Question 26

Created on Tue, 06/06/2017 - 04:59
Last updated on Thu, 08/10/2017 - 18:32
Pass rate: 72.5%
Highest mark: 7.5

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A 65-year-old male with a severe hypoxic brain injury following an out of hospital cardiac arrest has been   in your ICU for eight days. The only evidence of neurological activity is that he takes an occasionalbreath whilst on the ventilator. The decision has been made to withdraw treatment on the grounds of futility. You consider him to be a candidate for donation after cardiac death (DCD).

The family has indicated that they support a previously expressed desire by the patient to donate his organs should such a situation arise.

Outline  the  points  that  should  be   discussed  with  the  family  concerning  the  process  of  DCD.

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College answer

NB: Different states have different legislation and practices.

• Treatment withdrawal in patient’s best interest
• Discuss the process of treatment withdrawal including the location where treatment 
withdrawal will occur (ICU, OT or a room next to the OT etc.) as well as the family’s ability 
to be present until shortly after death
• Organ retrieval will need to occur very shortly after death thus limiting the time that the 
family can spend with their loved one after death has occurred
• Any medications including anxiolytics and analgesics can be administered at any time up 
until death to ensure patient comfort
• Predicting the time of death is very difficult, and, if it does not occur in a time frame, it may 
preclude organ donation but tissue donation is still a possibility
• The organs that can be donated will also be dependent on the time from withdrawal of 
treatment to death
• If organ donation is not possible because death has not occurred within the time frame, 
then the care of the patient will be continued either within the ICU or another suitable 
location
• Family consent will need to be gained for bloods to be taken for tissue typing and serology 
as well as for any procedures that need to be done to assess organ suitability, e.g.
bronchoscopy, femoral catheters
• Organ removal surgery may reveal medical reasons for organ donation not to proceed
• Depending on the circumstances surrounding the cardiac arrest, there may be a need to 
refer the case to the Coroner who may decide on a post-mortem examination
• The family has the right to 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.