DCD

Recommended practices for both the post-DCD recovery and non-recovery processes

Fact-Finding Questions Hospital Leadership Should Ask

1. Is our Operating Room (OR) staff familiar with the process concerning DCD donors who do not die within the time frame for DCD recovery?
2. Does our DCD policy include guidance for cases in which the DCD process must be aborted and a back-up bed is needed for ongoing comfort care?
3. Is our OR staff and hospital patient care team familiar with post-mortem care processes and documentation for patients that are DCD donors?
4. What real-time in-person grief support and routine updates on the donation process are provided to the family by the OPO?
5. Does the OPO conduct After Action Reviews (AARs) with our OR and hospital patient care team involved in the DCD case? How is the information gained during these AARs shared and acted upon?
6. What are the collaboration and protocols between our hospital, the OPO, and the Medical Examiner or Coroner (ME/C) for release for organ, tissue, and eye donation, especially as it pertains to the potential DCD donor?

Key Points Hospital Leadership Should Remember

1. The ICU bed or an alternative bed should be reserved in case the potential DCD donor does not die within the time frame required for organ recovery, necessitating a non-monitored bed for continued comfort care.
2. Organ, tissue, and eye donation can occur for patients whose death falls under the ME/C jurisdiction.
3. Donor families receive acute grief support and regular updates throughout the donation process from the OPO.
4. When donation is not able to proceed after authorization, the authorized donor and the donor family are honored as all donor’s and donor families are with recognition and support including in the OPO Aftercare programs.

Model Elements for DCD Practice Within the Hospital

Post-Recovery Procedures for the DCD Donor

In the context of organ donation, “recovery” refers to “the surgical procedure of removing an organ from a donor”¹ for the purpose of transplantation. “Non-recovery” indicates situations where organs cannot be recovered for transplant for various reasons, such as a finding revealing that organs are not medically suitable for transplantation, a matching recipient cannot be identified, or the dying process takes longer than anticipated, resulting in the organs no longer being suitable for donation.

After the recovery of transplantable organs, those unsuitable for transplantation may also be recovered by an OPO or transplant recovery team member for research purposes and packaged accordingly.

Specific roles and responsibilities following the recovery of organs are tailored to each hospital and OPO. Generally, additional tasks to complete for post-recovery procedures include:

OPO responsibilities:

• Closing the donor body
• Providing the hospital OR team with a signed operative note for the patient’s electronic health record (EHR)
• Assisting the hospital OR team with the removal of medical equipment (e.g., urinary catheter, arterial line, peripheral IVs) unless it is a ME/C case
• Assisting the hospital OR team with hospital protocols for draping the donor for transportation to the hospital morgue
• Assisting with transportation of the donor to the hospital morgue, if the donor will have an autopsy, the ME/C may require placement of the donor in a locked body bag
• Communication with the ME/C and seeking to meet their requests
• Notification to the donor family of the outcome of organ recovery

Hospital responsibilities:

• Post-operative OR responsibilities (e.g., counts, etc.)
• If provided by the OPO and requested, flashing chest and/or abdominal retractors
• Hospital post-mortem documentation
• Assisting the OPO recovery team with the removal of medical equipment (e.g., urinary catheter, arterial line, peripheral IVs) unless it is a ME/C case
• Assisting the OPO recovery team with draping the donor for transportation to the hospital morgue. If the donor will have an autopsy, the ME/C may require placement of the donor in a locked body bag.

Figure 9-1. Donation After Circulatory Death (DCD) process

Ongoing Care if the Patient Can Not Become a Donor (Non-Recovery)

In cases where the plan is to withdraw life-sustaining treatment (WLST) and provide comfort care in the OR, the plan for continued comfort care if the donation process is aborted, should be included and discussed during the huddles between the hospital patient care team and the OPO recovery team, as well as communicated to the hospital’s OR team. A location needs to be identified to which the patient will return in the event they do not die in the time frame needed for organ viability (see Essential 7). In some instances, the patient may return to their ICU room, where familiarity with the ICU staff can be comforting for the family. In other instances, as the patient no longer requires critical care, the patient may be transferred to an alternative unit or ward for continued comfort care. Because the decision for WLST was made independently of and prior to the donation decision, the patient is not reintubated and palliative or comfort care should continue seamlessly following hospital policies and protocols, as for all end-of-life (EOL) care patients.² As part of the donation conversation with the family, the OPO team member prepares the patient’s family for the possibility that death may not occur within the time frame required for organ donation to occur. They also communicate the contingency plan should this occur.

The hospital should address in policy the process for cases when DCD recovery needs to be aborted. In the event that the patient does not die in the time frame needed for organ recovery, the OPO recovery team should assist the hospital patient care team with transport of the patient back to the ICU or another identified location. During patient transport, the OPO team member dedicated to the family should provide ongoing emotional support and escort the family back to the appropriate waiting room. Once the patient is settled into the room, the OPO team member and hospital patient care team can invite the family to the bedside.

Following transport back to the predetermined location, the OPO team members are typically available to the hospital patient care team and family. They will conduct a final assessment of the family and hospital patient care team’s needs prior to departing from the hospital. Per Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP), the hospital patient care team is responsible for notifying the OPO of the patient’s time of death in a timely manner.^3,4  After their death, the patient will be evaluated as a potential tissue and eye donor. Final evaluation for tissue and eye suitability can only be performed after death. Even if the patient’s family declined tissue and eye donation during initial authorization for organ donation, the hospital must still notify the OPO of the death of the patient, as per CMS CoPs.^3,4

A separate debrief and AAR will be conducted by the OPO hospital development coordinator with the hospital patient care team and the OR staff who were present for the entire process. AARs may be conducted through one-on-one conversations with individuals involved and may be conducted in real-time, or they may be more formal meetings. The purpose of the AAR is to thank the hospital team, discuss and identify any parts of the process that went well or could be improved upon for the next time, and to plan for future process improvement as needed.

Ongoing Care of the Donor Family

It is important to provide family support and information throughout the donation process, especially during times of transition.

As part of huddles before the donation conversation and throughout the DCD case, the OPO and the hospital patient care team should determine roles and responsibilities of those communicating with the family and what is being communicated to ensure consistency of information for the family (see Essential 4). Throughout the donation process, the OPO staff will typically keep the family informed of key steps and expectations, including, but not limited to, the following:

• What to expect at the start of the DCD case (e.g., laboratory tests, imaging, procedures, assessments)
• Critical care management goals
• Start of allocation and organs expected to be allocated
• Estimated timeline and final determination for WLST
• What to expect for an Honor Walk, if planned
• What to expect during WLST and the dying process
• What to expect in the OR, if WLST occurs in OR
• Preparation to say goodbye and expectation for leaving once death is declared
• What will occur in the event that their family member does not die in the time frame needed for organ recovery
• How long the organ recovery will be and when to expect a follow-up call from the OPO
• Expectations following organ recovery (e.g., tissue and eye recovery and/or autopsy)
• What to expect regarding follow-up notifications once tissue and eye recovery is completed and donor is transported to the funeral home
• What to expect for ongoing communication from the OPO in the weeks and months to follow.

The OPO team member providing family support typically encourages the family to leave the hospital after death declaration while assuring them that they will receive follow-up by phone to inform them of which organs and tissues have been recovered for transplant along with additional phone calls following tissue and eye recovery and transport to the ME/C or funeral home, as applicable.

Medical Examiner/Coroner (ME/C) and the Morgue

Patients can be organ donors even when the death falls under the jurisdiction of the ME/C. The National Association of Medical Examiners encourages OPOs and ME/Cs to collaborate together to ensure that ME/Cs obtain what is needed while maximizing donation opportunities.⁵ Therefore, communication with the ME/Cs should be well integrated into the donation process.

In DCD cases, the ME/C is notified of the pending death, circumstances surrounding death, and intent for organ donation to proceed following death determination. Timing for this notification usually occurs once authorization for donation is known by the OPO. Depending on hospital policy, the hospital may make the first notification of the pending death to the ME/C.

OPOs typically discuss the donation potential (organ, eye, and tissue) potential early in the case timeline with the ME/C to determine release for donation and identify any ME/C requirements. OPO staff will work with the ME/C to preserve evidence or assess the state of injury (e.g., obtain blood and/or imaging) as needed to facilitate their investigations. Because ME/C jurisdiction occurs following death declaration, the ME/C may not make any final determination for release of donation until death occurs. Once determination of death occurs, the ME/C must be notified by the OPO or the hospital team (usually the nurse caring for the patient). The OPO will then obtain any additional permissions as needed (e.g., release for tissue/eye recovery, release for research, transportation of the patient to the ME/C office for autopsy), if not already determined in prior conversations between the OPO and the ME/C.

If an autopsy will be performed, all hospital medical devices still attached to the body (e.g., lines and drains) must be left in place.

Once the patient has been transported to the morgue, the OPO recovery team typically ensures the party responsible for transportation of the donor is notified of the location of the patient. From the morgue, the patient may be transported to the funeral home (if no further donation or autopsy will take place), the ME/C’s office for autopsy, or the OPO for tissue and eye donation.

Tissue and Eye Donation

Tissue and eye donation are separate to the organ donation process, but are related opportunities that provide families meaning and comfort in their family member’s death. Donated tissues such as skin, bone, blood vessels, tendons, ligaments, cartilage, nerves, heart valves, corneas, etc., can dramatically improve the quality of life for recipients and help to save and heal lives. One tissue and eye donor can heal the lives of more than 75 people.^7,8

Each year, nearly 58,000 donors provide necessary tissues for the nearly 2.5 million tissue transplants that are performed each year in the United States.^7,8 Some examples of how tissue may be used for lifesaving and life-enhancing transplants include skins grafts for severe burns and mastectomies with reconstruction, ligament and tendons to repair and rebuild joints, bone replacement for fusions or prevent amputation, veins to reestablish circulation, or heart valves to fix cardiac defects.^7,8 Eye donation can restore sight.⁹

In the DCD case, the potential donor will be screened for tissue and eye donation suitability. Final screening and acceptance occurs after death declaration.

Tissue and eye recovery typically takes place after death is declared and organ recovery is complete — unless organ donation was aborted because the patient did not die within the necessary time frame. If organ recovery is successful, the OPO recovery team will transition the case over to the tissue recovery team for tissue recovery. Tissue recovery can occur in various locations such as a hospital OR room, potentially in the hospital’s morgue, or in a dedicated tissue recovery suite often located at the OPO. Following tissue and eye recovery, the donor’s appearance is restored with prosthetics allowing for family and open casket viewing.

In the event that the patient does not die in the time frame needed for DCD recovery to occur, the hospital patient care team is responsible for notifying the OPO at time of death at which point the patient will be re-evaluated for tissue and eye donation.