University of Colorado Hospital Policy and Procedure

Donation After Circulatory Death

Related Policies and Procedures:
Organ and Tissue Donation
Consent for Medical Care and Procedures
Advance Directives
Determination of Death by Neurologic Criteria (Brain Death)
Mechanical entilation! Management and "iberation
#nd of "ife Care
Approved by: Professional Practice$ Policy and Procedure Committee
O% Committee
#thics Committee
Medical Board
#ffective! &'()
Current! *'++
Description: The ,ur,ose of this ,olicy is to outline the ,rocedure in -hich human organs
are recovered for the ,ur,ose of trans,lantation after the declaration of death according to
circulatory criteria.
Definitions:
Circulatory Death: (Per /niform Declaration of Death Act$ +*0+)! The cessation of circulation
and res,iration. 1urther defined by monitoring of death by confirming +) a ,ulse of 2ero via
arterial catheter or Do,,ler$ 3) that the ,atient is a,neic$ and )) the ,atient is unres,onsive to
verbal stimuli for a ,eriod of t-o minutes before ,ronouncement of death.
Donation after circulatory death (DCD): A ,rocedure that entails the recovery of organs after
death due to cessation of circulation in ,atients -ho have not met brain death criteria and
decisions are made to forego further life4,rolonging treatments.
Decision Makin Capacity (DMC): The individual has the ability to ,rovide informed consent
to or refusal of medical treatment.
Healthcare Decision Maker! +) A ,atient -ho retains DMC$ or 3) the ,erson authori2ed to
ma5e medical treatment decisions on behalf of an adult ,atient -ho does not have DMC. This
may include an agent under a Durable Medical Po-er of Attorney$ family or ,ro6y. A 7ealthcare
Decision Ma5er -ho meets the criteria set forth in 8ection 9 belo- is authori2ed to ma5e an
anatomical gift.
!ran Procure"ent !rani#ation (!P!): non4,rofit organi2ation that is res,onsible for the
evaluation and ,rocurement of deceased donor organs for organ trans,lantation (i.e. Donor
Alliance).
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Donation After Circulatory Death
$able of Contents
%& Deter"ination of the Healthcare Decision "aker'''''''''''&&(
%%& Discussion of Care (
%%%& Potential DCD Donor )valuation''''''''''''''''' *
%+& Consent,Approval'''''''''''''''''''''''' *
+& -ithdra.al of /ife 0ustainin Medical $reat"ent,0upport''''' *12
+%& Pronounce"ent of Death'''''''''''''''''''''2
+%%& !ran Recovery'''''''''''''''''''''''''2
+%%%& 3inancial Considerations'''''''''''''''&&&&&&&&&&&&&&&&&&&&&&&&2
%4& References'''''''''''''''''''''''''&&&&&&&&&215
4& Appendi6 A: Donation after Circulatory Death Procedural 3lo. Chart'&&7
4%& Appendi6 8: DCD Procedure Chart'''''''''''''''91::&

Policies:
%& Determination of the 7ealthcare Decision Ma5er for donation of anatomical gift. (C%8 :+34
)&4+(& and C%8 +34)&4+(; )
The 7ealthcare Decision Ma5er for the ,ur,ose of ma5ing an anatomical gift is the ,erson
designated in the follo-ing order of ,riority!
A& The donor$ if the donor has DMC and is an adult or is a minor and is emanci,ated.
8& An agent a,,ointed in a medical durable ,o-er of attorney signed by the ,atient ,ursuant
to C.%.8. : +;4+&4;(<. unless the ,o-er of attorney for health care or other record
,rohibits the agent from ma5ing an anatomical gift.(C%8 +34)&4+(&)
C& A court4a,,ointed guardian or conservator for the ,atient$ unless other-ise limited by the
court order a,,ointing the guardian or conservator.
D& The 7ealth Care Decision Ma5er as noted in the 7ealth Care Directive section in the
electronic medical record.
%%& Discussion of Care!
A. The discussion is had bet-een the ,atient$ and'or health care decision ma5er$ -ith the
attending ,hysician and health care team to discuss goals and values to customi2e the care ,lan.
B. The 7eath Care Decision Ma5er or attending ,hysician discusses -ithdra-al of life4
sustaining treatment.
C. The decision is made by the 7ealthcare Decision Ma5er and the Attending Physician to
transition the ,atient to end4of4life care. The DN% is com,leted in the #M% and co4signed by
the Attending Physician -ithin 3& hours.
%%%& Potential DCD Donor #valuation!
.
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Donation After Circulatory Death
A. The Donor 9nformation "ine ()()4)3+4((<() is notified as soon as the 7ealthcare
Decision Ma5er begins to consider -ithdra- of life sustaining treatment.
B. The assessment for DCD candidate suitability should be conducted in collaboration -ith
Donor Alliance and the ,atient=s ,rimary health care team. Donor Alliance determination
of donor suitability may include consultation from the Donor Alliance Medical Director
and Trans,lant Center teams that may be considering donor organs for trans,lantation.
C. A ,atient -ho has a non4recoverable and irreversible neurological in>ury or chronic
terminal illness resulting in ventilator de,endency but not fulfilling brain death criteria
may be a suitable candidate for DCD.
D. 9n assessment of the ,atient ensure that ,rogression of the ,atient to neurological criteria
for death is unli5ely.
#. A ,atient -ith chronic terminal illness or end stage disease -ho retains DMC and is on
life su,,ort may choose to be evaluated by Donor Alliance for DCD.
1. Donor Alliance should affirm on assessment that there is a reasonable chance of death
-ithin the time frame that allo-s for organ donation after the -ithdra-al of life
sustaining treatment.
%+& Consent'A,,roval
A. Donor Alliance and'or a ,hysician must receive authori2ation from the health care
decision ma5er for any ,rocedures or drugs administration to ,re,are the ,atient for DCD
recovery.
B. Conditions involving ,otential DCD donor being medically treated'su,,orted in a
conscious medical state shall re?uire that the OPO confirms the health care team has
assessed the ,atient=s mental com,etency and ca,acity to ma5e medical decisions
including -ithdra-al of life sustaining treatment.
C. Clearance from medical e6aminer'coroner must be obtained -hen a,,licable.
D. There should be a ,lan for ,atient care if death does not occur -ithin the established
timeframe after the -ithdra-al of life sustaining medical treatment. This ,lan should
include logistics and ,rovisions for continued end of life care$ including immediate
notification of the family'7ealthcare Decision Ma5er.
+& @ithdra-al of "ife 8ustaining Medical Treatment
A. Paralytics must be discontinued and allo-ed to clear ,rior to -ithdra-al of life sustaining
treatment$ as evidenced by train of four of &'&. (Per /C7 #nd4of A"ife ,olicy).
B. Prior to -ithdra-al of life sustaining medical treatment a timeout is re?uired to confirm!
a. Patient identification
b. The ,rocess for -ithdra-ing life4sustaining treatment or ventilated su,,ort.
c. %oles and res,onsibilities of the ,rimary ,atient care team$ the OPO team$ and the
organ recovery team.
d. The hos,itals ,lan for continued ,atient care in the event that the ,atient does not
become a donor and a,,ro,riate communication -ith the health care decision ma5er.
C. No recovery ,ersonnel may be ,resent for the -ithdra-al of life sustaining medical
treatment.
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Donation After Circulatory Death
D. No member of the organ recovery team or Donor Alliance staff may guide or administer
,alliative care$ or declare death.
#. 1amily members and other interested ,arties$ as a,,roved by the 7ealth Care Decision
Ma5er$ -ill be given the o,,ortunity to be ,resent in the O% during -ithdra-al of life
sustaining treatment and during the ,eriod bet-een -ithdra-al of su,,ort and circulatory
death.
1. @ithdra-al of life sustaining measures (e.g. #ndotracheal removal$ termination of blood
,ressure su,,ort medications) are removed in the o,erating room as ,er the attached
algorithm
+%& Pronouncement of Death
A. The ,atient care team member ,hysician that is authori2ed to declare death must not be a
member of the Donor Alliance or organ recovery team.
B. The method of declaring death must com,ly in all res,ects -ith the legal definition of
death by an irreversible cessation of circulatory and res,iratory functions for t-o
minutes before the ,ronouncement of death
+%%& Organ %ecovery
A. Organ recovery may be initiated immediately on ,ronouncement of death.
+%%%& 1inancial Considerations
A. Donor Alliance ,olicy shall ensure that no donation related charges are ,assed to the
donor family.
A,,endices! A,,endi6 A4 DCD Procedure 1lo- DiagramB A,,endi6 B4 DCD Procedure ChartB
%eferences!
+. Deita MA$ 8nyder C. Develo,ment of the /niversity of Pittsburgh Medical Center Policy
for the care of terminally ill ,atients -ho may become organ donors after death follo-ing
removal of life su,,ort. Dennedy 9nstitute of #thics Cournal +**)B)!++)43* ("O# ;)
3. #d-ards C. Mulvania P. Ma6imi2ing Organ Donation O,,ortunities Through Donation After
Cardiac Death. Critical Care Nurse$ vol 3<. no3.$3((< ("O# 0)
). McMahan C. The meta,hysics of death. Bioethics +**;B*!*+4+3< ("O# 0)
&. 8ills P.$ Blair 7A.$ Donation after Cardiac Death! "essons "earned. Cournal of Trauma
Nursing$ vol +&$ no +$ 3((E ("O# 0)
;. Fries$ C.$ et al. An Official American Thoracic 8ociety'9nternational 8ociety for 7eart and
"ung Trans,lantation'8ociety of Critical Care Medicine'Association of Organ and
Procurement Organi2ations'/nited Net-or5 of Organ 8haring 8tatement!#thical and Policy
Considerations in Organ Donation after Circulatory Determination of Death. Am C %es,ir
Crit Care Med$ ol +00$ 9ss +$ ,, +()4+(*$ 3(+) ("O# 0).
c3&(o++ Page & of +3
Donation After Circulatory Death
<. %eich$ D.C.$ et al. A8T8 %ecommended Practice Fuidelines for Controlled Donation after
Cardiac Death Organ Procurement and Trans,lantation. American Cournal of Trans,lantation
3((*B *! 3((&43(++ ("O# E).
E. Dare$ A.C.$ Bartlett$ A.8.$ 1raser$ C.1.$ Critical Care of the Potential Organ Donor. Curr Neurol
Neurosci %e, 3(+3 +3!&;<4&<;. ("O# ;).
0. Bastami$ 8.$ Matthes$ O.$ Drones$ T.$ Biller4Andorno$ N. 8ystematic %evie- of Attitudes
To-ard Donation after Cardiac Death Among 7eathcare Providers and the Feneral Public.
Crit Care Med 3(+)B &+! 0*E4*(;. ("O# ;).
*. Manara$ A.%.$Mur,hy$ P.F.$ O=Callaghan$ F. Donation after circulatory death. British
Cournal of Anaesthesia 3(+3$ +(0! +(04+3+. ("O# E).
+(. Cam,bell$ M.".(3(++) American Association of Critical Care Nurses! Procedure Manual for
Critical Care. Procedure +)E. 8t. "ouis$ MO! 8aunders!#lsevier.
++. Anatomical Fift Act$ Colorado %evised 8tatues. 3(E4)4& (3((E).
+3. 8heath$ DN.$ et. al. Autoresuscitation after asystole in ,atients being considered for organ
donation. Crit Care Med 3(+3 vol. &($ +;04+<+. ("O# <).
Appendi6 A
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Donation After Circulatory Death
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Donation After Circulatory Death
Appendi6 8
DCD Procedure Chart
0$)P ;
Description /ocation
<ey Personnel
<ey Points
=0upportive care for
patients and fa"ilies
>
Decision to
-ithdra- life4
sustaining
treatment
9C/
9C/ team
8,iritual Care
Decision to -ithdra- life sustaining
treatment M/8T be inde,endent (and
,recede) the DCD ,rocess
9nvolvement of 5ey ,ersonnel ,er family
D?AR "ust be co"pleted@ and sined
by Attendin Physician in the "edical
record
9m,lement 9C/ #O" order4set
G Patient sym,tom
management ,er
/C7 #nd4of4"ife
Fuidelines 4 9C/
team
G 1amily su,,ort
through 8,iritual
Care$ 9C/ team$
social -or5 H others
(as needed)
:
Notification of
Donor
9nformation "ine
(,otential donor)
9C/
9C/ nursing staff
Donor Alliance
Donor Alliance -ill assess eligibility of a
,otential donor (initial assessment should
not include contact -ith the ,atient or
family).
G Patient sym,tom
management ,er
/C7 #nd4of4"ife
Fuidelines 4 9C/
team
G 1amily su,,ort
through 8,iritual
Care$ 9C/ team$
social -or5 H others
(as needed)
(
Donor Alliance
1amily 8u,,ort
Coordinator
collaboratively
-ith /C7 staff
9C/
Designated
%e?uestor!
Donor Alliance
Organ re?uest M/8T be ,erformed
through a Donor Alliance 1amily 8u,,ort
Coordinator collaboratively -ith /C7
staff only
Organ re?uest must occur through face to
face contact. 9f the family does not s,ea5
#nglish$ a ?ualified inter,reter must be
available for accurate translation
%nfor"ed consent process! the health
care decision ma5er and'or donor
families must understand and agree to all
ste,s of the DCD ,rocess including
acce,tance of the follo-ing!
:& An a,,ro6imate time of <40 hours
,rior to -ithdra-al of life sustaining
treatment is needed to allo- for
necessary organ recovery
,re,arations.
(& The 9C/ team -ill remain at the
,atientIs bedside throughout the
-ithdra-al of life sustaining
treatment ,rocess&
*& Arterial cannulation$ for
hemodynamic monitoring$ is
G Patient sym,tom
management ,er
/C7 #nd4of4"ife
Fuidelines 4 9C/
team
G 1amily su,,ort
through 8,iritual
Care$ Donor Alliance
(1amily 8u,,ort
Team) H'4 9C/ team
and social -or5'
others (if ,resent)
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Donation After Circulatory Death
recommended to be ,erformed ,rior
to the DCD ,rocess. "ocal
anesthesia -ill be used to ensure
,atient comfort. 9f this is not
,ossible or acce,table to the health
care decision ma5er$ a Do,,ler -ill
be used to monitor blood ,ressure.
2& Administration of ,harmacologic
agents (e.g. he,arin$ vasodilators) for
the sole ,ur,ose of donor organ
function must be detailed in the
consent ,rocess and ordered on a
case by case basis by the
physician&
The family may be ,resent in the O%
during end4of4life care if the family so
-ishes. Donor Alliance %e,resentative
offers family the choice of accom,anying
family member',atient to O% for
removal of life sustaining treatment until
declaration of death$ and notifies O% of
family choice. At time of death family is
escorted from the O% in a timely manner
to avoid undue duress and assure
se,aration of declaration of death and the
,rocurement ,rocess.
%eassure family of ,atient comfort and
su,,ort throughout the DCD ,rocess.
1amilies should be reminded that the
,atient might not al-ays die in an
acce,table time frame for organ donation
after -ithdra-al of life4su,,ort. %eassure
families that their loved one -ould then
be returned to the 9C/ in this
circumstance.
1amilies should also be given the o,tion
to see the body of their loved one
follo-ing surgery (34& hrs ,ost4death)
*A
1amily does
NOT elect
donation!
Document
decision and
,rovide su,,ort
9C/
8,iritual Care
Donor Alliance
9C/ team
Provide continued su,,ort for ,atient and
familyB address further ?uestions'
concerns
Donor Alliance documents decision
including reason for no donation
G Patient sym,tom
management ,er
/C7 #nd4of4"ife
Fuidelines 4 9C/
team
G 1amily su,,ort
through 8,iritual
Care$ 9C/ team$
social -or5 H others
(as needed)
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Donation After Circulatory Death
*8
1amily elects
donation! Notify
7os,ital
manager$
Decedent Affairs
4 begin
mobili2ation
9C/
Donor Alliance
7os,ital
Manager
Decedent Affairs
8,iritual Care
9C/ team
Donor Alliance begins donor
management',lacement ,rocess
7os,ital manager -ill ensure a,,ro,riate
9C/ staff allocated and mobili2ed
Decedent Affairs -ill initiate ,a,er-or5
-ith family
Ongoing su,,ort of family
G Patient sym,tom
management ,er
/C7 #nd4of4"ife
Fuidelines 4 9C/
team
G 1amily su,,ort
through 8,iritual
Care$ Donor Alliance$
9C/ team$ social
-or5 H others (as
needed)
*C
O% staff initiates
contact -ith 9C/
staff and ,atient
family
9C/
9C/
O%
O% nurse contacts 9C/ nurse and ma5es
arrangements to come to the unit and
meet the ,atient and family'
O% nurse ,re,ares O% for ,atient and
family.
2
1amily$ Donor
Alliance and
staff ,re,arations
com,lete!
Trans,ort ,atient
to O%
Trans,ort
9C/ resident MD
9C/ nurse H %T
Donor Alliance
Trans,ort should occur after!
+. The family is ready$ consent is
signed$ and decision made by
9C/'O% staff',hysicians' if family
-ill accom,any ,atient to the O% or
remain in the 9C/ during -ithdra-al
of life sustaining treatment
3. Donor Alliance has com,leted ,re4
recovery ,rocess
). Necessary ,re,arations by the O%
and %ecovery teams are com,lete
&. Necessary 9C/ coverage has been
secured
9C/ resident MD$ %T and nurse then
,roceed -ith the ,atient to the O% and
continue ,atient su,,ort
G Patient sym,tom
management ,er
/C7 #nd4of4"ife
Fuidelines 4 9C/
resident MD$ nurse
and %T
G 1amily su,,ort
through 8,iritual
Care$ Donor Alliance
and 9C/ nursing staff
H others (as needed)
5
Patient
,re,aration for
organ recovery
O%
O% 8taff
9C/ resident MD
9C/ nurse
Donor Alliance
9C/ resident MD and nurse glove and
go-n for sterile field and continue
,atient su,,ort
O% nursing staff ,re,ares ,atient for
organ recovery ,atient
Primary team MD ,erforms arterial
cannulation if not already done and the
health care decision ma5er consents. Or
uses a Do,,ler for measuring arterial
im,ulse.
G Patient sym,tom
management ,er
/C7 #nd4of4"ife
Fuidelines 4 9C/
resident MD$ nurse
and %T
G 1amily su,,ort
through 8,iritual
Care$ Donor Alliance
and 9C/ nursing staff
H others (as needed)
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Donation After Circulatory Death
7
@ithdra-al of
life4sustaining
treatment
O%
9C/ resident MD
9C/ nurse and
%T Donor
Alliance
@ithdra-al of life sustaining treatment
should adhere to /C7 #nd4of4"ife
Fuidelines and %CU )!/ order1set@
includin discontinuation and
clearance@ of paralytics prior to
discontinuation of "echanical
ventilator&
9C/ resident and nurse remain ,resent
throughout the -ithdra-al ,rocess to the
time of death or the ,atientIs return to the
9C/. %T e6tubates ,atient ,er ,olicy
G Patient sym,tom
management ,er
/C7 #nd4of4"ife
Fuidelines 4 9C/
resident MD$ nurse
and %T
G 1amily su,,ort
through 8,iritual
Care$ Donor Alliance
and 9C/ nursing staff
H others (as needed)
9A
Patient does
NOT die! %eturn
,atient to 9C/
and continue
,atient and
family su,,ort
Trans,ort
9C/ resident MD
9C/ nurse
Donor Alliance
9f ,atient does not die -ithin one hour$ or
-ithin the allotted time s,ecified by the
OPO for organ viability$ the 9C/ nurse
-ill notify 9C/ charge nurse that the
,atient is returning to the 9C/ or
designated bed.
9C/ charge nurse 'Donor Alliance
notifies family that ,atient is alive and is
returning -ith the 9C/ team
G Patient sym,tom
management ,er
/C7 #nd4of4"ife
Fuidelines 4 9C/
resident MD and
nurse
G 1amily su,,ort
through 8,iritual
Care$ Donor Alliance$
9C/ team and social
-or5
98
Patient dies!
Proceed -ith
organ recovery
O%
9C/ resident MD
9C/ nurse
Donor Alliance
%ecovery team
Patient must have cessation of
circulation for ("inutes before
pronounce"ent of death& 9n accordance
-ith state la-$ a ,hysician declares J
documents death based on the 9nstitute of
MedicineIs criteria!
+) Confirm a ,ulse of 2ero by arterial
catheter or Do,,ler
3)Confirm that the ,atient is a,neic
)) Confirm that the ,atient is
unres,onsive to verbal stimuli
The incision for organ recovery may
occur immediately after ,ronouncement
of death.
Donor Alliance coordinates recovery
transition
9C/ nurse notifies 9C/ charge nurse of
death
Donor Alliance 1amily 8u,,ort
Coordinator'Organ %ecovery
Coordinator notifies family of death
%ecovery team ,roceeds -ith organ
recovery
9C/ team returns to the 9C/ 4
9C/ resident MD notifies Coroner of
death
Decedent affairs com,letes death ,ac5et
G Attention to ,ost4
mortem cultural'
religious rituals
(-here a,,licable) 4
O% team
G 1amily su,,ort
through 8,iritual
Care$ Donor Alliance$
9C/ nursing staff H'4
others at family
re?uest
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Donation After Circulatory Death
AA
1amily does
NOT -ant to
vie- body ,ost4
recovery! Move
body to morgue
Trans,ort
Donor Alliance
/C7 trans,ort
8,iritual Care
@hether the family -ants to vie- the
body after death or recovery of organs
should be established at the time of the
donation decision
G Attention to ,ost4
mortem cultural'
religious rituals
(-here a,,licable) 4
7os,ital staff
G 1amily su,,ort
through 8,iritual
Care H'4 others at
family re?uest
A8
1amily -ants to
vie- body ,ost4
recovery! Move
body to
designated
vie-ing room
Trans,ort
/C7 trans,ort
8,iritual Care

The 7os,ital Manager -ill arrange for
trans,ort to an available room -ithin
hos,ital and notify the 9C/ nursing staff
O% nurses -ill ,erform the ,ost mortem
care on the DCD ,atient
Donor Alliance 1amily 8u,,ort
Coordinator'8,iritual Care accom,anies
family to recovery' vie-ing room (or ,er
family re?uest)
Post recovery needs of family -ill be
su,,orted
G Attention to ,ost4
mortem cultural'
religious rituals
(-here a,,licable) 4
7os,ital staff
G 1amily su,,ort
through 8,iritual
Care H'4 others at
family re?uest
%CU tea" K Primary attending and resident MDs$ ,rimary 9C/ nurse and %es,iratory Thera,ist
(%T)
Recovery tea" K Donor Alliance$ recovery surgeons$ O% nurses and su,,ort staff
= Additional ,atient$ family or staff su,,ort is available through the Palliative Care Consult
8ervice and'or the #thics Consult 8ervice
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Donation After Circulatory Death
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