Introduction

A mandatory implementation of donation after circulatory death (DCD) from eligible patients facing imminent or cardiac death in hospitals across the USA was introduced at a national conference and is to be effective from January 2007 [1]. The DCD requirement is focused on patients who are neurologically intact or do not fulfill neurologic death criteria before withdrawal of ventilator support [2]. The mandatory requirement will be implemented through the collaboration of the Institute of Medicine, Joint Commission on Accreditation of Healthcare Organizations, Center for Medicare and Medicaid Services, and the Department of Health and Human Services (see the glossary of terms in Table 1) [3, 4].

Table 1 Glossary of terms used
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The transplantation community has been reorganized into 58 donation service areas (DSAs) to cover the entire country [5]. Each DSA is centered on one organ procurement organization (OPO) that facilitates the recovery and flow of transplantable organs from donor hospital(s) to regional transplant center(s) within a defined geographic location. Each of the DSAs will have to meet a target goal of 75% or higher of cadaveric organ donation rate from its affiliated hospitals.

Determination of circulatory death for organ procurement

The uniform determination of death relies on irreversible cessation of circulatory or neurologic function. The unitarian determination of death by either neurologic or circulatory criteria rather than fulfilling both criteria simultaneously is accepted as the standard for cadaveric organ procurement [2]. The DCD criteria relies on expert opinion, which permits the procurement process after 5 min of apnea, unresponsiveness, and pulselessness [6].

The pivotal assumption that DCD will eliminate the possibility that the procurement process is the direct cause of death has been challenged. Spontaneous return of both circulatory and neurologic function (autoresuscitation or Lazarus phenomenon) has been reported after 10 min of electric asystole [7]. The notion of a specific time interval for determination of irreversible cessation of circulatory function is also difficult to reconcile with the dead donor rule, when extracorporeal circulation and oxygenation during procurement are used to maintain organ viability in DCD [8]. Return of full neurologic function during extracorporeal circulation is well documented in victims of in-hospital and out-of-hospital cardiac arrest, because they are neurologically intact before circulatory death [9, 10]. Artificial circulatory support can also lead to cerebral and coronary resuscitation, and reanimation or return to life, which have to be suppressed by aortic balloon occlusion during procurement [8].

The DCD is applied to many individuals with intact neurologic and brain function before circulatory arrest, and therefore the presence of neurologic or brain activity during procurement is relevant [1, 5]. There are no published reports of spontaneous neurologic or cardiac recovery or return to life during procurement in DCD. However, it may not be feasible to obtain that type of evidence if the procurement process itself is the final cause of irreversibility. Also, such reporting will probably create medicolegal concerns within the community. Under such circumstances, organ donation can no longer be considered to fulfill the dead donor rule. Legislative abandonment of the dead donor rule has been proposed for procurement of transplantable organs because of lack of sufficient scientific foundation for current DCD practice [11].

Consent for organ procurement

The OPO or affiliates are the designated 'organ requesters' in the organ donation consent process [5]. Hospitals are required to notify the OPO of all imminent deaths early and before withdrawal of ventilator support in order to initiate independently the discussion and consent process for organ donation with surrogates [3]. The conflict of interest and self-serving bias of the OPO can limit the exchange of information with surrogates and violate the standards for true informed consent. The objective of OPOs is to obtain consent for organ donation and meet the target donation rate within each DSA [5]. The interlinking of OPO, donor, and transplant hospitals within a DSA can also heighten financial interests to maximize organ donation consent.

The donor's authorization for donation on an organ donor card, driver's license, or donor registry is legally binding and irrevocable, so in such cases the OPO can procure organs without family consent or after refusal [3]. Presumed consent has also been proposed to facilitate OPO recovery of transplantable organs [2]. In presumed consent, agreement for donation is the default choice, in the absence of express rejection by the potential donor. Therefore, in the absence of an individual's express decision, their consent rather than refusal for organ donation is presumed. The legislative enactment of presumed consent enables the OPO to override donation refusal by surrogates. A conscription model has also been proposed so that consent for organ donation will neither be required nor requested by the OPO because of compulsory requirement for removal of all needed transplantable cadaveric organs [2].

End-of-life care

OPO staff officially assume planning of medical care of the donor after organ donation consent has been established, in order to maintain organs viability and prepare for their procurement [12]. Compliance with metrics for quality of end-of-life (EOL) care has been emphasized to deliver patient and family centered care and to ensure a 'good death' experience in the intensive care unit (ICU; Table 2) [13]. The quality of EOL care has not been measured nor reported for ICU donors enrolled in DCD programs [1]. DCD enrollment is expected to deviate from more than 60% of the EOL care quality indicators (Table 2).

Table 2 Compliance of DCD with the quality indictors for EOL care in the donor
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Ante mortem invasive instrumentation and testing that are nonbeneficial and perhaps harmful interventions that expedite death are often performed in preparation for DCD. The Wisconsin protocol is used to select suitable candidates for DCD [1]. The protocol is intended to predict whether circulatory arrest can occur within 60 min of withdrawal of life support. The high false-positive rate for selection of DCD candidates in the ICU can expose many dying ICU patients to unnecessary ante mortem interventions [14]. The quality of EOL care also has profound psychologic sequelae for families. Post-traumatic stress reaction has been reported in family members of ICU patients who share in EOL decisions [15]. Organ donation is a stressful and difficult EOL decision that can lead to anxiety, depression, and decreased quality of life among family members of the deceased donor.

Conclusion

The DCD criteria do not universally fulfill the dead donor rule. Therefore, legislative abandonment of the dead donor rule to permit the recovery of transplantable organs is necessary because of lack of adequate scientific foundation for DCD practice. The conflict of interest and self-serving bias of OPOs can interfere with a true informed consent for organ donation. Finally, mandatory compliance with EOL care metrics can ensure that donor care is not sacrificed for the recovery of transplantable organs.