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Conducting donation after cardiac death
Educate hospital staff about DCD
Hospital ethics committees sometimes are called to handle cases involving donation after cardiac death (DCD), but handling these cases can be a challenge, an expert says.
"Some of the ethical issues you see particularly with ethics committees are concerns about withdrawing life-sustaining treatment," says James M. DuBois, PhD, DSc, the Hubert Mader chair of health care ethics at Saint Louis (MO) University. DuBois also is an adjunct professor of medicine at the Washington University School of Medicine and director of the Bander Center for Medical Business Ethics, the Social Science Research Group at Saint Louis University, and the Center for Research Ethics and Integrity, all in St. Louis.
Controlled DCD typically involves a ventilator-dependent patient who is still alive, but a decision has been made to discontinue life-sustaining treatment, DuBois says. "In most cases involving withdrawing life-sustaining treatment, there is no disagreement, no chance of recovery, and both families and staff are comfortable with removing the ventilator," he says.
However, when providers approach the family about donating the patient's organs and administering medications to the patient solely for this purpose, the ethical issues are highlighted, DuBois adds. "With standard donation, the patient is already dead before you approach the family to talk about organ donation, and the patient is dead before you prepare him for surgery," he says. "With DCD, the patient is still alive when you have to talk with the family to get permission for organ donation, and this can impact the location of the patient's death."
Clinicians have to ask the family for permission to administer medications such as heparin, which are given solely for the purpose of organ donation, he adds.
"This makes the hospital staff feel like they're in a dual role of caring for the sustained person as both a patient and as a potential donor," DuBois explains. "This is difficult for intensivist critical care staff."
Hospital ethics committees can help clinicians handle these delicate situations by following these recommendations:
Educate staff about death after cardiac death.
"If a hospital is going to start a DCD program, then they need to start it by having frank discussions with their staff about DCD, giving employees the opportunity to discuss it," DuBois suggests.
The staff's buy-in is essential, he notes. "With standard organ donors, it's easier for the OPO [organ procurement organization] staff to find out who is a potential donor," he says. "With DCD, the OPOs rely heavily on hospital staff to identify potential donors."
Thus, if the hospital staff does not buy into the DCD program, then the OPO will receive few referrals from the hospital, DuBois says. "Educating staff is very important for many reasons, including for the purpose of helping staff be comfortable with it ethically, psychologically, and for referral purposes," he says.
Hospitals can use some of the more efficient educational strategies employed in recent years, such as the brown bag lunch session and training during departmental rounds, he suggests. "Touch on the highlights of the actual hospital protocol that will be used," he adds.
Invite OPO representatives to speak with hospital staff.
"OPOs have staff members who are able to facilitate some of these educational discussions," DuBois says.
Also, there are OPO web sites with educational materials. For example, the Gift of Hope Organ and Tissue Donor Network of Itaska, IL, has free downloadable material about DCD that can be distributed to health care staff and families. Also, the University of Wisconsin School of Medicine and Public Health in Madison has free online brochures about DCD. (See resource section for contact information, below.)
Determine death criteria, and place these in institutional policies.
"DCD has attracted the most controversy over death criteria," DuBois says.
Hospitals could refer to the standard criteria approved by the Institute of Medicine and more than 15 other institutions and organizations participating in the 2005 National Conference on donation after cardiac death. The work group participants concluded that death occurs when cardiopulmonary function will not resume spontaneously, according to the "Report of a National Conference on Donation after Cardiac Death," published in 2006 in the American Journal of Transplantation. (See resource information, below.)
Educate hospital staff about these policies and death criteria to avoid controversy, DuBois suggests. Have the treating team, attending physician, and family in agreement that resuscitation should not be attempted in these cases even if no organ donation is possible, he adds. Also, obtain the family's permission in DCD cases, even if the patient has signed an organ donor card or has joined a registry, he says. "You should get the family's permission to withdraw the ventilator and administer medication for donation," he says.