Question 8

Created on Thu, 05/21/2015 - 15:35
Last updated on Thu, 08/10/2017 - 18:32
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A 40 year old male, with no significant past medical history, has a severe head injury following a motor vehicle accident one week previously. It is deemed that he has a non survivable injury, although  he is not brain dead. The wife has raised the possibility of organ donation  post cardiac death (DCD). In your conversation with his wife about donation  after cardiac death, outline the important discussion points about DCD.

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College Answer

DCD issues
Details of the process of treatment withdrawal, including the available locations, and ability for the
family to be present until shortly after the time of death.

That organ retrieval needs to begin without delay after death in order to minimise the effect of warm ischaemia. This allows family members very little time with their loved one after death has been declared.

That anxiolytics and analgesics will be given, as necessary, until the moment of death.

That predicting the time from treatment withdrawal to death is difficult. If this interval is greater than the maximum that allows organ retrieval for transplantation, organ donation will not be possible. Tissue donation may still occur if suitable and the family consents.

The organs that may be suitable for transplantation and the effect on this of the time from treatment withdrawal to death.

That if organ donation is not possible, care for the patient will be continued in the ICU or another suitable location. That consenting to donation will usually result in a significant delay in the time that treatment may be withdrawn, due to the complex logistics associated with arranging donation and transplantation. The family must be prepared for and consent to this.

That blood is taken for serology and tissue typing before treatment is withdrawn.

That the family’s permission will be sought for the administration of drugs (e.g. IV heparin)
and procedures (e.g. bronchoscopy) to facilitate organ donation.

That pre-operative assessment or organ removal surgery may reveal medical reasons why donation may not proceed.

That the circumstances of the death may need to be reported to the coroner and a coronial post- mortem examination may occur. This is independent of the donation process.

That families may change their minds and withdraw consent at any time.

Discussion

Consent:

  • Under most Australian and NZ legislations, organ donation can only take place "if the deceased patient had expressed a wish or given consent to donation of issue, which had not been revoked, and had not expressed an objection to donation".
  • Donation should  not proceed if the family disagrees.
  • Consent for organ donation can be withdrawn at any time.
  • Though Australian  state legislation refers to the consent of a "senior available next-of-kin",  any member of the family may raise concerns about organ donation.
  • Though there may not be unanimous support for organ donation within the family, such consensus is required which would represent "agreement as defined by the family".

Inconveniences for the family, for their patience with which we are grateful:

  • Detailed questions about their loved one will be asked by the donation coordinator
  • Many forms will need to be signed by the family
  • The senior next of kin may be approached to give consent to various procedures such as bronchoscopy, angiography etc.
  • Consent for bloods and serologies will be required
  • Testing for hepatitis virus and HIV will take place
  • After the withdrawal, there may be little time for the family to spend with their loved one
  • The organ retrieval process takes time and is an imposition on the grieving time
  • Following organ retrieval, the family may spend time with their loved one, but this may not be in the ICU and may instead take place in the viewing room of the mortuary (or a similar location)

Reassurance of high standards:

  • Patient-centered care with a focus on dignity and respect will be continued throughout the process, irrespective of whether or not donation takes place

Pre-conditions for donation after circulatory death:

  • Treatment withdrawal is in the patient’s best interest, and is agreed upon by the family and all relavant medical staff involved
  • The family agree to organ donation after death is confirmed (or, more rarely, the competent patient may give consent)
  • The decision to withdraw treatment is made independently of the decision to go ahead with organ donation
  • Circulatory death is confirmed

Ongoing treatment which is unhelpful to the patient, but which maintains organ viability:

  • There are certain procedures and techniques which may be required to either maintain organ viability pre-retrieval, or to ascertain their suitability. 
  • These may include such benign procedures as the injection of subcutaneous heparin, or such invasive procedures as bronchoscopy or antemortem insertion of femoral cannulae and injection of 20,000 units of heparin prior to withdrawal.
  • These may go ahead if the patient or family have consented to organ donation and have no objections to these interventions, nor do they contribute to death or compromise the quality of otherwise comfort-directed care.

Conditions during and after treatment withdrawal

  • Location for withdrawal can be variable and is open for negotation
  • Possible locations include ICU, OT or a room close to the OT 
  • "Comfort care" including anxiolytics and analgesics can be administered at any time up until death
  • If the patient does not die wthin the specified timeframe, such "comfort care" will continue (in the ICU or at another suitable location, such as a palliative care unit).
  • It is unethical to make any changes to management which might be seen to hasten the dying process

Possible ineligibility

  • The timing of death is unpredictable
  • If death does not occur within a specific time frame, organ donation may not be possible (but tissue donation may still be possible)
  • Organ removal surgery may reveal medical reasons for organ donation not to proceed
  • The Coroner may decide that a post-mortem examination is necessary (depending on the circumstances of death), which may either limit the range of organs available for donation or preclude the possibility of donation altogether.