DCD

Fact-Finding Questions Hospital Leadership Should Ask

1. Does our hospital have a DCD order set programmed into our Health Information System (HIS), which can be activated when we have a DCD donor? If not, what is the current process, and who is responsible for entering all needed orders for the DCD donor?
2. Is the hospital patient care team supporting the timely fulfillment of the orders for the DCD donor management?
3. Do our healthcare team members receive education and training on care for DCD patients related to donor management goals (DMGs)?
4. What is our hospital’s performance in meeting donor management goals (DMGs)?

Key Points Hospital Leadership Should Remember

1. A DCD order set within the EHR streamlines the entry and execution of DCD orders by the hospital patient care team and the organ procurement organization (OPO) clinical coordinator.
2. Achieving DMGs during critical care management of the patient is associated with improved stewardship of the gift the family may make if the patient deteriorates and becomes a donor. Meeting DMGs also results in more organs being viable for transplant and improved post-transplant graft survival.
3. DMGs align with standard critical care management goals.
4. The Organ Procurement and Transplant Network (OPTN) and the Centers for Medicare and Medicaid Services (CMS) regulate requirements of donor management, including laboratory testing and organ evaluation tests.
5. Timely turnaround of required laboratory and organ evaluation tests (e.g., chest x-rays, echocardiograms, computerized tomography scans) help expedite critical care management to optimize organ function and organ allocation.
6. Unlike in brain death/death by neurologic criteria (BD/DNC) donors, after donation authorization, the physician or physician designee is responsible for the medical management of the potential DCD donor in collaboration with the OPO clinical coordinator.

Model Elements for DCD Practice Within the Hospital

The hospital has the responsibility to “maintain potential donors while the necessary testing and placement of potential donated organs takes place in order to maximize the viability of donor organs for transplant.”^1,2  The OPTN and CMS outline the OPO requirements for clinical management of the organ donor, including required testing.^1,3

Transferring DCD Donors

Some OPOs may transfer hemodynamically stable, potential DCD donors to a hospital-based Donor Care Unit (DCU). A hospital-based DCU is a collaborative partnership between an OPO and one of its hospital partners. The hospital serves as the receiving facility for authorized potential organ donors and provides dedicated space in the Intensive Care Unit (ICU) and Operating Room (OR), along with hospital staff support. The benefits of DCUs include consistent and standardized care and improved outcomes, thus maximizing the stewardship of the gift. Prior to any transfer, authorization for donation is obtained, the transfer is discussed with the family, and an attending physician accepts the potential DCD donor to the receiving hospital. The remainder of donor management, withdrawal of life-sustaining treatment (WLST), and organ recovery occurs at the receiving hospital.

A transfer for DCD donation may also occur when a hospital lacks a policy that permits DCD organ recovery. In such cases, donor management is completed at the originating hospital. The potential donor is transferred only after donor management is complete and the organs have been allocated, to avoid unnecessary transfers if organs are not able to be allocated. Once donor management and organ allocation are complete, a receiving hospital and attending physician are identified. The receiving attending must admit the patient prior to transferring the patient to the OR for WLST and organ recovery.

It is important to recognize that the absence of a hospital policy supporting DCD organ donation can negatively impact donor families. Some families may be reluctant to proceed with a transfer. It also carries the risk of a hemodynamically unstable patient dying during transfer without their family present. Additionally, the transfer may place an added burden on the family to have to reestablish rapport with a new hospital patient care team just prior to WLST and organ recovery.

Donor Management and Organ Function Evaluation

The OPO clinical coordinator will collaborate with the hospital patient care team for interventions to maximize organ viability and to evaluate organ function.³ Since death has not yet occurred, the physician or physician designee continues to be responsible for overall medical care of the potential DCD donor. Interventions such as circulatory and ventilatory support, along with required testing, are fairly standard. It is recommended that the hospital have a DCD organ donor order set, provided by the OPO, that is embedded into the HIS for activation in the patient’s EHR – thereby driving efficient implementation of DCD orders.

Active critical care medical management of the potential organ donor can lead to an increase in the number of organs available for transplant,⁴ along with improved post-transplant graft survival.⁵ Routinely measured critical care endpoints have been utilized by OPOs in the establishment of DMGs as mutual goals between the OPO and the hospital patient care team for potential organ donor management. DMGs (as defined by the DMG Registry⁵) include:

Donor Management and Organ Function Evaluation

The OPO clinical coordinator will collaborate with the hospital patient care team for interventions to maximize organ viability and to evaluate organ function.³ Since death has not yet occurred, the physician or designee continues to be responsible for overall medical care of the potential DCD donor. Interventions such as circulatory and ventilatory support, along with required testing, are fairly standard. It is recommended that the hospital have a DCD organ donor order set, provided by the OPO, that is embedded into the HIS for activation in the patient’s EHR – thereby driving efficient implementation of DCD orders.

Active critical care medical management of the potential organ donor can lead to an increase in the number of organs available for transplant.⁴ along with improved post-transplant graft survival.⁵ Routinely measured critical care end points⁴ have been utilized by OPOs in the establishment of DMGs as mutual goals between the OPO and the hospital patient care team for potential organ donor management. DMGs (as defined by the DMG Registry⁵) include:

The first several hours after donation authorization are often the busiest for the hospital patient care team and the OPO clinical coordinator. The immediate focus will be to implement the new order set and obtain all the required tests. Laboratory tests are ordered at the initiation of donor management and serial (typically every 4-6 hours) after that. OPTN regulates the frequency of certain tests,³ and it is therefore important to assist the OPO clinical coordinator in obtaining tests as ordered and reporting results as soon as possible.

The OPO must perform a complete assessment of the potential DCD organ donor, which includes:³

• Obtaining a medical and behavior health history.
• Reviewing the potential DCD donor’s medical record.
• Conducting a thorough physical examination and assessment of the potential organ donor, including the notation of vital signs.

All of these findings must be reported to the transplant programs that will receive the organs from the donor.

The OPO is required to obtain and report the following donor testing:³

• Arterial Blood Gas results (ABGs)
• Electrolytes and serum glucose
• Complete Blood Count (CBC)
• Urinalysis
• Blood and urine cultures
• Chest X-ray
• Blood type determination:
  • Blood for blood type testing will likely be sent to an OPO-based or contracted laboratory. If testing is performed at the hospital, two blood type determinations must be made on two separate specimens and must include subtyping for blood type A. If the hospital does not have the capabilities to perform A subtyping, the OPO clinical coordinator should be informed.
  • The OPO clinical coordinator will contact the blood bank to determine the volume of all blood products administered to the patient to determine if blood samples for testing are hemodiluted.
• Infectious Disease Testing:
  • Infectious disease testing will be completed by the OPO-based or contracted laboratory.
  • Tests include antibody, antigen, and/or nucleic acid testing for HIV, Hepatitis B, Hepatitis C, Cytomegalovirus, Epstein-Barr Virus, Syphilis, and Toxoplasma Immunoglobulin G.
    Positive results – including those for HIV – do not necessarily rule out organ donation.

Additional OPO requested testing may include:³

• Hepatic function tests
• International normalized ratio (INR), Prothrombin (PT), Partial thromboplastin time (PTT)
• Computed tomography (CT) scan for chest and/or abdomen
• 12-lead electrocardiogram interpretation
• Echocardiogram
• Cardiac labs – Troponin and creatine phosphokinase/creatine kinase-myocardial band (CPK/CKMB)
• Cardiac catheterization
• Sputum gram stain
• Lower respiratory sample for SARS-CoV-2 by nucleic acid test (NAT) if lung transplant is planned
• Bronchoscopy
• ABGs and ventilator settings on 5 cm/H₂0/PEEP including PO₂/FiO₂ ratio and preferably 100% FiO₂
• Hemoglobin A1C
• Serum amylase and lipase

Additional therapies and medications may be requested to support or improve organ function such as:

• Central and/or arterial line insertion
• Antibiotics, either surgical prophylaxis or treatment of infection
• Corticosteroids
• Pulmonary hygiene techniques
• Alveolar recruitment maneuvers
• Intravenous Heparin administration prior to WLST to prevent micro-emboli/thrombi formation in small vessels of transplanted organs
• Renal replacement therapy such as hemodialysis or continuous renal replacement therapy to manage abnormal electrolytes or ultrafiltration only for fluid overload

Successful evaluation of a donor to determine which organs are likely to be transplanted may involve hospital consultative physicians and services beyond the ICU setting that the OPO coordinator will need to request. For instance, echocardiograms and cardiac catheterizations require consultation from a cardiologist and interventional cardiologist. Having the availability to perform these tests anytime of the day or night ensures that donor management, evaluation, and subsequent allocation of organs is not delayed.

The hospital patient care team should also consider how it can make imaging (X-rays, CT scans, echocardiograms, and cardiac catheterization) available to the OPO, such as loaded onto a CD-ROM disc. The OPO clinical coordinator will upload the imaging for viewing by the potential transplant teams during the allocation process. The duration of a DCD donation is dependent on many factors some of which are outside of the control of the OPO. These factors include family expectation based on information they were given (correct or incorrect), testing for evaluation of organs, OR availability, the number of organs viable for transplant, transplant team availability and timelines, physician or physician designee availability for death pronouncement, and the stability of the donor, among other considerations.