A 35 year old man sustained a severe penetrating traumatic brain injury. His injuries were deemed to be unsurvivable, but he was not brainstem dead. He was on the organ donor register, and his family were keen to proceed with donation. He was admitted to the ICU to manage his end of life care and facilitate organ donation after circulatory death.

What are the eligibility criteria and contra-indications to organ donation after circulatory death?

Adrian Wong

There are currently around 8000 people on the organ transplant register and demand for organ far outstrips the supply. On the ICU, most organs tend to be from ‘Death After Brainstem Death’ (DBD) patients. The falling number of patients who meet the criteria for DBD and increasing success in the use of organs from DCD donors has led to a rapid rise in the number of DCD donors in the UK over recent years. This was previously known as non-heart beating donors.

There is no longer an age limit to potential donors. Absolute contraindications to donation are:
• active invasive cancer within the last 3 years (non-melanoma skin cancer and primary brain tumours are excluded)
• haematological malignancy
• untreated systemic infection
• variant Creutzfeldt-Jakob disease
• HIV disease

When in doubt, discussion with the local organ transplant coordinator is recommended.

There has been a ten-fold increase in the number of DCD donors in the UK in the past 10 years. They now account for 35% of all deceased donors. DCD can be considered in any patient who does not fulfill brainstem death criteria but has no hope of recovery. They can thus be classified according to the modified Maastricht classification.

Category 1 Dead on arrival at hospital
Category 2 Unsuccessful resuscitation
Category 3 Awaiting cardiac arrest
Category 4 Cardiac arrest in a brainstem dead patient
Category 5 Unexpected cardiac arrest in a critically ill patient

In DBD, the organs continues to be perfused as cardiac output is maintained. Hence the difference between DBD and DCD is the duration of warm ischaemia due to inadequate oxygenation or perfusion. Warm ischaemia is inevitably longer in DCD organs as the patient needs to be declared dead before the protective cold perfusion can be established. Hence, organs from DCD donors develop irreversible damage due to accumulation of ischaemic metabolites. To minimise warm ischaemia, controlled DCD is preferred and in the ICU setting, this would mostly compromised of patients from category 3.

The decision to withdraw therapy on the grounds of futility is difficult and needs to be communicated to the family. These decisions should be made transparently and consistently regardless of the potential for organ donation. The organ transplant coordinator should be informed early regarding potential donors. Once the decision is made to proceed to donation, the retrieval team should be informed and the withdrawal process should be agreed upon. The level of organ support here after is an area of controversy but essentially are based on the principle that interventions should not cause the donor any harm or distress. The consensus meeting suggests that this withdrawal process be managed on the ICU but recognise that this might be controversial and discussions should be made at a local level.

Upon cardiorespiratory arrest, death is confirmed after a period of 5 minutes of observation. The relatives are then allowed 5 minutes with the patient before being transferred to the operating theatre.

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References

1. Organ Donation after Circulatory Death. report of a consensus meeting. Intensive Care Society, NHS Blood and Transplant, and British Transplant Society 2010. http://www.ics.ac.uk/intensive_care_professional/standards_and_guidelines/dcd
2. Organ Donation Taskforce. Organs for Transplant. A Report from the Organ Donation Taskforce. London: Department of Health, 2008.
3. UK Donation Ethics Committee. An ethical framework for controlled donation after circulatory death. January 2011.
4. Dept of Health. Legal issues relevant to non-heartbeating organ donation. 2009.