DCD

Determination of medical suitability of the potential donor

Fact-Finding Questions Hospital Leadership Should Ask

1. Are we complying with the agreed-upon timeliness of the notification of a potential donor to the OPO to ensure the OPO has sufficient time for determining medical suitability for donation?
2. Do we have protocols in place to follow the Brain Trauma Foundation’s Guidelines for Traumatic Brain Injury?¹ These protocols aim to give patients the greatest chance of survival while also maintaining the opportunity for donation.
3. Do we address in policy and in practice that no treatment or clinical support is withdrawn from a ventilated patient until the OPO has evaluated the donation potential and offered the family the opportunity of donation?
4. Do we ensure that the OPO has the ability to evaluate the potential donor’s medical suitability for donation?
5. Do we routinely involve patient care specialists (e.g., Palliative Care, Pastoral Care, Social Services) in end-of-life care discussions and medical management?
6. Is Palliative Care integrated into the donation process and working in partnership with the OPO? Could Palliative Care take the lead on providing comfort care during DCD cases and potentially be available for the pronouncement of death of the potential donor?

Key Points Hospital Leadership Should Remember

1. The OPO is responsible for determining medical suitability of potential organ donors.
2. Providing remote access to the patient’s electronic health record (EHR) assists the OPO in efficiently and expediently evaluating donation potential.
3. The hospital maintains adequate ventilation and circulatory support of the potential donors while the OPO determines medical suitability for donation.
4. Palliative Care can be a valuable partner for the OPO in facilitating a smooth DCD process.

Model Elements for Evaluation for DCD Potential

After being notified of the potential DCD donor, the OPO is responsible for determining medical suitability for organ donation.^2,3,4,5,6 The hospital patient care team must maintain potential DCD donors “in a manner that maintains the viability of their organs”^2,3,4,5,6,7 by continuing to ventilate and medically support the patient during this time frame. The evaluation by the OPO may include some or all of the following elements:

• Complete medical history
• Acute injury or course of events leading to hospitalization
• Initial, peak, and current organ function tests (e.g., comprehensive metabolic panel, liver enzymes)
• Any additional testing such as chest x-rays, computed tomography scans, echocardiograms, etc.
• Required ventilatory support (ventilator settings)
• Required vasopressor support
• Neurological examination (brainstem reflexes)
• Evaluation of likelihood of death following withdrawal of life-sustaining treatment (WLST)

Most transplant surgeons in the United States will not transplant organs from a patient who took longer than 60-120 minutes to die due to the damaging effects of warm ischemic time (WIT) on the viability of organs for transplant. As it would be unethical to hasten death,^7,8,9 efforts were made to predict the likelihood of death occurring within a time frame allowing for donation. Tools (e.g., University of Wisconsin Donation after Cardiac Death Evaluation Tool,¹⁰ the DCD-N Score¹¹) were developed to predict whether the patient would likely die within 60-120 minutes after extubation and were utilized by the OPO to evaluate donation potential. Unfortunately, by using some of these tools, donation potential has been lost¹² and the predictability of death occurring within a couple of hours of WLST continues to be a challenging step in DCD evaluation. Scoring systems, currently, have little value due to unreliability in predicting deaths within specific time frames.¹² Researchers continue to seek reliable predictive tools such as machine learning models.¹³ Thus, given the scarcity of organs, less value is given to death predictability scores. Every patient facing WLST is evaluated on their own merit. In addition, some OPOs place little emphasis on the expected timeline for death to occur and offer donation as long as death is expected imminently following WLST so as to not rule out any donation opportunity.

Evaluation by the OPO may be conducted over the phone, by remote review of the patient’s EHR, and/or on-site at the hospital. Unless the potential DCD donor is determined to be medically ineligible based on non-changing elements of the medical history, evaluation is an ongoing process. In most instances, a combination of phone screening, EHR review and on-site evaluation will be utilized by the OPO. Thereafter, OPO coordinators will regularly check-in with members of the hospital patient care team via phone and in person, typically twice daily. The hospital patient care team is responsible for updating the OPO of significant changes during this time frame; these include (but are not limited to) declining status (neurological or circulatory), circulatory arrest, family gatherings in anticipation of death or discussions of funeral arrangements, or communication of plans for WLST.

Hospital patient care teams often express interest in understanding donation eligibility. It is important to recognize that a specific patient’s donation eligibility may change during the hospital treatment course of the patient and should not be based on a single point in time. The OPO will continue to evaluate the potential organ donor for suitability until the time for the donation conversation. If the OPO has determined the patient is a potential DCD candidate, the donation conversation for authorization is held once the family has made a decision to pursue WLST.

Donors over the age of 75 years old are not uncommon.

Role of Palliative Care

Role of Palliative Care

Palliative Care can be helpful before, during, and after WLST.¹⁴ Palliative Care consultations can explore prognosis, establish goals including code status, assist with communication and collaboration between medical teams, plan symptom management, identify and address psychosocial and spiritual needs, and provide family support. Palliative Care skills and principles applicable to the DCD process include communication, coordination of care, and management of the WLST process. When death occurs after WLST and within a defined time frame, organs may be successfully recovered for transplantation (see Essential 7). In cases where potential donor patients do not die within the time frame needed for organs to remain viable and donation to occur (see Essential 9), Palliative Care is valuable in providing continued comfort care to the patient. Palliative Care can contribute to standardizing quality end-of-life care practices in the DCD process and provide education for involved personnel and families, including:

• Nursing and healthcare team education
  • Compassionate communication strategies for discussing prognosis and WLST
  • Palliative pharmacologic and non-pharmacologic algorithms and strategies to manage end-of-life symptoms
• Interdisciplinary family education and support
  • Educating on the process of WLST
  • Family grief support

Integrating Palliative Care into the DCD process not only helps to standardize quality end-of-life practices and ensure continuity of care before, during, and after the withdrawal of life-sustaining treatment, it also ensures that the donor’s comfort and dignity are prioritized during the dying process.