The American Thoracic Society has released an official statement on the ethical and health policy considerations surrounding adult and pediatric controlled organ donation after circulatory determination of death (DCDD), the recovery of organs after cessation of circulation from patients with severe neurological, neuromuscular or pulmonary disease for whom decisions are made to forego additional life-prolonging treatments.
The ATS developed the statement with input from the Society of Critical Care Medicine, the International Society for Heart and Lung Transplantation, the Association of Organ Procurement Organizations, and the United Network of Organ Sharing.
The statement appears in the July 1, 2013, issue of the American Journal of Respiratory and Critical Care Medicine.
"The recovery of viable organs must be performed with maximum respect for dying patients and their families," said Cynthia Gries, MD, MSc, assistant professor of medicine and clinical translational sciences in the Division of Pulmonary, Allergy, and Critical Care Medicine at the University of Pittsburgh Medical Center and chair of the committee that drafted the statement. "With that goal in mind, we developed a framework to help guide the various stakeholders involved in the DCDD process."
Recommendations in the statement include the following:
- When patients themselves have consented to organ donation, hospital critical care and organ procurement organization (OPO) representatives should respect the patient's decision and provide this information to surrogate decision makers.
- After clinicians lead discussions with patients or surrogates about the decisions to withdraw life-sustaining therapies, discussions about DCDD should proceed promptly and be coordinated jointly by clinicians and OPO representatives.
- Consent for DCDD should be obtained by individuals with appropriate experience and training; these individuals' organizational affiliations should be disclosed clearly.
- Use of ante-mortem interventions and medications should be disclosed to surrogates at the time of consent and identified as being administered solely for the purpose of organ donation.
- Ante-mortem interventions are ethically appropriate if they contribute to good transplant outcomes and have a low chance of harming the prospective donor.
- Post-mortem donor management interventions that may stimulate physiologic functions require further analysis of their clinical usefulness and ethical merit.
Determination of death
- Death can be declared after the cessation of circulation and respiratory function for 2 minutes.
- Information about how death will be determined should be provided to the patient or the surrogates.
- Surrogates should be informed during the consent process regarding: (1) how and where life-sustaining therapies will be withdrawn, (2) the amount of time they can spend with their loved one post mortem and (3) the possibility that the patient may not die within the time interval necessary for DCDD to occur.
- Hospitals that participate in DCDD should ensure that experienced personnel with competency in palliative care are available to participate in end-of-life care if needed.
- Hospitals that participate in DCDD should have a clear policy regarding how and where patients will be cared for if they do not expire within the time interval acceptable for donation.
- Although pediatric patients cannot provide consent to their own donation, consent of the parent or of another legal surrogate can be used.
- The ethical principles related to consent, intervention, declaration of death and end-of-life care in pediatric DCDD patients are similar to those for adults.
"Increased use of DCDD organs could have a substantial impact on the chronic shortage of donor organs available for transplantation, but as the consent and management of potential DCDD donors occurs before death, it raises a number of important ethical and policy issues," Dr. Gries said. "This statement, which incorporates input from a number of critical care and transplant societies, addresses those issues."