May 12, 2009 Although a large number of children's hospitals have developed or are developing policies regarding organ donation after cardiac death, there is considerable variation among policies, including the criteria for declaring death, according to a new study.
Donation after cardiac death (DCD) potentially permits patients who do not meet the neurological criteria for death to donate solid organs. "Controlled DCD occurs following planned withdrawal of life-sustaining treatment, and uncontrolled DCD occurs after unanticipated cardiac arrest. Potential controlled DCD donors include patients with irreversible catastrophic brain injury or end-stage neuromuscular diseases," the authors write. Although the Joint Commission requires all hospitals to address DCD, little is known about actual hospital policies.
Armand H. Matheny Antommaria, M.D., Ph.D., of the University of Utah School of Medicine, Salt Lake City, and colleagues conducted a study to evaluate the development and content of DCD policies at children's hospitals and evaluate variation among policies, which were collected between November 2007 and January 2008 from hospitals in the United States, Puerto Rico, and Canada. Of inquiries to 124 children's hospitals, a response was received from 105 (85 percent). Of these respondents, 72 percent had DCD policies, 19 percent were developing policies, and 7 percent neither had nor were developing policies.
The researchers received and analyzed 73 approved policies. Sixty-one (84 percent) specify criteria or tests for declaring death, including electrocardiogram (ECG) findings, pulselessness, apnea, and unresponsiveness. Four policies require total waiting periods prior to organ recovery at variance with professional guidelines: 1 less than 2 minutes and 3 longer than 5 minutes. Sixty-four policies (88 percent) preclude transplant personnel from declaring death and 51 percent prohibit them from involvement in premortem (taking place immediately before death) management.
While 65 policies (89 percent) indicate the importance of palliative care, only 7 percent recommend or require palliative care consultation. Thirty-two policies (44 percent) preclude the use of medications with the intention to hasten death.
Policies differ in the location of withdrawal of life-sustaining treatment. Sixty-eight policies (93 percent) specify the location, with the majority (54 percent) requiring withdrawal of treatment to occur in the operating room. Other potential locations include areas adjacent to the operating room (19 percent), the emergency department (4 percent), or the intensive care unit (4 percent).
"This study demonstrates that, consistent with a national emphasis on increasing the supply of transplantable organs, a large number of children's hospitals have developed or are developing DCD policies," the authors write.
"The policies exhibit notable variation both within those we studied and compared with authoritative reports and statements. Further research will be required to determine the importance of variation in the tests for declaring death or the processes for withdrawing life-sustaining treatment. In the long run, public policy may need to address strategies to promote adherence to recommendations for DCD processes based on sufficient clinical evidence and/or ethical justification."
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- Antommaria et al. Policies on Donation After Cardiac Death at Children's Hospitals: A Mixed-Methods Analysis of Variation. JAMA The Journal of the American Medical Association, 2009; 301 (18): 1902 DOI: 10.1001/jama.2009.637
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