Organ Donation after Cardiac Death: A New Trend in Pediatrics

In 1997 the Institute of Medicine (IOM) published a groundbreaking recommendation addressing the resurgent phenomenon known as “Non-Heart-Beating Organ Transplantation” (1). Non-heart-beating donation, also described as Donation after Cardiac Death (DCD), involves the procurement for transplantation of solid organs from dying patients who do not meet the standard criteria for brain death. This alternative to brain-dead donation and living donation was not new at the time of the IOM report. The use of solid organs from a body after the heart had stopped beating (i.e., DCD) was first described in the early 1960's, and preceded the establishment of brain death criteria. All donors were allowed to die a “cardiac death” before organ procurement. Criteria for brain death were established starting in 1968 with the advent of mechanical ventilation and intensive care. With the ability to maintain organ viability and to procure perfused solid organs from heart-beating donors (brain-dead donation), the DCD concept gradually lost favor (2). Living donation involves the use of a partial liver, pancreas, lung, or a single kidney from a healthy living donor. This practice has surged ahead of brain-dead donation in frequency. In 2002 there were 6182 brain-dead donors and 6614 living donors in the US (3). Despite the living donor option and the efforts by health care practitioners and organ procurement organizations (OPOs) to increase brain dead donations, 6439 potential transplant recipients in the U.S. died in 2001 while waiting for solid organs (3). The increasing success of solid organ transplantation and the stagnant donor pool has sparked a renewed interest in DCD (4–9). The search for a new source of solid organs for transplantation is urgent and understandable. In the United States, 82,027 patients are listed for organ transplant. In the state of Colorado, where 27 pediatric patients from newborn to ten years old await solid organs (kidney, liver, heart or lung), we average only six brain dead donors per year in this age group (10). Family denials are rare and there is excellent support in our community and hospitals for brain dead donation. However, the incidence of brain death has decreased over the past several years. Improved neurotrauma resuscitation and aggressive physiologic support after central nervous system (CNS) injury may explain why. Death in the Pediatric Intensive Care Unit (PICU) setting has become “institutionalized, mechanized and managed” (11). Up to 75% of the deaths in our unit are planned withdrawals of care. A recent review of 260 consecutive deaths in our PICU of children under 18 years revealed only 19 brain dead donors over five years. When strict criteria for DCD were applied to the deceased patients who had not met brain death criteria, but who had been near brain death prior to managed withdrawal of life-sustaining medical therapy (LSMT), an additional 14 potential solid organ donors were identified. This represents a possible 72% increase in the donor pool (12). Donation after cardiac death with successful organ recovery may result in more pediatric organs available for transplantation. How do we identify these potential DCD donors? We start by recognizing that the continuum from near brain death to brain death is murky (13). Candidates for DCD are typically victims of isolated head injury. However, not all patients near brain death fit an ideal profile. The impairment can be moderate to severe, with minimal hope of meaningful recovery and CNS function ranging from higher brainstem activity to agonal respiratory effort. If a patient is identified as a possible DCD donor, the timing, location and nature of the death will be greatly affected. This innovative organ donation process sparks many ethical questions about the very nature of dying in the PICU. If we choose to implement a DCD policy will we inadvertently alter the decision-making surrounding medical futility? Will we unintentionally increase the value of a person at the end of their life by creating a new way to use their precious organs? Will we hasten a death simply to save another life? One author describes the “rapacious demand” for organs as driving this need of the medical community to redefine what is really dead (14). These questions reflect critical concerns of every medical professional involved with organ procurement and transplantation. The IOM addresses these issues by defining the criteria that must be met to create and implement a protocol that will foster the use of solid organs from the cardiac dead. It is expected that a U.S. hospital choosing to implement a DCD protocol will adhere to the following guidelines: All OPOs should explore the option of non-heart-beating organ transplantation in cooperation with local hospitals, health care professionals and communities; A protocol must be in place in order for non-heart-beating organ and tissue donation to proceed; The decision to withdraw life-sustaining treatment should be made independently of and prior to any staff-initiated discussion of organ and tissue donation; Like all care at the end of life, non-heart-beating organ and tissue donation should focus on the patient and family; organ procurement must not hasten death (1). A national protocol for DCD published by the United Network for Organ Sharing (UNOS) provides a framework for the successful management of a DCD donor (15). Improved outcomes after transplantation have stimulated a nationwide effort to increase the supply of organs. In our pediatric setting, the diagnosis of brain death is on the decline, as children are kept alive with aggressive ICU management. While living donation is a viable choice for the pediatric population, it is still inadequate to fill the need. We continue to watch as more children are listed for organs in the face of a donor pool that clearly has not kept up with the demand. The creation, implementation and on-going evaluation of a DCD protocol requires early cooperation of hospital personnel as well as physician-champions to support its use. With strict adherence to the IOM guidelines, DCD may become a sound practice both medically and ethically.