrawing the ventilator,
the family will remain in the first operating room.
The ICU attending and fellow will take the patient's body
into a separate operating room, where the organ recovery
surgery will take place.
When five minutes have passed after the pulseless arrest
and there has been no spontaneous return of pulses,
the patient is declared dead and the organ recovery surgery
commences.
If the patient does not die within the required time
frame for donation, they return to the ICU for continuing
end-of-life care.
Now that you know what DCDD is, you
may be wondering which of our patients
can potentially become organ donors via the DCDD pathway.
Any patient who is mechanically ventilated
and whose family and medical team
have decided that the ventilator and cardiac support,
including ECMO, will be withdrawn at the end of life
is a potential DCDD candidate.
At Boston Children's, we refer all patients
who meet these criteria for evaluation
by our Organ Procurement Organization,
or OPO, the New England Organ Bank, or NEOB.
When should the referral take place?
Federal regulations require that every hospital
has defined triggers for referring patients
for evaluation by an OPO.
At Boston Children's, we refer all
mechanically ventilated patients who
will have the ventilator withdrawn, as soon as
that decision has been made by a family and the ICU team.
If a family inquires about organ donation earlier,
we may refer the patient earlier.
And the NEOB determines the patient's medical eligibility
for organ donation.
The NEOB's evaluation for medical eligibility
includes several important factors, namely the patient's
organ function, particularly that of the kidneys and liver,
any systemic infectious concerns,
or an unknown diagnosis that could be infectious,
the chance for metastatic or primary cancer of the organs
that would be transplanted, any underlying systemic genetic
or metabolic disease that may affect organ function
in the future, and whether there are potential recipients who
need the patient's size of organs.
Another very important issue for eligibility in DCDD
is the likelihood that the patient
will die within one hour of withdrawing the ventilator
and any cardiac support.
The NEOB will consult the ICU team about this likelihood.
You may be wondering why the patient has
to progress to pulselessness within one hour.
The period of time after the ventilator
and any cardiac support is stopped
is a period of diminishing delivery
of oxygen and nutrients to the organs that
will be transplanted.
We call this warm ischemic time.
Generally speaking, the shorter the warm ischemic time,
the healthier the transplanted organ will be.
Up to one hour is acceptable for the kidneys,
and up to 30 minutes is acceptable for the liver.
So what is the best way to talk to families
about organ donation?
It is common that someone in the patient's family or a family
friend will ask about the option of organ donation
before the OPO referral has been made or completed.
Our first reaction to them should be the most natural one,
which is to acknowledge that even raising this question
is tremendously considerate and selfless.
If the child is indeed mechanically ventilated
and approaching the end of life, we
need to let the family know that we do not
know whether the patient is a candidate for organ donation,
because we need to ask the New England Organ Bank to evaluate.
It's important to notify the patient's ICU attending
that the family has asked about organ donation.
The attending or their designee should inform the NEOB
that the family has inquired.
It's also important to avoid speculating
with the family about organ donation,
or encouraging them to talk about it before the NEOB has
been able to evaluate the patient
and meet with the family.
Families are struggling to make so many different decisions
during this difficult time.
It's important that they don't reach a premature decision
about donation before they have all of the correct information.
So how do we introduce the idea of donation
to a family that hasn't brought it up?
The best way to introduce the subject to a family
will depend on the family and the circumstances.
Our goal at Boston Children's is to have no unplanned mentions.
That is, the introduction of the possibility
of organ donation to a family should
happen in a planned and deliberate fashion
after a collaborative discussion between all members of the ICU
team and the NEOB.
The introduction should be timed so
that the appropriate information resource, namely the NEOB team,
is readily available to meet with the family,
whether that be in person or by phone.
If the family is interested in proceeding with DCDD,
a meeting should be planned to explain the process in detail
and obtain informed consent.
In preparation for that meeting, members of the ICU team
should review the Boston Children's Hospital policies
and protocols for DCDD, which are
available from the eLibrary.
The charge nurse, nursing director, and clinical director
should be informed of the impending consent meeting.
The clinical and nursing directors
will ensure that any ethical concerns of the team members
are addressed and that the team members understand
that they may opt out of participation in DCDD.
Some team members may be concerned
about the exact definition of death
or that any escalation of care for a patient who
is at the end of life or prolonging of life
to travel to the operating room is not
consistent with ideal end-of-life care,
even when the family wants the escalation
and prolongation to be performed in pursuit of DCDD.
Unit leadership will change patient assignments
as necessary, and an ethics consult
may be called at any time to aid in the discussion
of these important issues.
The NEOB and Boston Children's Hospital have separate consent
forms, but the issues from both forms
can ideally be addressed with the family in one conversation.
Most importantly, the family should
know that they may change their minds about DCDD at any point,
and that no one on the NEOB or ICU team
will be upset with them.
We will simply proceed with the withdrawal
of life-sustaining treatments in the ICU,
as we do for most patients at the end of life.
This concludes part one of the video series on DCDD
at Boston Children's Hospital.
Any questions about this material
can be directed to your unit, clinical, or nursing director,
or to the Organ Donation Oversight Committee
representatives from your unit.
Thank you for taking the time to help improve the quality
of our organ donation process at Boston Children's.