The Role of the OPTN/UNOS in the Evolving Practice of Donation after Cardiac Death
The unique aspect of organ donation after cardiac death (DCD) is that a patient is removed from life support at the wishes of the family, and after death occurs the organs are procured. As such, this option for organ donation becomes an integral part of end of life care. The medical community and the public have examined and debated this concept over many years. Testimony of families who have consented to DCD, emphasize that the opportunity to save other lives by their altruistic act has been of comfort to them.
The Institute of Medicine (IOM) conducted three in-depth reviews published in 1997, 20001 and 20052, all of which concluded that DCD was not only an ethical practice, but an important option to improve the supply of donor organs to patients awaiting organ transplantation.
In the 2000 IOM study funded by HRSA, several UNOS staff members were recognized by the study director, Ellen Agard, for their assistance with this study. The following recommendation from the study was particularly compelling: Recommendation for efforts to develop voluntary consensus on non-heart-beating donation practices and protocols should be continued. Based upon this recommendation, Task 10 of the OPTN contract proposal was written to address the efforts necessary to educate the transplantation community about NHBD (currently DCD) issues. Upon acceptance of this proposal by HRSA the following resources/activities were carried out:
- DCD Focus Group Study: UNOS contracted with the Southeastern Institute of Research and, guided by an OPTN Focus Group Advisory Council, conducted a qualitative study to determine health care professionals perceived barriers to recovery of organs from DCD donors. A paper titled National evaluation of healthcare provider attitudes toward organ donation after cardiac death was published in Critical Care Medicine in 2006.
- Donation after Cardiac Death--a Reference Guide: Guided by an OPTN Critical Care Advisory Council, this guide was published in 2002. This group was also responsible for the development of the Critical Pathway for Donation after Cardiac Death (DCD).
- Operating Room Initiative: An OR Advisory Council developed a generic DCD operative procedure card and published an article titled Executive Summary from the Intraoperative Advisory Council on Donation after Cardiac Death of the United Network for Organ Sharing: Practice Guidelines. This article was published in Liver Transplantation in Oct. 2003. They also published an article titled Donation after Cardiac Death--the Reinvention of a Forgotten Procedure in Surgical Services Management in June 2003.
- Medical Examiners/Coroners: The Medical Examiners/Coroners Advisory Council produced an educational resource titled Death Investigation and Organ and Tissue Donation: a Resource for Organ and Tissue Recovery Agencies, Medical Examiners and Coroners. A discussion of DCD was included in this resource.
- Critical Care Nurses: Through the OPTN Critical Care Nurses Advisory Council, two issues of Critical Care Nurse were dedicated to the issues surrounding organ donation. Each issue contained a DCD article: Organs from Non-Heart-Beating Donors: An Answer to the Organ Shortage (1999) and Maximizing Organ Donation Opportunities through Donation after Cardiac Death (2006).
In 2004, under the leadership of Dr. Frank Delmonico, planning began for a national conference on donation after cardiac death to address controversies about the procedure itself, to examine criteria that would predict DCD candidacy following the withdrawal of life support, to advance protocols for recovery, to examine data regarding ischemia time and function of the transplanted organ, to increase DCD and to allocate these organs appropriately. The conference occurred in April of 2005 and the proceedings of the meeting were published in the American Journal of Transplantation in 2006 3.
- A recommendation from this conference was that protocols for DCD procurements should be a requirement of OPTN/UNOS membership for transplant centers and OPOs. In March 2006, the OPTN/UNOS Membership and Professional Standards (MPSC) committee requested that the Organ Procurement Organization (OPO) Committee consider this matter. On April 5, 2006 the OPO committee resolved unanimously that all OPTN member organizations be required to have protocols to facilitate the recovery of DCD organs. The MPSC supported this resolution at its May 2006 meeting, and also resolved that "a working group be created under the auspices of the OPO Committee to develop the important elements that must be addressed in protocols for DCD procurements and addressed by OPTN members in developing such protocols."
- In reviewing the resolutions of the OPO and MPSC committees at the June 2006 OPTN/UNOS Board meeting--the Board approved amended language to strengthen the intent of the Committees' resolutions, resolving that the By-laws be amended so that OPOs and transplant hospitals "must develop by January 1, 2007 (and once developed must comply with), protocols to facilitate the recovery of organs from DCD donors." The Board noted that the JCAHO requirement, announced in June 2006, for all hospitals to have DCD protocols did not give prescribe required elements in such protocols.
- At the December 2006 OPTN/UNOS Board meeting, the DCD working group reported to the Board and presented a proposal for important elements to be included in DCD protocols. The Board found that more detail and clarification was required in this first proposal. The Board did approve an Attachment to Bylaws that set forth broad categories of model elements required in OPO and transplant hospital protocols. The Board instructed the OPO DCD Working Group to revise their proposal and return to the Board with the modifications.
- At the March 2007 OPTN/UNOS Board meeting, the OPTN/UNOS Board of Directors adopted a set of "model elements" that member organizations must include in their protocols for recovering organs from DCD donors. The elements include a series of points in the DCD process, including potential donor selection, donation consent, withdrawal of life-sustaining measures, pronouncement of death and organ recovery. The model elements address the separation of duties of the transplant team from the care providers, specifying that no member of the transplant team shall be present for the withdrawal of life-sustaining measures, and that no member of the organ recovery team or organ procurement organization staff may participate in the guidance or administration of palliative care, or the declaration of death. As with all donations, the model elements also call on organ procurement organizations to ensure that no donation-related financial charges are passed to the donor family. The elements also include resource information addressing clinical and legal aspects of DCD donation.
- Institute of Medicine, National Academy of Sciences. Non-heart-beating organ transplantation: Practice and protocols. Washington, DC: National Academy Press, 2000.
- Institute of Medicine, National Academy of Sciences. Non-heart-beating organ transplantation: Practice and protocols. Washington, DC: National Academy Press, 2005.
- Bernat JL, D'Alessandro AM, Port, TP et al. Report of a National Conference on Donation after Cardiac Death. American Journal of Transplantation 2006;6:281-291.