Saturday, April 14, 2007

Donation After Cardiac Death (DCD)

The very first experimental organ transplants came from donors who had recently died, whose hearts had stopped beating. These were superceded by living organ donations between twins and other relatives for the first "successful" kidney transplants, but "dead donors" would ultimately make up the bulk of organs donated. The earliest and most logical definition of "dead" was supremely intuitive--those whose heartbeats and breathing had stopped. Over the course of several years, brain death came into the picture as a new definition of death, and the 1968 Harvard Ad Hoc Committee on Brain Death formalized its definition and criteria. Brain death generated some controversy, but has become accepted as a medical and legal definition of death, and brain-dead patients became the pool of candidates for organ donation. However, some in the transplant profession had not forgotten the early donors, and in the mid-to-late 1990s the practice of recovering organs from donors whose hearts had stopped was resurrected as "donation after cardiac death" or DCD.

The principles of each are simple. Brain death is when the brainstem has been damaged beyond repair, when someone cannot breathe or maintain essential life functions without artificial support. Brain death can be diagnosed and declared by standard criteria, and after brain death is declared, death is declared as well and life support is removed. This time period is also the window for possible organ donation. DCD is for donors who do not meet brain death criteria but still have no meaningful chance of survival. In these cases, mechanical support is withdrawn as it commonly is for many people in these circumstances. The only difference from the usual practice is that organs are recovered after death for transplantation.


In the decades between the early and the recent use of DCD, the biggest change in the US transplant system was the development of UNOS. Its history is another very long post, but the end result is that UNOS allocates organs for transplant, sets up the rules and systems by which organs are allocated, and sets conditions that member hospitals have to follow to legally get organs for transplant. UNOS is responsible for current DCD practices, and it also holds responsibility for an extremely long waiting list and a huge number of transplant centers. Recently, faced with criticism over its effectiveness, incoming UNOS President Sue McDiarmid, a pediatric liver transplant specialist at UCLA, set the amazing goal of eliminating death on the waiting list of children. No child would die waiting for a transplant...this is a result that could definitely show UNOS's effectiveness to be beyond question. It would obviously require an increase in organ donations (in addition to tweaking current practices) and this increase could logically come from DCD donation.

UNOS set forth with proposals to increase DCD donations, including requiring all hospitals to have a DCD policy. This effort was not met with unbridled enthusiasm, but instead with a lot of resistance. The report of a recent meeting of the UNOS Pediatric Committee details the resistance, which is especially strong for pediatric donors. This is ironic given that the push was partly designed to help children needing transplants, but it is also very understandable given the medical uncertainty of prognosis in children and the pure tragedy of a child's death. To understand and work through this concern, UNOS recently held a Summit on Pediatric Organ Donation and Transplantation, including both pediatric transplant professionals and pediatric intensivists (ICU physicians). A report from this summit is not available, but one fact that has been brought up is that pediatric intensivists are often in the unique position of caring for both potential organ donors and recipients. While most in the transplant field aren't in this same position, they are experienced medical professionals, so have undoubtedly dealt with issues surrounding the death of a patient.

Just as the initiatives to increase DCD were gaining momentum, a devastating blow was dealt to the practice by the misconduct of a transplant surgeon. The Los Angeles Times exposed the story of a transplant surgeon seeming to order medications for a potential DCD donor. The intent may or may not have been to hasten the donor's death, but even the presence of the transplant surgeon before death is improper and filled with conflict. Faced with such a blatant violation of DCD practices, the reaction of the transplant community was relatively poor, with a response from UNOS that was essentially a non-response of "we can't comment on an ongoing investigation" and grumblings from others in the transplant world that "The LA Times is at it again..." (my reaction being "don't shoot the messenger"). While this incident never should have happened, and cast DCD donation in a poor light, confusion is not limited to the DCD situation, with the LA Times recently reporting confusion in declaration of brain death of a potential organ donor. This confusion isn't even limited to cases where organ donation is a consideration, with the story a couple of years ago about a girl in California who was declared dead but was actually alive.

Current Opinions

Unfortunately, current opinions about DCD seem to be drastically negative. The Washington Post recently ran a feature article on DCD, discussing the resistance and including a number of quotes that are quite questionable. Jerry Menikoff of the University of Kansas stated that "we're starting to remove the organs a few minutes before they meet the legal definition of death" which is completely contradicted by the multiple statements earlier about how organ recovery begins several minutes after death, not a moment before. Dr. David Crippen of the University of Pittsburgh asks if "we're going to take organs from patients who have a prognosis of death but who do not meet the strict definition of death, might we become more interested in taking organs from patients who are not dead at all but who are incapacitated or disabled?" which is also false since organs are not taken from patients when they "have a prognosis of death" but rather when they are dead. The only published reply from the transplant community was a brief letter to the editor by UNOS President Sue McDiarmid, stating generally that some statements were not fully true. Since this article has been circulated so widely in the blogosphere and beyond, it's concerning to me that it's been contested or debunked so little.

Blogs have a great deal of insight into current opinions of DCD, insight that builds on the published works and expands on them. A comment to a post on the popular blog Kevin, MD include the information that all of the pediatric anesthesiologists at St. Louis Children's Hospital have refused to participate in the practice. A similar feeling has been reflected at other hospitals, but the bluntness and honesty of this response is particularly telling. A more deeply insightful post on pediatric DCD comes from Donorcycle, a blog by a transplant procurement coordinator with an excellent post titled "When You Watch A Child Die".

My opinion on DCD donations is that they're as rough as everything else. Donations after brain death also come under tragic circumstances and strike a family at the time of a loved one's death, and living organ donation is fraught with worries of its own. DCD strikes me as being equally viable and as beneficial as other forms of organ donation, so I see no reason why it shouldn't be supported and expanded. That said, it does seem like the transplant community's efforts in this area haven't panned out as well as they could. My suggestion for the transplant community is (1) set clear policies and regulations to enable DCD to happen in an ethical and respectful manner and (2) show no tolerance for breaches of these policies, affirming that we strive for maximal organ donation within strict bounds of ethics and dignity. My request to the rest of the world is much simpler: please bear with the transplant community during changing times, understand just how valuable organ donations are, and how profound it is to "donate life."


nancy erhard said...

I wish more of my interview with Rob Stein had been used in the washington post article. I am the mother who is pictured with her handsome son, and I detailed how our family stood by him, after removing supprt, and watched his skin turn blue and his eyes open wide, due to hypoxia, as we played the Beatle's White album...and the song Blackbird started: "Blackbird singing in the dead of night, take these broken wings and fly..."
I saw my son just 2 hours before the tragic dissected carotid caused his collapse, sharing leftovers from thanksgiving dinner..20 of his friends were standing with him when he suddenly dropped, without a warning and no health concerns.
There was an RN and 2 other brave girls there, who kept his pulse going, and averted a death at the scene. I am a healthcare professional who worked 11 years at Mass General, and received adolescent help for my son there 10 years earlier, so I was very comfortable once he was admitted to Neuro ICU that every effort would be made to save him.
When the MRI and CT Scan were done, I wanted to show value of his life...scores of his friends and family lined the halls those 3 one would the nurses set up water and cups and worked around us...we were allowed to stay in his room as long as we were careful to contain the groups, and respect the other patient's privacy....the staff said: choose the time you want to have a ceremony and remove support and have anyone who wants to come visit him before we do this. The compassion was wonderful.
The gift I made for Bo was huge: eyes, heart valves, kidneys, liver, adrenals, leg bones (helped 30 people) veins, and skin from his buttocks for burn victims.
Looking at his smile in this 'Post picture makes me smile also now.I had a wonderful, if challenging, son for 25 years, and he lives on within the miracles he made happen when fate took him...and those friends carried a bigger purpose...with me.
Those friends and I raised $4000 on his next birthday for someone in trade school at his high school this spring to reach their dreams! Bo was a plumber, always with that beautiful smile, always forgetting something and struggling to grow up. I grew so close to him that way. Now I see how much of a gift his life was over and over...
Life is so precious; more so when you lose your only son and see the life he came to create by his untimely death. Now you feel the mystery of life itself and know you gave him dignity, and everlasting impact by his existence. What more could I ask for?
Nancy Erhard his mom...

TC said...

your post is so good and thank you for including donorcycle. But I really have to thank Nancy for what she shared. As much as organ donation is about the recipients, it is also about the donors and the families left behind. There is no better legacy to leave when you die than to know that you saved anothers life. When I hear from families like Nancy and hers, I know that DCD is the right thing to do. Thank you Nancy, my heart goes out to you.

Gworn2000 said...

Nancy and her family are heros - remarkable people, who, during a time of deep grief and sorrow, are able to unselfishly and generously consider passing "The Gift of Life" on to others. Thank you Nancy and thank you for your son's gift to others.

I am the father of four sons - one a donor (after Jesse Jake Warren died in a car accident the day after Thanksgiving of 2004, we donated his eyes and tissues - bettering the lives of 21 others). My other son Tyler Andrew received a heart at age 16 - he lived wonderfully for 4 1/2 more years, attended college, was planning his future, found a girl and fell in love. Tyler's new heart gave out and he passed away June 12, 2005. He is with his brother Jesse.

Gil Warren
Lead Ambassador,
Donate Life California/
California Transplant Donor Network

Anonymous said...

I have recently read a washington post article on DCD and was so frustrated as to how little people know about the tranplant community. As a person working in a procurement organization, I can see how devastating such articles can be to the entire process.