Table of Contents
DCD
Educational Guide
A Comprehensive Resource for OPOs & Hospital Patient Care Teams for Building and Supporting Effective Practices Surrounding Organ Donation After Circulatory Death
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Introduction
About this Guide
The Donation after Circulatory Death (DCD) workgroup under the guidance of The Alliance National Donation Leadership Council developed this DCD Educational Guide to enhance collaboration between organ procurement organizations (OPOs), transplant centers, and hospitals as a means to maximize stewardship of the gifts of the donors and to increase the availability of organs for transplantation.
This comprehensive resource is designed to:
- Provide regulatory and legal considerations and historical information about organ donation practices, including DCD, and its impact on the donation and transplantation crisis in the United States.
- Increase knowledge of national DCD performance data and provide hospitals with donation outcome and process measures to track performance.
- Describe successful processes for potential donor identification, timely OPO notification, and DCD donor management.
- Identify the importance of collaborative donation conversations.
- Discuss withdrawal of life-sustaining measures in the intensive care or alternative settings to facilitate DCD cases
- Outline operating room recovery processes.
- Describe strategies to implement model elements to achieve a continuous quality improvement (CQI) process to drive improvement in the hospital’s organ, eye, and tissue donation program and to increase collaboration between OPOs, hospitals, and transplant programs.
- Provide resources for implementing effective DCD donation processes.
This guide includes 11 essential areas of focus (including regulatory and accreditation compliance) that enhance a successful hospital DCD program. Utilizing the principles outlined in this guide, your designated OPO will be able to guide you and support your efforts to develop a well-organized organ donation program that includes a robust DCD process.
We invite hospital senior leaders to critically evaluate their DCD processes in relation to the Essentials and to partner and collaborate with their local OPO for process improvement opportunities to facilitate and optimize every donation opportunity.
How to Use this Guide
This Educational Guide has been developed to provide a comprehensive resource of key concepts and effective practices to build a successful DCD process in the hospital. Each Essential includes:
- Fact-finding Questions to learn about current processes within the hospital.
- Key Points hospital leadership should remember.
- Model Elements to describe concepts and processes of each Essential.
To best utilize the information provided, organizational leaders should:
- Examine their DCD process including key roles and responsibilities for:
- Notifying the OPO of potential donors.
- Coordinating the timing of the withdrawal of life-sustaining treatment (WLST) conversations and decisions as it pertains to a DCD potential.
- Ensuring the OPO can have the donation conversation to obtain authorization for donation from the
Legal Next of Kin / Legal Authorizing Party (LNOK/LAP). - Medically managing the DCD donor patient.
- Supporting necessary tests and procedures to facilitate the allocation of organs for transplant.
- Coordinating WLST measures to facilitate a safe DCD process.
- Declaring the death of the DCD potential.
- Facilitating collaboration between the hospital, OPO, and transplant program for the coordination of the
recovery of organs for transplant.
- Identify opportunities for improvement that exist such as missing processes or processes with workarounds, variations, unnecessary steps, points where breakdowns exist, or processes with unsatisfactory outcomes. (The CMS PDSA Cycle Template could be a beneficial tool for these next few steps.)
- Identify key participants to plan and run simulations to identify areas of improvement, necessary resources, duration, data collection, and necessary education for staff.
- Study and analyze the results to adapt or adopt the changes.
- Implement new or improved processes and track outcomes to:
- Ensure all DCD donor potential is identified and the OPO is notified.
- Honor every designated donor’s decision or where no decision exists, offer the opportunity to make a decision about donation to the LNOK/LAP.
- Standardize processes to support donor management, organ allocation, withdrawal of life-sustaining treatments, declaration of death, and organ recovery.
Terminology Standardized throughout this Guide
Attempts have been made to standardize terminology in this guide, and as part of this effort, the following frequently used terms have been defined.
| TERM | DEFINITION |
|---|---|
| Brain Death / Death by Neurologic Criteria (BD/DNC) | Death by neurologic criteria (DNC) is often referred to as “brain death” (BD), hence both terms and acronyms are utilized throughout this guide. BD/DNC is defined by the American Academy of Neurology (2023) as the “loss of function of the brain as a whole, including the brainstem, resulting in coma, brainstem areflexia and apnea in the setting of an adequate stimulus.” Furthermore, it defines the severity of the brain injury as permanent. |
| Cold Ischemic Time (CIT) | It is important to note that there is no standardized definition of cold ischemic time (CIT). In this guide, the Organ Procurement and Transplantation Network‘s definition of CIT will be utilized, “the amount of time an organ spends being preserved after recovery from the donor.” The organs are typically held in cold storage, which is why this time is classified as CIT. |
| Donation after Circulatory Death (DCD) | The recovery of organs from patients who are declared dead following the irreversible cessation of circulatory and respiratory function and who do not meet criteria for BD/DNC. Donation after Circulatory Death (DCD) is the same as Donation after Circulatory Determination of Death (DCDD). Antiquated terminology includes Donation after Cardiac Death (DCD), Non-Heart Beating Donation (NHBD), and asystolic donation. |
| Hospital patient care team | The hospital patient care team includes the entire team caring for the patient, which at minimum would include physicians, nurses, respiratory therapists, and if involved with the patient, would also include social workers, case managers, and chaplains. If the patient goes to the operating room for organ recovery, an anesthesia provider may also be needed. |
| Legal Next of Kin / Legal Authorizing Party (LNOK/LAP) | A legal next of kin (LNOK) refers to someone a patient designated to make decisions on their behalf. If the patient did not determine someone to make decision, it is usually the closest living blood relative who could make a decision on behalf of the patient if they are unable to make their own decisions. Most states have a list identifying the order of the LNOK for healthcare decisions. In donation, there is a specific hierarchy of decision-makers determined by the state’s Uniform Anatomical Gift Act. This hierarchy does not always match the other state’s LNOK list and also includes non-relatives. Hence, the term Legal Authorizing Party (LAP) is a better description of decision-makers for donation. As LAP may still be new to some, both acronyms LNOK/LAP will be utilized together throughout this guide. |
| OPO recovery team | A team of staff from the organ procurement organization (OPO) that plays various roles in the organ recovery process. The team typically involves:
It’s important to note that every OPO will have their own titles for each of these roles. Additionally, there are OPOs that may have staff who serve in hybrid roles. |
| Transplant recovery team | A team of staff who come to the hospital from the transplant programs that will be receiving organs. This team is typically made up of one or two transplant surgeons and possibly an organ preservation technician. |
| Warm Ischemic Time (WIT) | It is important to note that there is no standardized definition of warm ischemic time (WIT). In this guide, the Organ Procurement and Transplantation Network‘s definition of WIT will be utilized: “the time of agonal phase onset to the time when core cooling is initiated” or “the calculated time using the serial data to be collected along with the agonal phase and ending with the initiation of core cooling.” In other words, it is the length of time there is a lack of blood supply and oxygen to the organs and normally body temperature reaches 34°C during the dying process and until the body can be cooled down with ice. |
| Withdrawal of life sustaining treatment (WLST) | To actively cease or discontinue interventions that are currently contributing to sustaining life. |