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Memorandum addresses DCD investigation

Published on: Wednesday, February 28, 2007

To: UNOS Representatives and Alternates, Transplant Program Directors, Transplant Administrators, Histocompatibility Lab Directors, OPO Executive Directors and Member Public Relations Contacts

From: Sue V. McDiarmid, M.D., President, OPTN/UNOS and Walter K. Graham, Executive Director, OPTN/UNOS

Subject: Reports of DCD investigation

News reports have disclosed ongoing state and local investigations of two San Francisco-area surgeons and staff at a hospital in San Luis Obispo, Calif. The investigations concern an alleged attempt to hasten cardiac death of a potential organ donor. The reports state that the potential donor did not expire in the operating room, and that he was returned to the ICU where he died several hours later.

We caution everyone that the investigations are continuing, and that the parties involved are entitled to a presumption of innocence. However, everyone in the transplant community must share in the concern over this development. We must also share in a commitment to prevent any action or attempted action that could compromise patient care.

We are not in a position to participate in or comment about potential criminal or professional investigations. The OPTN's authority under federal regulation and OPTN bylaws and policies extends to its member institutions, not over individual medical professionals. The OPTN/UNOS Membership and Professional Standards Committee (MPSC) conducted a peer review of the member organ procurement organization (OPO) activities in this instance. This review resulted in a letter of reprimand for the OPO's failure to follow its established protocol for recovery of a donor after cardiac death (DCD). The MPSC is continuing to monitor the OPO's adherence to a corrective action plan that provides for improved DCD processes and procedures as well as extensive professional training regarding DCD recovery.

The development of DCD protocols has been evolving over a number of years. The OPTN/UNOS' specific involvement in these protocols is detailed in the following report:  The Role of the OPTN/UNOS in the Evolving Practice of Donation after Cardiac Death. Most recently, at its December 2006 meeting, the OPTN/UNOS Board of Directors adopted a bylaw directing OPOs and transplant hospitals to develop specific protocols for DCD donor recovery and, once those protocols are developed, to ensure they are followed. Among other reasons for this bylaw, it is intended to ensure that DCD donor recovery should always occur in an environment where the roles and responsibilities of transplant professionals are clearly defined, and the actions undertaken provide the utmost ethical consideration of the donor and the donor family. Given our role in maintaining public trust in the donation and transplantation system, we all must uphold these principles.

We will continue to inform you of any further developments in this situation.