DCD

Fact-Finding Questions Hospital Leadership Should Ask

1. What is the turnaround time for completing and reporting laboratory tests, radiology tests, and consults (e.g., echocardiogram, bronchoscopies?) Does this meet the needs of the organ procurement organization (OPO) for imely organ allocation?
2. Does the OPO have access to information, including the radiographic images (e.g., computed tomography [CT] scans, chest x-rays [CXRs], echocardiograms [ECHOs]) necessary for organ allocation?
3. What limitations (if any) do we have for timing of consultations (e.g., echocardiograms) outside of routine business hours that may impact the OPO’s timing for for organ allocation?
4. Does the critical care management of potential DCD donors enable the OPO to allocate the organs intended for transplantation?

Key Points Hospital Leadership Should Remember

1. Organ allocation is the responsibility of the OPO¹ and ideally begins once donor testing, management, and organ optimization are completed.
2. The Organ Procurement and Transplant Network (OPTN) establishes policies for organ matching and allocation, including what information must be obtained and shared by the OPO, as well as how organs are to be allocated.
3. Donor family members may directly donate their family member’s organs to a potential recipient, provided that the recipient is actively listed for transplant and is determined to be a match by the transplant center.
4. If a case must be expedited due to family-imposed time constraints or potential donor medical instability, organs, commonly the kidneys, may sometimes be allocated after being recovered for transplant.

Model Elements for DCD Practice Within the Hospital

Organ allocation is a complex process, both in principle and practically. In 1984, the National Organ Transplant Act (NOTA) required the establishment of the OPTN to address the nation’s critical organ donation shortage; it created a national system for organ matching and organ allocation or placement.¹ The OPTN is a public-private partnership connecting all professionals working within donation and transplantation and is administered by a federal contractor.² Ethical principles guide the OPTN in the development of allocation policies. Policies are developed by committees within the OPTN and public comment is sought on the drafted policies, which are then reviewed by the committees. The finalized policy is sent to the OPTN Board of Directors for a vote, after which – if the policy is approved – the community is notified of the new policy.³ These federal policies are then put into practice. The policies specifically related to organ matching and placement are programmed into a database where the donor organs are matched with potential recipients.

OPOs initiate the organ allocation process, notifying transplant programs of potential organ matches for their recipients through a highly secure database system. This database system has been pre-programmed with algorithms that facilitate the matching of the donor’s details to potential recipients following federal organ allocation policies. Transplant programs are responsible for reviewing all information about the offered organ and making an acceptance or denial of the organ. Once all organs intended for transplant are provisionally accepted, the OPO collaborates with the transplant programs and the hospital on timing for the withdrawal of life-sustaining treatment (WLST) and Operating Room (OR) availability. Logistical considerations such as travel time between the transplant hospital and donor hospital and timing of the transplant surgery are factors that must be considered.

Although the OPO is responsible for the allocation of organs to transplant centers⁴, OPO coordinators rely heavily on the collaboration of the hospital patient care team to optimize organ viability through good critical care management (see Essential 5) and timely completion and reporting of required testing. Ideally, organ allocation begins once organ function has been maximized and required testing has been completed. In instances in which there are logistical time constraints (e.g., family-imposed time restrictions for WLST) or medical instability of the DCD donor, some organs, most commonly kidneys, can be recovered prior to allocation. In these situations, the organ is often put on an organ pump to extend its viability for transplantation while all relevant donor data is collected.

Allocation Considerations

Organ allocation in DCD donation involves many ethical, medical, and logistical considerations:

Ethical Considerations⁵

Principles adopted by the OPTN include those of utility, justice, and respect for persons. Utility refers to increasing the number of transplants performed and the length of time the transplanted organ and patients survive following transplant. Justice “refers to fairness in the pattern of distribution of the benefits and burdens of an organ procurement and allocation program.”⁵ Meeting both the utility and justice principles would be considered an “equitable” allocation system according to NOTA. The OPTN strives for allocation policies that are guided by principles of fairness, avoiding discrimination based on factors such as age, biological sex, race, or socioeconomic status. Potential recipients are prioritized based on objective medical criteria and urgency of need. Respect for persons “embraces the concept of respect for autonomy”⁵ and adheres to the belief that humans should be treated as “ends in themselves” and not merely a means.

Medical Considerations

Factors such as blood type match, height and/or weight, and medical factors specific to each organ type (such as histocompatibility matching) are utilized to match donor organs to potential recipients. Allocation of organs are not influenced by national origin, political influence, ethnicity, race, sex, or financial status.⁶ Additional medical factors that transplant centers must consider when accepting an organ for a particular recipient include the overall function of that organ and how it is expected to function for the intended recipient.

Logistical Considerations

Historically, once removed from the donor, organs needed to be transplanted within a short amount of time, necessitating their allocation to transplant centers within a nearby geographic area. Organ pumps that support functionality outside the human body and allow more time between recovery and transplantation are emerging,⁷ but geographic and transportation limitations remain realities. For several decades now, kidney pumps have been available to diagnose and support the function of kidneys outside a human body, allowing longer amounts of time to pass before they must be transplanted.⁷ Pumps for non-renal organs such as the liver, heart, and lung are newer innovations. These innovations facilitate the assessment and at times restoration of organs, and allow for longer recovery to transplantation times, thus overcoming geographical distances impacting allocation. Despite the benefits of organ pumps, challenges such as transportation logistics, costs, and related limitations still persist.

Allocation Process

The organ allocation process requires the OPO to disclose the following information over a secure, Health Insurance Portability and Accountability Act (HIPAA)-compliant platform managed by the OPTN contractor to the transplant programs:

Once the minimally required information is uploaded from the OPO’s electronic donor medical record to the OPTN contractor’s secure, HIPAA-compliant platform, organ match lists are generated by the system for each organ intended for transplant. Organ allocation lists, also known as match runs, are a dynamic list of potential transplant recipients who could be acceptable matches to the donor.

Utilizing the secure platform, the OPO follows the order of the match run to notify transplant programs of an organ offer for the potential transplant recipients. Each transplant program utilizes the secure platform to review all donor information and communicate its interest, acceptance, or declination of the organ offered. Directed donation – in which the donor family knows of a potential transplant recipient and wants to direct the donation of their family member’s organ to that individual – is also a possibility, as long as that individual is actively listed and is compatible.

The time frame for allocation is extremely variable and depends on the organ being allocated. Several factors can affect the overall length of the allocation process, including the specific organ being allocated, the time transplant programs take to evaluate the information, the number of programs being considered, and any additional donor testing requested (e.g., CT scans, bronchoscopies, cardiac catheterizations).

Specific to DCD cases, transplant programs may take into account the anticipated time frame from WLST until the time of death of the potential donor, which will impact organ viability and can negatively impact function of the organ once transplanted. This accounting is due to concerns for warm ischemic time (WIT) on the organs. WIT is defined by the OPTN as “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 beginning with the agonal phase and ending with the initiation of core cooling.”⁸ In cases involving difficult-to-place organs, the OPO also has the option for expedited placement of organs that is consistent with an approved expedited placement protocol.⁶

Organ allocation is completed once each of the donor organs has been accepted or when all transplant programs with potential transplant recipients on the match run have declined the organ. Final acceptance of the organ only occurs after the surgeon has visualized and examined the recovered organ in the operating room (OR). Finally, the OPO may discontinue allocation of an organ if no transplant programs have demonstrated interest in the organ.⁹

Expedited DCD Process

An expedited DCD, also referred to as a rapid or accelerated DCD process, may be necessary to meet family-imposed time restrictions or respond to potential donor medical instability. Family-imposed time restrictions and potential donor medical instability may necessitate an expedited donation process. In these situations, the OPO recovery team and hospital patient care team work together to obtain the minimum required testing and information prior to organ recovery. Simultaneously or after recovery of the organs, the OPO assimilates all the required information and proceeds with organ allocation. These situations are fast-paced and can be stressful. It is highly recommended that the OPO recovery team and hospital patient care team develop and utilize a protocol for these cases to ensure that all requirements are met. It is also helpful to clearly define roles of each member involved during these situations and conduct training to better prepare teams for expedited cases.

Figure 6-1. Required information about the donor and the source of the information

Preparing for WLST and Organ Recovery

During the allocation process, the OPO recovery team and hospital patient care team should communicate frequently and start planning for the WLST, death pronouncement, and organ recovery. Determining the location where WLST will occur and identifying a declaring physician or physician designee are vital preparation steps (see Essential 7). In addition, the OPO coordinators should conduct team huddles with the OR to prepare OR team members for what to expect and how to prepare for a DCD recovery.

Once intended organs for transplant are provisionally accepted, the OPO, in collaboration with the hospital patient care team, coordinates a time for WLST, death pronouncement and organ recovery. Selection of a specific time can be challenging when trying to meet the needs of the many key stakeholders. If the donor family has presented the OPO with a time constraint or a specific time in which WLST is to begin, the OPO will attempt to honor that request. Ultimately, however, this timing must also be acceptable to the declaring physician or physician designee, the hospital OR teams, the hospital patient care team members that will be involved in WLST, the OPO recovery team, and the transplant recovery teams.