How Can We Maximize the Potential of Donation After Circulatory Death?* Jonathan Ball, EDIC, FFICM, FCCP, MSc, MD General Intensive Care Unit St George’s Hospital London, United Kingdom olid organ transplantation from dead donors is a lauded success that enjoys wide public support. However, it is significantly limited by the small number of donors and exacerbated by a steadily increasing number of patients on recipient waiting lists, especially for kidneys. Consequently, maximizing the potential for donation after death is essential but presents a number of societal, medical, logistical, ethical, and legal challenges (1). In the United Kingdom, the greatest of these by far is familial refusal to consent to donation (1). The societal disparity is the near zero refusal to be a recipient. Donation following brain death (DBD) benefits from the broad, but not universal (2), acceptance of the concept of a heart beating but brain-dead individual, who, with appropriate critical care interventions, can be supported for a protracted time period, during which consent can be sought and physi ological optimization achieved, thereby maximizing the num ber of retrievable organs and optimizing their function (3, 4). Hence, from an organ retrieval perspective, DBD remains the optimal scenario. By contrast, planned (termed controlled) donation follow ing circulatory death (DCD) requires a patient to have suffered a catastrophic illness, most commonly some form of brain injury, that necessitates a critical degree of cardiovascular and/ or respiratory supportive care that by consensus is judged to be futile and therefore is planned to be withdrawn to allow the patient to die. In order to proceed with DCD, the with drawal process must be delayed to allow donation potential to be assessed, consent to be gained, retrieval to be organized, and recipients to be identified. This inevitably leads to the ques tion: what, if anything, can and should be done in terms of physiological and pharmacological therapy during this time interval in order to maximize both the number of retrievable organs and optimize their function? There are strong but con flicting ethical arguments as to whether such interventions are justifiable (5,6). On the one hand, since several recipients may benefit, such interventions can be justified on the basis of mak ing the most of the altruistic gift of DCD. Indeed, the logical
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* S e e a ls o p. 2 2 1 9 .
Key W o rd s: consent; donation after circulatory death; end-of-life care; organ d o nor m anagem ent The author has disclosed that he does not have any potential conflicts of interest. C opyright © 2 0 1 4 by the S ociety of C ritical C are M edicine and Lipp incott W illiam s & W ilkins
DOI: 10.1097/CCM.0000000000000559
Critical Care Medicine
extension to this altruism argument would be to proceed to organ retrieval following the declaration of futility and not wait for cardiac death (7, 8). However, the determination of futility is probabilistic, of variable reliability, and, at least in part, is subjective and related to beliefs regarding the quality and sanctity of life. Furthermore, there are isolated anecdotes of significant and even miraculous recovery following the dec laration of futility, making such arguments and the practice of DCD highly controversial (9). On the other hand, such inter ventions are arguably unpleasant/burdensome to the individ ual, of no benefit to them and might potentially protract their dying process, with the unintended result that organ retrieval, to which consent has been obtained, cannot occur within the acceptable (limited) time frame following withdrawal of sup portive therapies. To address these issues in the United King dom, best practice guidance for DCD was published in 2011 (5) and in the United States in 2013 (6). Of note, both of these guidelines endorse active interventions. Faced with governmental and specialist interest group pres sures to maximize the potential from DCD and in the context of the dilemmas outlined above, a number of initiatives have been introduced over recent years. In an effort to assess the impact of these on DCD beliefs and practices in England, Patel et al (10) have conducted a short survey, the results of which are published in this issue of Critical Care Medicine. Their survey was sent to a senior critical care clinician and/or clinical lead for organ donation at each National Health Ser vice (NHS) organization in England deemed capable of refer ring patients for DCD. Of note, since 2008, there has been a requirement for each NHS organization to appoint a clinical lead for organ donation, a position which is centrally funded and a registry of post holders is actively managed by NHS Blood and Transplant (NHSBT), who are the national admin istrative organization. However, in the survey, the recipients were identified using the NHS e-mail directory, which is less than reliable. The survey canvassed opinions but made no attempt to quantify responses, such as asking for the classifica tion, never, occasionally, usually, or always. The response rate was a respectable 119 (76.3% of organizations) though only 118 responded to the intervention questions. The vast major ity, 112 (94.1% of respondents), reported that their institution (which might represent two or more hospitals) had, on at least one occasion, referred a patient for DCD. The majority, 93 (78.1% of respondents), had a local protocol for DCD, as is suggested in National Guidance (5), yet despite this, 89 (74.7% of respondents) desired a more detailed/proscriptive national protocol, which is a recurrent theme in similar surveys (9). The survey next asked about five interventions undertaken “on referral of a patient for consideration of DCD” detailed in Table 1 in the article by Patel et al (10). The survey results suggest that the majority of respondents continue to actively w w w .c c m jo u r n a l.o r g
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titrate cardiovascular (78%) and respiratory (75%) support ive therapies during the time interval between referral for consideration of DCD and the withdrawal of these therapies. However, due to the poorly phrased questions, these maybe underestimates. The cardiovascular support question asked about the use of “inotropes to maintain a target blood pres sure.” However, most patients with cardiovascular instability in this situation require vasopressors (± inotropes); hence, some of the “no” responses may have interpreted the question literally and do actively support patients to a target blood pressure. Similarly, the respiratory question asked only about F io2 and positive end-expiratory pressure (PEEP) but not other active interventions to optimize oxygenation and ven tilation, let alone lung-protective strategies. These questions also fail to capture whether or not local protocols endorse the initiation (as opposed to the maintenance) of organ support ive therapies and/or other active interventions, in the event that the patient deteriorates during the time interval between referral for consideration of DCD and the withdrawal of sup portive therapies. Three immediately “premortem” or rather “prewithdrawal” interventions were also inquired about heparin, phentolamine, and vascular cannulation (to facilitate the initiation of mechanical perfusion following the declaration of death). Only a very small minority 7%, 2%, and 4%, respectively, reported that they ever or routinely used these practices. Not only is this unlikely, as all of these practices are currently not endorsed by NHSBT (who keep detailed records of all organ retrievals), but if they were initiated, this would be done at the request of the retrieval team and not the referring physicians, whom the sur vey has attempted to canvas. The authors have made no attempt to compare their results with the detailed official registry held by NHSBT and hence what they have captured represents individual beliefs and not actual practice. Nor have they made any comparison with related studies (9), whose findings are broadly similar. The authors’ discussion ranges far wider than their survey and they propose a number of, in my opinion, flawed argu ments to justify the development of a more detailed and
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proscriptive national protocol. Having been a member of a number of national working groups tasked with developing detailed guidance for donor management in the context of DBD, I can see the potential value in such an exercise. How ever, as the 2020 strategy document (1) clearly explains, until donation becomes a routine part of end-of-life care and the consent issues are favorably resolved, the effects of improving donor management during the prewithdrawal phase of DCD on increasing the number and function of retrieved organs, will be marginal. That said, the benefits of defining best prac tice through the conduct of clinical research and agreeing on a standardized approach would be to everyone’s benefit.
REFERENCES 1. NHSBT: Taking Organ Transplantation to 2020: A detailed strategy. 2013. Available at: http://www.nhsbt.nhs.uk/to2020/get-the-strategy/. Accessed June 8, 2014 2. Morrissey PE, Monaco AP: Donation after circulatory death: Current practices, ongoing challenges, and potential improvements. Transplantation 2014; 97:258-264 3. Ball J: Optimal management of the potential organ donor following catastrophic brain injury. ICU Manag 2013; 13:10-13 4. McKeown DW, Ball J: Treating the donor. Curr Opin Organ Transplant 2014; 19:85-91 5. UK Donation Ethics Committee AoMRC: An Ethical Framework for Controlled Donation After Circulatory Death. 2011. Available at: http://www.aomrc.org.uk/doc_details/9425-an-ethical-framework-forcontrolled-donation-after-circulatory-death. Accessed June 8, 2014 6. Gries CJ, White DB, Truog RD, et al; American Thoracic Society Health Policy Committee: An official American Thoracic Society/ International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: Ethical and policy considerations in organ donation after circulatory determi nation of death. Am J Respir Crit Care Med 2013; 188:103-109 7. Morrissey PE: The case for kidney donation before end-of-life care. Am J Bioeth 2012; 12:1-8 8. Truog RD, Miller FG, Halpern SD: The dead-donor rule and the future of organ donation. N Engl J Med 2013; 369:1 287-1289 9. Bastami S, Matthes O, Krones T, et al: Systematic review of attitudes toward donation after cardiac death among healthcare providers and the general public. Crit Care Med 2013; 41:897-905 10. Patel S, Martin JR, Marino PS: Donation After Circulatory Death: A National Survey of Current Practice in England 2012. Crit Care Med 2014; 42:2219-2224
October 2014 • Volume 42 • Number 10
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
S
* S e e a ls o p. 2 2 1 9 .
Key W o rd s: consent; donation after circulatory death; end-of-life care; organ d o nor m anagem ent The author has disclosed that he does not have any potential conflicts of interest. C opyright © 2 0 1 4 by the S ociety of C ritical C are M edicine and Lipp incott W illiam s & W ilkins
DOI: 10.1097/CCM.0000000000000559
Critical Care Medicine
extension to this altruism argument would be to proceed to organ retrieval following the declaration of futility and not wait for cardiac death (7, 8). However, the determination of futility is probabilistic, of variable reliability, and, at least in part, is subjective and related to beliefs regarding the quality and sanctity of life. Furthermore, there are isolated anecdotes of significant and even miraculous recovery following the dec laration of futility, making such arguments and the practice of DCD highly controversial (9). On the other hand, such inter ventions are arguably unpleasant/burdensome to the individ ual, of no benefit to them and might potentially protract their dying process, with the unintended result that organ retrieval, to which consent has been obtained, cannot occur within the acceptable (limited) time frame following withdrawal of sup portive therapies. To address these issues in the United King dom, best practice guidance for DCD was published in 2011 (5) and in the United States in 2013 (6). Of note, both of these guidelines endorse active interventions. Faced with governmental and specialist interest group pres sures to maximize the potential from DCD and in the context of the dilemmas outlined above, a number of initiatives have been introduced over recent years. In an effort to assess the impact of these on DCD beliefs and practices in England, Patel et al (10) have conducted a short survey, the results of which are published in this issue of Critical Care Medicine. Their survey was sent to a senior critical care clinician and/or clinical lead for organ donation at each National Health Ser vice (NHS) organization in England deemed capable of refer ring patients for DCD. Of note, since 2008, there has been a requirement for each NHS organization to appoint a clinical lead for organ donation, a position which is centrally funded and a registry of post holders is actively managed by NHS Blood and Transplant (NHSBT), who are the national admin istrative organization. However, in the survey, the recipients were identified using the NHS e-mail directory, which is less than reliable. The survey canvassed opinions but made no attempt to quantify responses, such as asking for the classifica tion, never, occasionally, usually, or always. The response rate was a respectable 119 (76.3% of organizations) though only 118 responded to the intervention questions. The vast major ity, 112 (94.1% of respondents), reported that their institution (which might represent two or more hospitals) had, on at least one occasion, referred a patient for DCD. The majority, 93 (78.1% of respondents), had a local protocol for DCD, as is suggested in National Guidance (5), yet despite this, 89 (74.7% of respondents) desired a more detailed/proscriptive national protocol, which is a recurrent theme in similar surveys (9). The survey next asked about five interventions undertaken “on referral of a patient for consideration of DCD” detailed in Table 1 in the article by Patel et al (10). The survey results suggest that the majority of respondents continue to actively w w w .c c m jo u r n a l.o r g
2301
Editorials
titrate cardiovascular (78%) and respiratory (75%) support ive therapies during the time interval between referral for consideration of DCD and the withdrawal of these therapies. However, due to the poorly phrased questions, these maybe underestimates. The cardiovascular support question asked about the use of “inotropes to maintain a target blood pres sure.” However, most patients with cardiovascular instability in this situation require vasopressors (± inotropes); hence, some of the “no” responses may have interpreted the question literally and do actively support patients to a target blood pressure. Similarly, the respiratory question asked only about F io2 and positive end-expiratory pressure (PEEP) but not other active interventions to optimize oxygenation and ven tilation, let alone lung-protective strategies. These questions also fail to capture whether or not local protocols endorse the initiation (as opposed to the maintenance) of organ support ive therapies and/or other active interventions, in the event that the patient deteriorates during the time interval between referral for consideration of DCD and the withdrawal of sup portive therapies. Three immediately “premortem” or rather “prewithdrawal” interventions were also inquired about heparin, phentolamine, and vascular cannulation (to facilitate the initiation of mechanical perfusion following the declaration of death). Only a very small minority 7%, 2%, and 4%, respectively, reported that they ever or routinely used these practices. Not only is this unlikely, as all of these practices are currently not endorsed by NHSBT (who keep detailed records of all organ retrievals), but if they were initiated, this would be done at the request of the retrieval team and not the referring physicians, whom the sur vey has attempted to canvas. The authors have made no attempt to compare their results with the detailed official registry held by NHSBT and hence what they have captured represents individual beliefs and not actual practice. Nor have they made any comparison with related studies (9), whose findings are broadly similar. The authors’ discussion ranges far wider than their survey and they propose a number of, in my opinion, flawed argu ments to justify the development of a more detailed and
2302
w w w .c c m jo u r n a l.o r g
proscriptive national protocol. Having been a member of a number of national working groups tasked with developing detailed guidance for donor management in the context of DBD, I can see the potential value in such an exercise. How ever, as the 2020 strategy document (1) clearly explains, until donation becomes a routine part of end-of-life care and the consent issues are favorably resolved, the effects of improving donor management during the prewithdrawal phase of DCD on increasing the number and function of retrieved organs, will be marginal. That said, the benefits of defining best prac tice through the conduct of clinical research and agreeing on a standardized approach would be to everyone’s benefit.
REFERENCES 1. NHSBT: Taking Organ Transplantation to 2020: A detailed strategy. 2013. Available at: http://www.nhsbt.nhs.uk/to2020/get-the-strategy/. Accessed June 8, 2014 2. Morrissey PE, Monaco AP: Donation after circulatory death: Current practices, ongoing challenges, and potential improvements. Transplantation 2014; 97:258-264 3. Ball J: Optimal management of the potential organ donor following catastrophic brain injury. ICU Manag 2013; 13:10-13 4. McKeown DW, Ball J: Treating the donor. Curr Opin Organ Transplant 2014; 19:85-91 5. UK Donation Ethics Committee AoMRC: An Ethical Framework for Controlled Donation After Circulatory Death. 2011. Available at: http://www.aomrc.org.uk/doc_details/9425-an-ethical-framework-forcontrolled-donation-after-circulatory-death. Accessed June 8, 2014 6. Gries CJ, White DB, Truog RD, et al; American Thoracic Society Health Policy Committee: An official American Thoracic Society/ International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: Ethical and policy considerations in organ donation after circulatory determi nation of death. Am J Respir Crit Care Med 2013; 188:103-109 7. Morrissey PE: The case for kidney donation before end-of-life care. Am J Bioeth 2012; 12:1-8 8. Truog RD, Miller FG, Halpern SD: The dead-donor rule and the future of organ donation. N Engl J Med 2013; 369:1 287-1289 9. Bastami S, Matthes O, Krones T, et al: Systematic review of attitudes toward donation after cardiac death among healthcare providers and the general public. Crit Care Med 2013; 41:897-905 10. Patel S, Martin JR, Marino PS: Donation After Circulatory Death: A National Survey of Current Practice in England 2012. Crit Care Med 2014; 42:2219-2224
October 2014 • Volume 42 • Number 10
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
