There is a need for a uniform standard in donation after cardiac death (DCD) protocols and death-determination practices, according to a study published in Transplantation (2011;91:386–389).
Lead author Jennifer E. Fugate, DO, of the Department of Neurology at Mayo Clinic, and colleagues contacted 36 organ procurement organizations (OPOs), and 19 (53%) provided a total of 64 DCD protocols from 16 different states. Of the protocols, 48 (75%) were definitely hospital derived, not OPO derived.
Trigger points, or clinical characteristics used to identify DCD candidates, were outlined in 58 protocols (91%), with 37 (58%) describing ”non-recoverable” or irreversible neurologic injury resulting in ventilator dependence but not meeting criteria for brain death.
Age criteria were designated in only four protocols (6%), and the criteria themselves varied. One protocol specified a necessary body weight ranging from 36 kg to 114 kg, and 40 protocols (63%) included a statement that death should be imminent after withdrawal of support.
In addition, 12 protocols stated that the patient should be “expected to suffer cardiac death within a very short time frame” after withdrawal of life support. In 24 protocols (38%), there was no mention of any method to assess whether a patient would die “in a short time frame,” and one-third of protocols required the use of both electrical activity and blood pressure as the predominant means by which to pronounce death.
The majority of protocols—75%—included a statement indicating a strict separation of transplant team members from the clinicians responsible for withdrawing life-sustaining measures and declaring death.
Dr. Fugate and colleagues noted that a limitation of the study is that they were unaware of the number of DCD procedures that are carried out by the institutions.
“Variability in DCD protocols is expected, but we were struck by the marked, potentially consequential differences in definitions and recommendation in the DCD protocols surveyed,” Dr. Fugate and colleagues wrote. “The current standard for declaration of death is the demonstration of permanent cessation of circulatory and respiratory functions.”
As of 2007, all organ procurement organizations and transplant hospitals in the United States are required to have a DCD policy.