Organ Donation after Circulatory Death (DCD) Adults

Background

1. Decision to withdraw therapy
2. Donor Identification
3. Donor Assessment
4. Pre-Approach Brief
5. Collaborative family approach
6. Consent
7. Patient management prior to withdrawal
8. Location of Withdrawal
9. Treatment withdrawal
10. Organ Retrieval
    Short Form Information and flow chart
    Appendix 1 - Guidelines for post-mortem management of potential lung donors.
    Appendix 2 - Guidelines for DCD donation where extubation occurs in the Anaesthetic Room
    Appendix 3 - Checklist: Withdrawal in the Anaesthetic Room (WiAR)
    Appendix 4 - Guidelines for DCD donation from patient’s already diagnosed dead by neurological criteria.
    

Background

Introduction

Donation after Circulatory Death (DCD), previously referred to as donation after cardiac death or non-heart beating organ donation (NHBD) refers to the retrieval of organs for transplantation from patients whose death is diagnosed and confirmed using cardio-respiratory criteria. This is in contrast to Donation after Brainstem Death (DBD) which follows confirmation of death by brainstem death testing, previously referred to as heart beating donation (HBD).

Contribution of DCD to transplantation in the UK

DCD donation has increased substantially in the United Kingdom over the last decade, from 288 donors in 2008-2009 to 619 in 2017-2018, representing 39% of all deceased organ donors in this year.¹

Number of DCD donors in the UK, 2000/01 – 2017/18.¹

In the UK, an average of 2.8 transplantable organs are retrieved from DCD donors, compared to 3.7 from DBD donors. The lower donation potential of DCD donors is in large part a result of the ischaemic injury suffered by solid organs in the time interval between treatment withdrawal and cold perfusion, with the liver and pancreas being particularly vulnerable.¹

The biggest contribution of DCD is to kidney transplantation, with 39% of all deceased donor kidney transplants coming from this source in 2017-2018, and long-term outcomes similar to DBD grafts. The consequences of ischaemic injury to the liver are more significant, and although outcomes are acceptable, there is a higher incidence of graft failure, post-operative morbidity and ischaemic cholangiopathy in the DCD cohort. In contrast, DCD donors may be the preferred source of transplantable lungs because the organs have not been exposed to the sympathetic storm suffered by potential DBD donors.¹

DCD has now developed to the point at which heart retrieval and transplantation from these donors is now possible. Although this programme is in its infancy and not widely performed, further advances in post-mortem interventions such as regional normothermic recirculation and ex vivo reperfusion may result in it being increasingly common over the next few years.

Description of DCD

DCD is the retrieval of tissue and solid organs from a body following irreversible cardiopulmonary arrest. Since the circulation is not restored for retrieval, the priority is to expedite removal of the organs before they deteriorate (warm ischaemia) and before transplantation cannot take place. There are a number of possible sources of potential donors in whom death has been certified by cardiorespiratory criteria; the Maastricht group identified four well-established categories²:

Category 1: Dead on arrival at hospital. This group includes any individual who suffers an out-of-hospital arrest and arrives in hospital with an accurate documentation of the time of death and pre-hospital resuscitation.

Category 2: Unsuccessful resuscitation. This includes any patients who arrest in hospital and again have a failed resuscitation accurately documented.

Category 3: Awaiting cardiac arrest. These are patients presenting to the Emergency Department (ED) with a non-survivable injury or patients, in general or neurosurgical intensive therapy units (ITUs), whose death is inevitable. They do not fulfill brain stem death criteria and therefore cannot become a brainstem dead donor.

Category 4: Cardiac arrest in brainstem dead donor. This refers to a patient whose death has been confirmed by neurological criteria (brain stem testing) but arrests before organ retrieval can take place.

Categories 1, 2, and 4 are described as 'uncontrolled' donation. This is because all of the preparations for retrieval have to take place from the time of death and be completed before the recommended warm ischaemic time (variable depending upon which organs are being harvested but generally between 30-90 minutes) has been reached. These preparations include addressing consent, counseling relatives, preparation of the donor (tissue typing and viral status), mobilizing a surgical team and finally cold perfusion of the organs.

Category 3 is a ‘controlled’ donation. (Category 4 can occasionally be considered a controlled donation. This depends on how far along a DBD process events have progressed when the patient arrests.) These patients are generally more stable, their medical condition is deemed to be futile and a decision has been made either not to introduce invasive support or to withdraw invasive support, thereby making the time of death more predictable. The preparations mentioned above can be made before death occurs and the retrieval can be scheduled. This makes it easier to remain within the recommended ischaemic times and consequently the organs retrieved should be of a higher quality and carry a better prognosis after transplantation.

The advantage of a less time-pressured process compared to uncontrolled donation means that controlled donation offers the best opportunity to introduce DCD successfully. It has been proposed that general and neurosurgical intensive therapy units should therefore become the focus for identifying potential donors, but that Emergency Departments (ED) departments also have patients fulfilling Maastricht Category 3 status.

Legal and Ethical Position

The judgment that a patient's condition is futile, the process of withdrawing invasive support and the provision of palliative measures to allow a comfortable death, are well established. However, there is concern that the timing of this process could be influenced by the need to ensure optimum organ viability if considering DCD. To avoid criticism of a conflict of interest, the initial decision to withdraw support should be made on the basis of multi-disciplinary discussions, which includes intensive care consultants, parent specialty consultants, senior nursing staff and the next-of-kin. It should precede and be clearly separate from consideration for donation, and should not involve any of the transplant team. The process itself needs to be transparent and meticulously documented.

Once futility has been determined, DCD can be justified if decision-making is guided by the patient’s wishes and beliefs concerning organ donation. The underpinning principle of the programme is that donation can on many occasions legitimately be viewed as part of the care that a person might wish to receive at the end of their lives. This was clarified in the DoH report - Legal issues relevant to non-heart beating organ donation.ⁱ3

Summary - DoH legal recommendations for NHDB:

1.3 In the UK, NHBD takes place most commonly when death follows the withdrawal of life-sustaining cardiorespiratory support that has been judged to be no longer in a patient’s best clinical interests. It is recognised that the care and treatment that a patient receives around the time of death may need to be adjusted if the patient’s potential to donate is to be maintained or optimised. Such adjustments may include the timing and place of death and also blood sampling for purposes such as tissue typing and virological screening.

1.4 People who are potential non-heart beating donors will almost always lack the capacity to make their own treatment decisions because they will have had a catastrophic brain injury and are likely to be unconscious. The Mental Capacity Act 2005 (MCA) allows health professionals to treat someone who lacks capacity, provided that they reasonably believe their actions to be in the person’s best interests.

1.5 A person’s best interests depend on their individual circumstances – it is therefore not possible to say categorically whether a specific action or decision will always be in every patient’s best interests. However, the courts have established that best interests are wider than simply treating a person’s medical condition and include a person’s social, emotional, cultural and religious interests. Therefore a clinician will need to consider not only all the factors relevant to the person’s medical condition but also consult their family to take full account of the person’s previously expressed wishes, general preferences and beliefs^1,ii.

1.6 [The DoH Guidance] sets out the general principles governing decision-making for people who lack capacity when their potential for non-heart beating organ donation is being considered. In general terms, decision-making will be guided by the person’s wishes and beliefs concerning donation. It is therefore important to establish these either through knowledge of the individual’s wishes (for example, by registration on the NHS Organ Donor Register (ODR)) or through an assessment of what the individual would have wanted (for example through the person’s family and their knowledge of them). If a person’s wishes were to be a donor, then certain actions which facilitate donation may be considered to be in their best interests if they do not cause the person harm or distress or place them at a material risk of experiencing harm or distress.

1.7 As with any decision concerning medical treatment, the details of individual cases may vary. As a result, trusts and health professionals must always be able to satisfy themselves that individual decisions are made in that person’s best interests and are therefore in compliance with the law.

¹In addition to this guidance from the DoH, the General Medical Council has also recently made recommendation in their guidance for doctors Treatment and care towards the end of life: good practice in decision making. Specifically, the GMC states: “If a patient is close to death and their views cannot be determined, you should be prepared to explore with those close to them whether they had expressed any views about organ or tissue donation, if donation is likely to be a possibility.”⁴

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Management

1.0 Decision to Withdraw Therapy

This decision should:

• Be based upon a multi-disciplinary consensus on the futility of continued organ support. The next-of-kin should be involved in this decision making process. The personnel involved in the decision making should clearly be documented in the patient’s notes
• Be sufficiently robust to bear objective scrutiny
• Be transparently independent from any subsequent discussion regarding organ donation
• Not involve staff involved in transplantation.

Unless brought up by the family, the issue of organ donation should not be discussed in the same interview as that in which futility, and the decision to withdraw, has been made.

Once a decision to withdraw life supporting therapy has been made by the MDT, in conjunction with the family, and once the family have accepted this treatment plan is in their relative’s best interests, then a DNACPR form should be completed and placed in the medical notes.

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2.0 Donor Identification

Potential donors can be identified by medical and nursing staff working within ICU. All potential donors should fulfil the following criteria:

• Age. No lower limit. Up to 85 years of age
• Planned withdrawal of life supporting treatment
• Family informed of the decision to withdraw support, and agree this course of action is in the patient’s best interests
• The National Organ Donation Register (ODR) should be accessed by the Specialist Nurse for Organ Donation (SNOD), to establish whether the patient is a registered donor. If the patient is not a registered donor, this does not preclude asking the family about DCD, however the information that they are registered as a potential donor gives an indication that they agreed with donation and may help the family give their assent to donation.
• There is now an “opt out system” in place in England, Wales and Scotland. The assumption being, that by not opting out, the patient would have wished to be a potential donor. The potential donors family may still refuse assent.

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3.0 Donor Assessment

The only absolute contraindications to DCD organ donation are:

1. New variant CJD
2. HIV disease (but not infection with the HIV virus), HTLV

In addition, it is highly likely that donors with the following conditions will be declined, although there are occasions when organs are accepted if the alternative for a specific recipient is imminent death

1. Untreated systemic infection
2. Known active tuberculosis
3. Disseminated malignancy
4. Melanoma (except local melanoma treated >5 years before donation).

Additionally, there may be organ specific contra-indications to donation. However, an assessment of donor suitability can only be made by the Specialist Nurse for Organ Donation (SNOD) in consultation with the transplant teams, who adhere to strict practice guidelines issued by SaBTO (Advisory Committee on the Safety of Blood, Tissues and Organs) and their own professional associations. Where clinicians looking after potential donors, have made attempted to second guess organ suitability through their own assessment of a potential organ donor, opportunities (and organs) have been lost through non-referral. To avoid this:

ALL PATIENTS SHOULD BE DISCUSSED WITH THE SNOD ON CALL.

Contact the SNOD on call. They can be reached via:

The SNOD will confirm whether a patient is a potential donor, and make arrangements to attend the ICU, to take part in approaching the family regarding donation and subsequently, if consent is granted, to conduct the donation process.

Another aspect to consider when assessing the suitability of a patient for donation is the requirement for discussion and/or referral to the Coroner. This may impact on the organ donation process particularly if it is deemed that a forensic post-mortem is required. Early referral and discussion is advised as these processes may take a significant amount of time to complete.

Information on Coroner referrals can be found on the Trust’s Risk Management page on the intra-net, and there are also helpful suggestions in the Bereavement section. An out of hours referral may be required, due to the time-sensitive nature of organ donation, so contacting the on call coroner’s officer via the police switch board, on (0113) 2435353 , is often necessary. The Coroner’s Officers are aware of requests for permission to perform Organ Donation, and have been instructed to treat such referrals as priority. Typically, they will ask for a brief medical report to accompany the medical notes to the bereavement office, stating permission for donation has been granted by the Coroner, with a brief description of injuries/medical condition of the patient, treatment received on the ICU, a suggested primary cause of death, and a description of which organs have been retrieved.

If the patient is not a potential donor, or permission to donate is refused by the Coroner, end-of-life care can continue according to normal practice, with family members spared discussions regarding donation. Naturally, should family members enquire about potential donation, the clinical team can now confidently answer their request with any reasons why donation is not an option.

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4.0 Pre-Approach Brief

It is highly recommended that prior to any approach, the Intensive Care doctors, nurse in charge, bed-side nurse, SNOD and any other relevant health care professionals involved in this process, meet to discuss the pertinent issues individual to each case. These may include views already expressed regarding organ donation, family considerations and the impact of donation on the continued provision of critical care services. This will allow all team members to understand what has already been raised in discussions, and avoid elements of the process being omitted e.g. proper communication with parent doctors (typically neurosurgeons) and specifically the coroner’s service.

The appropriate location of treatment withdrawal should be decided on an individual basis but must take into account where the patient’s interests will be best served in both the context of an organ donor and as a family member. Consideration to the individual’s right to comfort, dignity & privacy, continuity of care, access and opinions of family and friends, and the demands on the service will all contribute to this decision. Should a medical or nursing shift change occur before donation is completed (or stood down) then the team brief should be repeated.

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5.0 Collaborative family approach

Seeking consent for organ donation from a soon to be bereaved family can be a daunting prospect. Guidance from National Blood and Transplant (NHSBT) recommends that the family approach should be collaborative and involve the consultant Intensivist, SNOD and the bedside nurse.

The bedside nurse will be able to provide valuable continuity of support during the various discussions. The consultant will usually take the lead in breaking bad news to the family and discussing withdrawal of invasive support. The SNOD would normally lead on exploring the option of donation. Defining these roles and avoiding one person attempting to break bad news and then seek consent for donation avoids any potential conflict of interest. These should ideally be two distinct conversations, led by different healthcare professionals.

We suggest the following 4 stage collaborative family approach:

1. Planning the approach: identify key family members, consider additional family support (faith representative or interpreter) and agree the role of each professional.
2. Breaking bad news: explanation as to why continuing invasive support is no longer considered in the patient’s best interests, usually led by the ICU consultant.
3. Confirming acceptance: it is unreasonable to expect any family to consider post mortem procedures such as organ donation before they have accepted the imminent death of their loved one. Families that have ‘taken on board’ the bad news given above often move from questions about treatment, prognosis and coming home to asking about pain control, religious last rites and funeral arrangements.
4. Discussing donation: transition to the SNOD who will use open questions to sensitively explore the patient’s views, beliefs and likely end of life wishes.

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6.0 Consent

Once the donation request has been made, and the family give their verbal assent, there then follows a detailed process whereby the SNOD will:

1. Carry out a detailed assessment of the patient
2. Discuss the procedure with the family (if not already done during the approach for donation)
3. Gain consent from the family, who will be informed they can withdraw their consent at any time
4. Arrange for all necessary blood tests to be drawn and analysed
5. Liaise with the transplant and retrieval teams, and set a time for withdrawal
6. Liaise (along with medical staff) with the Coroner if applicable

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7.0 Patient management prior to withdrawal

Patients will be managed on ITU or, under exceptional circumstances within PACU, according to best palliative care practice:

1. Patients should be accorded dignity and respect
2. Family members should be allowed ample time with their dying relative, ideally in a side room or secluded bay.
3. Palliative care interventions to ensure comfort care should be instituted according to perceived levels of discomfort. Typically, this would entail infusions of morphine and midazolam, titrated to effect.
4. Inotropes and ventilation should be continued, to achieve physiological stability. Small escalations in inotropes can be countenanced as, in doing so, the perceived wishes of the patient – i.e. to become a donor and provide usable organs for donation – is being met.
5. CPR would not be attempted were a cardiorespiratory arrest to occur.
6. Maintenance hydration, temperature management etc. should be continued and/or commenced to ensure patient comfort. Blood transfusions would not be undertaken.
7. If the patient undergoes brainstem herniation, a discussion with the family would occur regarding performing brainstem death tests. After confirmation of brainstem death, the family would then be given the option to consider donation after brainstem death (DBD) or to continue with the DCD (see Appendix 4).

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8.0 Location of Withdrawal

Withdrawal of life sustaining treatments which in this context often includes extubation may occur on the Intensive Care Unit (WiICU) or in the anaesthetic room (WiAR) adjacent to the theatre set aside for organ retrieval.

The rationale for the latter includes the potential to improve organ quality by reducing warm ischaemic times, and in some instances allowing for the retrieval of DCD hearts, which would otherwise not be possible. These benefits must be considered in the context of individual patient specific factors as detailed in section 4.0.

Whilst uniformity in practice is in many ways desirable, those responsible for offering DCD as a component of end of life care must always be sensitive to, and directed by, their primary obligations to the comfort and dignity of their dying patient. Therefore decisions regarding location of withdrawal should be made on an individual basis during the consent process with the family.

Special consideration to WiAR should be given to those instances where death has been confirmed by brain stem death testing, but where family consent for donation is contingent on their relative being in asystole (see Appendix 4).

Where the SNOD has consented families for withdrawal of care within an anaesthetic room further details and an appropriate checklist are provided to ensure that the provision of end of life care is not in any way compromised (Appendix 2 & 3 respectively).

There should be clear on-going responsibility for the care of the patient and their family, regardless of the location of treatment withdrawal. If necessary this responsibility may be transferred between teams. There should also be a robust and acceptable plan for subsequent care should donation not take place.

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9.0 Treatment Withdrawal

Once the retrieval team are prepared and, in agreement with the family and next- of-kin:

1. All members of the MDT need to clearly understand their roles in the donation process. A pre-extubation brief should occur regardless of location, with a structure broadly similar to that described in the WiAR checklist (Appendix 3)
2. Withdrawal of life supporting therapies SHOULD NOT OCCUR without confirmation from the attending SNOD that all appropriate arrangements are in place (i.e. family ready and aware of time of withdrawal, retrieval teams in place and suitably prepared, necessary attending medical personnel available, ward nurse ready etc.).
3. Patients should be extubated and nursed on their back. Nasal or oral airways should not be inserted to alleviate upper airway obstruction.
4. All infusions, with the exception of infusions for comfort care, should be stopped.
5. Infusions of morphine and midazolam should be commenced and then titrated, in response to perceived discomfort of the patient. Where nursing staff have relocated to theatre for the purpose of withdrawal of care, either full access to theatre drugs is necessary, or pre-prepared syringes of morphine and midazolam made up before leaving for theatre, together with other drugs anticipated to be required to ensure comfort to the dying patient.
6. Time of death should be anticipated and a member of the attending medical staff (including accredited Acute Critical Care Practitioners (ACCP’s)) should be present in advance of asystole so that there are no delays in identifying onset of cardiorespiratory arrest. This may entail getting additional medical staff to attend the ICU, ED, or theatre suite prior to extubation, and may require the consultant on call to attend from home.
7. Cardiorespiratory death is confirmed according to the Academy of Medical Royal Colleges Guidance on the diagnosis and confirmation of death⁶. Individuals should be observed for a minimum of 5 minutes, once cardiorespiratory arrest has occurred, to confirm that cardiorespiratory arrest is irreversible. Accredited ACCP’s can confirm death for DCD donation..
8. Absence of the circulation may be confirmed by using an arterial line (or echocardiography if expertise exists)⁶. Any spontaneous return of cardiac pulsation on invasive arterial waveform or respiratory activity during this period of observation should prompt a further 5 minutes observation from the next point of cardiorespiratory arrest. In the absence of an arterial line, asystole on the ECG is required to confirm cardiac arrest. Digital palpation of a central pulse is not sufficiently reliable to confirm the absence of mechanical systole.
9. After 5 minutes of continued cardiorespiratory arrest the absence of pupillary responses to light, of corneal reflexes, and of any motor response to supra- orbital pressure should be confirmed. The need for these tests should be anticipated, and performed promptly to avoid introducing unnecessary warm ischaemia.
10. The time of death is recorded as the time at which these criteria are fulfilled. The physical act of documenting death within the medical notes should not delay commencing any transfer to theatre.

In the event that asystole does not occur within the allotted time frame (as dictated by the transplant teams), then the retrieval team will be contacted by the SNOD and ‘stepped-down.’

The ward (or the accompanying ward nurse with the patient if extubation has occurred within theatre) will continue to provide palliative care to the dying individual according to usual practice. This may entail moving them to a side room or to another ward as is appropriate. In instances of extubation in theatre, pre-arranged plans for discharge from the theatre environment, and on-going palliative care, must have been made prior to transfer to theatre.

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10.0 Organ Retrieval

After confirmation of death, the potential donor should be moved to the prepared theatre as quickly as possible, but in a manner that affords them as much dignity as possible. Clearly, if the process of extubation and the patient’s subsequent death has occurred in an anaesthetic room, this will involve a simple transfer to the operating room, without having to move the now deceased patient through public corridors within the hospital. Where extubation has occurred on ICU the following considerations should be made:

1. Family members should be escorted to a waiting room after confirmation of their relative’s death. This ensures they are not confronted with their now deceased relative being transferred to theatre.
2. Porters should have been called in advance, so there are no delays in transferring to theatre (with the attendant prolongation of warm ischaemic time).
3. Unit staff may elect to porter the potential donor to theatre themselves.
4. Theatres should be informed, once asystole has occurred, so that available staff can assist in directing the potential donor to the appropriate theatre, and can assist in transferring the potential donor to the operating table.

The organ retrieval procedure can commence immediately after confirmation and declaration of death (i.e. after 5 minutes of continuous asystole and demonstration of absent brainstem function through the prescribed examination of cranial nerves, as described above). Initial DCD programs, including that practiced within LTHT, formerly stipulated a total of 10 minutes of asystole before organ retrieval. This was to guarantee against auto-resuscitation occurring. However, there is no recorded instance of auto-resuscitation occurring in this patient group.⁷ This is a change to previous practice, but places LTHT in accord with perceived “Best Practice” as laid out in the consensus statement for DCD donation, from NHSBT, the Intensive Care Society and the British Transplantation Society.⁵

After retrieval, the donor’s body will be taken to the mortuary and not returned to their original ward or location (typically the ICU), unless by prior arrangement with that ward.

An LTHT donation audit form should be filled out for each potential donation, whether successful or not

Please refer to Short form Flowchart and Appendices 1,2 and 3 for further information

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Short form Flowchart - Protocol for DCD for patients within Critical Care

1. Decision to withdraw therapy
Following a consensus of all involved consultant medical staff, a decision regarding medical futility is made.

In conjunction with the family, life supporting medical treatment is agreed to be withdrawn.

A documented entry, in the medical notes/PPM, is made by the consultant in charge of care regarding the diagnosis, the consensus view of the MDT, and the nature of the conversation with relatives.

2. Donor Identification
Potential donors can be identified by all clinical staff. All potential donors should fulfil the following criteria:

1) Age – under 85

2) The intention to withdraw life-sustaining treatment in patients with a life- threatening or life-limiting condition which will, or is expected to, result in circulatory death. – NICE Clinical Guideline 135

3) Family informed of the decision to withdraw support and agree this is the best course of action.

The ODR is checked to establish whether the patient has registered to be a donor.

3. Donor Assessment
Unless there is a history of new variant CJD or HIV disease, uncontrolled sepsis, haematological or active malignancy, all patients identified as potential donors, are discussed with the SN-OD.

The SN-OD will confirm suitability, or otherwise, based on medical history, the current active transplant waiting list, and discussions with the relevant transplant teams.

4. Pre-Approach Brief
Involving ICU Consultant, SN-OD, nurse in charge, bedside nurse and other healthcare professionals where appropriate. Consideration of the most appropriate way forward for each individual patient and their families.

5. Collaborative Family Approach
Through a collaborative family approach planned between the bedside nurse, consultant and SNOD, the family will be informed of the possibility of organ donation after cardiac death. The views of the patient, regarding donation, will be sought from the family (and they will be informed of the patient’s ODR status if appropriate).

The process of DCD will be explained and family’s assent for donation will be requested.

6. Consent
The SN-OD will gain written consent for DCD. Consent may include specifying where withdrawal of care will occur.

The medical team will contact the Coroner’s office (if necessary)

7. Patient management prior to withdrawal
The SN-OD will make all necessary arrangements for the donation procedure. The caring team will maintain physiological stability, within the limits set out in this guideline.

Palliative care measures will be implemented to ensure patient comfort. The attending medical team, and the SN-OD, will provide pastoral support to the family and next-of-kin

8. Location of Withdrawal
Decisions regarding location of withdrawal should be made on an individual basis during the consent process with the family and will take into account a multitude of factors including but not limited to expressed wishes of patients and their families including the organs they wish to donate e.g. hearts.

9. Treatment withdrawal – The SNOD will co-ordinate time of Withdrawal The patient will be extubated once all necessary preparations for retrieval are in place, and after the family have paid their final respects. Where families have agreed to withdrawal within theatre, the patient is transferred to theatre in preparation for withdrawal of care. Families can accompany their relative to theatre. Comfort of the dying patient is paramount – morphine and midazolam infusions may be commenced, or increased if already started.

The death of the patient will be confirmed according to the guidance of the Academy of Medical Royal Colleges, the British Transplantation Society (BTS) and the Intensive Care Society (ICS).

The death of the patient should be documented by the attending doctor.

10. Organ Retrieval
The patient is transferred to theatre expediently, but maintaining dignity at all times

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Appendix 1 - Guidelines for the post-mortem management of potential lung donors

With the increasing use of ex-vivo lung perfusion and the recognition that lungs, which have not been subjected to the haemodynamic consequences of ‘coning’ (specifically sympathetically mediated lung injury) may provide suitable, or even better, organs for transplantation, there is increasing interest in DCD lung donation.

The ICS and BTS guidelines on post-mortem lung donor management makes the following recommendations5:

1. If the patient had been extubated as part of the process of withdrawal of treatment, successful lung donation requires re-intubation after the diagnosis of death to protect the lungs from aspiration.
2. Re-intubation can be performed after the declaration of death and before the start of abdominal organ retrieval.
3. Re-ventilation of the lungs might provoke resumption of mechanical cardiac function. It was agreed therefore that reinstitution of mechanical ventilation should not resume before satisfactory exclusion of the cerebral circulation.
4. However, there was agreement that re-inflation of the lungs can be achieved 10 minutes after circulatory arrest (5 minutes after confirmation of death) using the application of a “recruitment” manoeuvre that does not involve mechanical ventilation – for example by applying a high level of CPAP (such as 40 cm H₂O) for 45 seconds followed by maintenance of 5 cm H₂O CPAP.

Therefore, for any patient who has been accepted as a potential DCD lung donor, the following variations to ‘standard’ non-lung DCD donation should be applied:

1. It should be made clear at the pre-extubation brief that lung donation is being considered. The attending doctor should understand they will be expected to re- intubate the patient after death has been confirmed. A waters circuit with a variable CPAP valve should be made available pre-extubation. This should accompany the patient to theatre.
2. After 5 minutes of continuous asystole, death is confirmed in the usual manner and the patient is transferred to theatre. Re-intubation, for the purpose of lung donation should not delay confirmation and documentation of death, nor the transfer to theatre. This will only introduce unnecessary warm ischaemia to other organs and to the lungs themselves. The attending ICU doctor should accompany the patient to theatre for the purpose of re-intubation.
3. Once in theatre, the deceased donor’s lungs should be re-intubated. This should occur once the patient has been transferred to the operating table. It can occur before the start of abdominal retrieval, but it should not delay the start of surgery. An endotracheal tube with inflated cuff will offer the lungs some protection from aspiration of gastric contents during abdominal retrieval. Typically, it will occur simultaneously with the start of surgery. The attending doctor from ICU should perform the re-intubation. No anaesthetic drugs (hypnotics, muscle relaxants etc.) will be required for the purpose. The presence of end-tidal CO2 will not be available to confirm successful re-intubation. Therefore, in the event of uncertainty over correct endotracheal tube placement, this information must be conveyed to the retrieval team in attendance. Retrieval teams may have training in intubation and may be able to intubate the donor themselves. Otherwise another anaesthetist should be found to re-attempt intubation. Uncertainty over successful endotracheal placement should not delay the start of retrieval of abdominal organs.
4. Provided ten minutes after the start of continuous asystole (5 minutes after confirmation of death) has elapsed, the now intubated lungs should be re-inflated with a single recruitment manoeuvre – applying 40cm H₂O of CPAP to the lungs for 45 seconds followed by 5 cm H₂O continuous CPAP.
5. After re-intubation and successful re-expansion of the lungs, the attending ICU doctor can leave theatre. After the cerebral circulation has been excluded (a surgical intervention involving cross-clamping the arch of the aorta) mechanical ventilation can be re-started, should the retrieval team wish it. This should be regarded as part of the lung retrieval process and as such it is the responsibility of the retrieval team. Protective lung ventilation is recommended.

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Appendix 2 - Guidelines for DCD donation where extubation occurs in the Anaesthetic Room

Families should be given the option, at the discretion of the medical, nursing and organ donation teams, for extubation within the theatre complex. This may occur, but is not limited to instances such as:

1. Families who express a desire for their relative’s donated organs to be in the best possible condition for transplantation, and understand that this can be achieved by eliminating unnecessary warm ischaemic times.
2. Those patients and or families who have expressed a desire for heart donation
3. Where families do not desire to stay with their relative up to and beyond the point of extubation. Under this circumstance, extubating a patient within an anaesthetic room will not affect the ‘quality’ of any relative’s experience(s) of end-of-life care as they have elected not to be present.
4. Where the patient is already brain dead, but where asystole is a condition for donation (e.g. where relatives aren’t comfortable that their loved one is dead until their heart has stopped). See Appendix 3.

Therefore, where extubation is to occur within the Anaesthetic Room:

1. Together with gaining consent for organ donation, including which organs are to be removed, the SN-OD consents relatives for withdrawal of care within the Anaesthetic Room. Families should always be made aware that his may not be possible due to logistical reasons such as staffing.
2. The SN-OD communicates this decision to the ICU nurse in charge, and to the ICU medical team. The ICU needs to arrange:
   1. Adequate nursing provision for the bedside nurse to be able to leave the unit and remain within the theatre complex for up to 4 hours. This might entail exploring whether a nurse might be prepared to come in early for their shift, or stay beyond their usual end of shift. (Remuneration from NHSBT for each consented donor should allow payment of overtime in this situation).
   2. An additional doctor to be nominated to go to theatre and be in attendance for extubation, timely certification of death, and re- intubation in the case of potential DCD lung donors. Out of hours, the ICU and theatre consultant(s) need to liaise to determine which member of the on-call team is best placed to service this role.
   3. Arrangements for on-going end-of-life care need to be finalised – typically where the patient will go to should they still be alive after the appropriate warm ischaemic times/thresholds are exceeded. Ideally, a side room on a ward should be identified in advance of leaving the ICU where the patient and his /her family can go. In rare circumstances, a return to the ICU might be possible depending on levels of other clinical activity/bed state but this must have been agreed before leaving the ICU.
3. Usual DCD arrangements proceed e.g. informing the coroner, as outlined above.
4. Theatres arrangements proceed as usual, however preparation of the identified anaesthetic room within the theatre complex for end-of-life care (typically the anaesthetic room adjoining the nominated retrieval theatre) should include:
   1. Removing unnecessary anaesthetic equipment, bench equipment etc. to make the environment as fit for a palliative vigil as possible.
   2. Drug cupboard access ensured for non-controlled drugs.
   3. Chairs, tissues, tea & coffee making facilities, a music player etc. made available for family members.
   4. Where family members can be taken should they wish to leave theatre, and where they will be taken after their relative has died.
5. Once all usual arrangements have been made, the patient, with any attendant family, are taken to the anaesthetic room. The patient should be taken here first and then family members brought in separately. This allows control of who the family might encounter within the theatre complex. Under no circumstances should they encounter any members of the retrieval team.
6. Any controlled drugs (typically morphine and midazolam) which the patient is receiving, or is anticipated to require, should be made up in advance and accompany the patient to theatre. In the event that they are not used, they can be disposed of appropriately.
7. Once the patient, any family members (if any are in attendance), the SN-OD, the dedicated ICU nurse and dedicated doctor are relocated, a pre-extubation brief should occur. This should check specifically on :
   1. All necessary arrangements are in place.
   2. Drug access and an acceptable plan for subsequent care should donation not take place are arranged.
   3. The attending medical staff is clear on their responsibilities (including post-mortem re-intubation) and how to certify death.
   4. The SN-OD needs to remind the retrieval team that absolute silence, from inside the theatre, is required after extubation.
   5. Where family members can go should they wish to leave theatre.

Additionally, arrangements should exist as to how family members can re-enter the theatre complex to re-join the patient.

1. Treatment withdrawal, palliative care interventions, diagnosis and confirmation of death all proceed in exactly the same way as if the patient had been extubated on the ICU. After 5 minutes of continuous asystole, family are escorted out of theatre to a pre-identified area. The patient, is confirmed dead, and then moved to the operating theatre, and prepared for surgery. Organ retrieval can commence as soon as possible, with no need to wait beyond 5 minutes of continuous asystole. Re-intubation can occur before organ retrieval after confirmation of death.
2. Should warm ischaemic times/thresholds be exceeded the retrieval team is stepped down and arrangements made to move the patient out of theatre. This is necessary as the retrieval team will need to remove themselves and their equipment from theatre, and this can be accomplished more easily if the patient has been moved to a definitive place for the rest of their end of life care.

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Appendix 3

Checklist: Withdrawal in the Anaesthetic Room (WiAR)

Appendix 4 – Guidelines for DCD donation from patient’s already diagnosed dead by neurological criteria

Where a patient has clinically become brain stem dead, it is regarded as best practice that that they undergo neurological testing to confirm a neurological diagnosis of death, regardless of their donor potential.. Despite brain stem death being confirmed, some families may then only consent to organ donation after a cardiovascular (and more conventionally understood) diagnosis of death. Under these circumstances, DCD donation can still be offered.

As the patient is already dead (confirmed by brain stem testing), once mechanical ventilation is stopped they will be apnoeic and asystole will occur predictably shortly afterwards. Five minutes of continuous asystole is not needed to confirm death, as the patient is already dead, although 2 minutes of continuous asystole pragmatically should be observed, being in line with current best evidence as the period after which auto-resuscitation will not occur. The endotracheal tube should remain in place, to facilitate lung re-inflation should lung donation be part of organ retrieval.

Whether cessation of mechanical ventilation occurs on ICU or within theatre will be decided by the family and the SN-OD, during the consent process for donation. The presumption will be that patients are taken to theatre and extubated in theatre, although (since caveats to donation have already at this stage been placed by the family on the donation process, specifically that asystole must have occurred) it can be expected that some families will prefer extubation on ICU.

Therefore, for any brain dead patient who is to become a DCD donor:

1. During consenting for donation, a discussion should take place as to where cessation of mechanical ventilation will occur. LTHT supports a default scenario of switching off mechanical ventilation within the theatre complex, however if families object to this, termination of mechanical ventilation can occur on ICU. Families should also be consented for the administration of heparin prior to cessation of mechanical ventilation. (Since the patient is legally dead, there can be no conflict of interest at this stage in administering heparin).
2. In consultation with the retrieval team, dose and timing of heparin administration should be established and given accordingly.
3. If cessation of ventilation is to occur in theatre:
   1. Once all arrangements for retrieval have taken place, the patient is escorted to the allotted theatre anaesthetic room. A doctor or suitably qualified Acute Critical Care Practitioner (ACCP) should transfer them with full monitoring and using a portable mechanical ventilator.
   2. Once the patient is stable within the anaesthetic room, either the SN- OD or the attending bed-side nurse should return to ICU and accompany any family members to theatre, should any wish to be present whilst the ventilator is disconnected.
   3. Once all family members are in attendance, and they have had as much time as is required for their final farewells, the ventilator should be switched off, and the endotracheal tube disconnected. The ETT should however remain in situ.
   4. Once asystole is diagnosed, there should be 2 minutes of continuous asystole observed. After this time, family members should be escorted, by the attending bedside nurse, out of theatre back to ICU.
   5. There is no need to perform any additional tests to certify death, nor record anything additional within the medical documentation regarding certification. The patient has already been certified dead.
   6. The deceased patient should be moved into theatre, and prepared and draped for retrieval. Lung recruitment may be instituted at this point, if lung retrieval is being planned.
   7. Retrieval can commence immediately. There is no need for any additional time delays.
   8. If no family members have elected to accompany their relative to theatre, then cessation of mechanical ventilation should occur within theatre itself, and not in the adjoining anaesthetic room. The patient, unaccompanied by any relatives, is brought into the theatre, prepared and draped for surgery. Ventilation should be stopped. Decision regarding actual disconnection from the ventilator should be left to the senior retrieval surgeon. Once asystole commences, there should be 2 minutes of continuous asystole after which retrieval can commence immediately. Again, lung recruitment can be applied if applicable.
4. If cessation of ventilation is to occur on ICU:
   1. Once all arrangements for retrieval have taken place (including having porters in attendance on the ICU) and with all necessary family member who wish to be, in attendance, the ventilator should be switched off, and the endotracheal tube disconnected. The ETT should however remain in situ.
   2. Once asystole is diagnosed, there should be 2 minutes of continuous asystole observed. After this time, family members should be escorted, by the attending bedside nurse, out of the ICU into the waiting room.
   3. There is no need to perform any additional tests to certify death, nor record anything additional within the medical documentation regarding certification. The patient has already been certified dead.
   4. The deceased patient should be moved to theatre as quickly as possible. Efforts should be made to prevent family members meeting the former patient being transferred to theatre.
   5. Once on the operating table they should be prepared and draped for retrieval. Lung recruitment may be instituted at this point, if lung retrieval is being planned.
   6. Retrieval can commence immediately. There is no need for any additional time delays.