Opinion 2.157 - Organ Donation After Cardiac Death
Given the increasing need for donor organs, protocols for donation after cardiac death (DCD) have been developed. Controlled DCD allows patients who have agreed to be taken off of life support or their surrogate decision makers the opportunity to donate the patients' organs once death has been declared. In these cases, life support is discontinued in or near the operating room so that organs can be removed promptly after death is pronounced. DCD also may be considered from patients who suffer unexpected cardiac death (uncontrolled DCD). It requires that they be cannulated and perfused with cold preservation fluid (in situ preservation) within minutes after death to maintain the viability of organs. Both of these methods may be ethically permissible, with attention to certain safeguards.
(1) Hospital policies should specify important details of the DCD process, such as the required time delay before death can be pronounced after cardiac arrest.
(2) In all instances, it is critical to avoid perceived or actual conflicts of interest in the health care team with respect to caring for the patient versus facilitating organ donation. The health care professionals providing care at the end of life should be distinct from those participating on the transplant team. No member of the transplant team may have any role in the decision to withdraw life support or in the process leading to pronouncement of death.
(3) Clear clinical criteria should be in place to ensure that only appropriate candidates, whose organs are reasonably likely to be suitable for transplantation, are considered eligible to donate organs under these protocols.
(4) Palliative care for DCD candidates should continue after removal of life support until death is declared.
(5) In controlled DCD, the decision to withdraw life support should be made by the patient or the patient’s surrogate decision maker before any mention of organ donation (unless the patient or surrogate spontaneously broaches the subject). This is meant to ensure that withdrawal of life support is not influenced by the prospect of organ donation.
The informed consent for controlled DCD should include specific discussion of pre-mortem interventions aimed at organ preservation, to improve the opportunity for successful transplantation, rather than to benefit the patient. Interventions that are likely to hasten death must not be used.
(6) In cases of uncontrolled DCD, prior consent of the decedent or consent of the decedent’s surrogate decision maker is ethically required. Perfusion without consent to organ donation violates requirements of informed consent for medical procedures and is not permissible. (I, III, V)