A Comparison of Request Process and Outcomes in Donation After Cardiac Death and Donation After Brain Death: Results From a National Study

Available literature points to healthcare providers’ discomfort with donation after cardiac death (DCD) and their perception of public reluctance toward the procedure. Using a national sample, we report on the communication content of actual DCD and donation after brain death (DBD) approaches by organ procurement organization (OPO) requesters and compare family decision makers’ (FDMs’) experiences of both modalities. We recruited 1601 FDMs using a validated protocol; 347 (21.7%) were of potential DCD donors. Semistructured telephone interviews yielded FDMs’ sociodemographic data, donation attitudes, assessment of approach, final outcomes, and substantiating reasons. Initial analysis consisted of bivariate analyses. Multilevel mixture models compared groups representing authorization outcome and DCD/DBD status. No significant differences in family authorization were found between DCD and DBD cases. Statistically significant associations were found between sociodemographic characteristics and authorization, with white FDMs more likely to authorize DCD or DBD than black FDMs. FDMs of both modalities had similar evaluations of requester skills, topics discussed, satisfaction, and refusal reasons. The findings suggest that the DCD/DBD distinction may not be notable to families. We recommend the use of similar approach strategies and communication skills and the development of education campaigns about the public's acceptance of DCD.     

An Empirical Examination of the Antecedents of the Acceptance of Donation After Cardiac Death by Health Care Professionals

Findings are reported from a US Department of Health and Human Services (DHHS) funded study to identify barriers to increasing support for donations after cardiac death by health professionals. A donations after cardiac death (DCD) acceptance model is conceptualized and tested via 806 survey responses from certified requestors, all of whom had their identities protected through Institutional Review Board (IRB) protocol. The overall model was significant and explained 35% of the variation in DCD support. Greater knowledge about DCD, greater trust in the organ procurement organization (OPO) and a belief that futility has been reached were all positively associated with DCD acceptance. Negative perceptions of DCD versus brain death, transitioning from caregiving to donation advocate, concerns about the DCD process and the idea that DCD leads to active participation in the death reduced its support. The three greatest impediments to support of DCD exist when health professionals feel they are playing an active role in killing the patient, that a state of death has not yet been reached, and that DCD has more psychological barriers than does the brain death donation process. Opportunities and strategic initiatives are discussed to overcome these barriers, including the value of communication and education initiatives and the need for well-trained requestors. The implementation of these strategic guidelines helped to increase the number of DCD donors by 225%.     

Increasing Organ Donations After Cardiac Death by Increasing DCD Support Among Health Care Professionals: A Case Report

This case report focuses on the University of Wisconsin Hospital and Clinics Organ Procurement Organization (UWHC-OPO) efforts to produce a verifiable and demonstrable increase in organ donations by developing a replicable, transferable and feasible model intervention for increasing health care professionals' support for donation after cardiac death (DCD). A grant from the US Department of Health and Human Services funded a 3-year study allowing the UWHC-OPO to (i) identify barriers to and opportunities for increasing DCD support among those involved in the donation request process, (ii) implement this better understanding of these support factors in the creation of intervention materials designed to increase knowledge of and support for DCD and finally (iii) to track and document the progress made in increasing knowledge, support, number of hospitals with DCD protocols, actual requests made and number of DCD donors. The results of the model intervention were extremely positive, showing lasting increases in DCD knowledge and support, adoption of DCD protocols and referrals in the two tracking survey stages following the intervention. Perhaps most notably, DCD donor numbers within the UWHC-OPO region increased 93% in the year following the intervention and 179% to date.     

Derivation of the Uncontrolled Donation after Circulatory Determination of Death Protocol for New York City

Evidence from Europe suggests establishing out‐of‐hospital, uncontrolled donation after circulatory determination of death (UDCDD) protocols has potential to substantially increase organ availability. The study objective was to derive an out‐of‐hospital UDCDD protocol that would be acceptable to New York City (NYC) residents. Participatory action research and the SEED‐SCALE process for social change guided protocol development in NYC from July 2007 to September 2010. A coalition of government officials, subject experts and communities necessary to achieve support was formed. Authorized NY State and NYC government officials and their legal representatives collaboratively investigated how the program could be implemented under current law and regulations. Community stakeholders (secular and religious organizations) were engaged in town hall style meetings. Ethnographic data (meeting minutes, field notes, quantitative surveys) were collected and posted in a collaborative internet environment. Data were analyzed using an iterative coding scheme to discern themes, theoretical constructs and a summary narrative to guide protocol development. A clinically appropriate, ethically sound UDCDD protocol for out‐of‐hospital settings has been derived. This program is likely to be accepted by NYC residents since the protocol was derived through partnership with government officials, subject experts and community participants.     

Impact of a National Controlled Donation After Circulatory Death (DCD) Program on Organ Donation in the United Kingdom: A 10‐Year Study

Organ transplantation is the most successful treatment for some forms of organ failure, yet a lack of organs means many die on the waiting list. In the United Kingdom, the Organ Donation Taskforce was set up to identify barriers to organ donation and in 2008 released its first report (Organ Donation Taskforce Report; ODTR). This study assesses the success since the ODTR and examines the impact of the United Kingdom's controlled donation after circulatory death (DCD) program and the controversies surrounding it. There were 12 864 intended donation after brain death (DBD) or DCD donors from April 2004 to March 2014. When the 5 years preceding the ODTR was compared to the 5 years following, intended DCD donors increased 292% (1187 to 4652), and intended DBD donors increased 11% (3327 to 3698). Organs retrieved per intended DBD donor remained static (3.30 to 3.26), whereas there was a decrease in DCD (1.54 to 0.99) due to a large rise in donors who did not proceed to donation (325 to 2464). The majority of DCD donors who proceeded did so within 30 min from time of withdrawal. Our study suggests further work on converting eligible referrals to organ donation and exploring methods of converting DCD to DBD donors.     

Kidney Transplantation from Donors after Cardiac Death: Uncontrolled versus Controlled Donation

Kidney donation after cardiac death has been popularized over the last decade. The majority of these kidneys are from controlled donors. The number of organs for transplantation can be further increased by uncontrolled donors after cardiac death. The outcome of uncontrolled compared to controlled donor kidney transplantation is relatively unknown. We compared the long‐term outcome of kidney transplantation from uncontrolled (n = 128) and controlled (n = 208) donor kidneys procured in the Maastricht region from January 1, 1981 until January 1, 2008, and transplanted in the Eurotransplant region. The incidence of primary nonfunction and delayed graft function in both uncontrolled and controlled donor kidneys is relatively high (22% vs. 21%, and 61% vs. 56%, p = 0.43, respectively). Ten‐year graft and recipient survival are similar in both groups (50% vs. 46%, p = 0.74 and 61% vs. 60%, p = 0.76, respectively). Estimated glomerular filtration rates 1 year after transplantation are 40 ± 16 versus 42 ± 19 mL/min/1.73 m², p = 0.55, with a yearly decline thereafter of 0.67 ± 3 versus 0.70 ± 7 mL/min/1.73 m²/year, p = 0.97. The outcome of kidney transplantation from uncontrolled and controlled donors after cardiac death is equivalent. This justifies the expansion of the donor pool with uncontrolled donors to reduce the still growing waiting list for renal transplantation, and may stimulate the implementation of uncontrolled kidney donation programs.     

Attitudes of the American Public toward Organ Donation after Uncontrolled (Sudden) Cardiac Death

Concerns about public support for organ donation after cardiac death have hindered expansion of this practice, particularly rapid organ recovery in the context of uncontrolled (sudden) cardiac death (uDCD). A nationally representative Internet‐based panel was provided scenarios describing donation in the context of brain death, controlled cardiac death and uncontrolled cardiac death. Participants were randomized to receive questions about trust in the medical system before or after the rapid organ recovery scenario. Among 1631 panelists, 1049 (64%) completed the survey. Participants expressed slightly more willingness to donate in the context of controlled and uncontrolled cardiac death than after brain death (70% and 69% vs. 66%, respectively, p < 0.01). Eighty percent of subjects (95% CI 77–84%) would support having a rapid organ recovery program in their community, though 83% would require family consent or a signed donor card prior to invasive procedures for organ preservation. The idea of uDCD slightly decreased trust in the medical system from 59% expressing trust to 51% (p = 0.02), but did not increase belief that a signed donor card would interfere with medical care (28% vs. 32%, p = 0.37). These findings provide support for the careful expansion of uDCD, albeit with formal consent prior to organ preservation.     

Donors After Cardiac Death: Validation of Identification Criteria (DVIC) Study for Predictors of Rapid Death

Donation after cardiac death (DCD) is uncommon in part because clinicians cannot prospectively identify patients who are likely to die within 60 min of withdrawal of life-sustaining treatments (LST). UNOS criteria exist but have not been validated. Consecutive patients electively withdrawn from LST at five university-affiliated hospitals were prospectively enrolled. Demographic and treatment characteristics were collected. Chi-square was used to determine risk for death within 60 min and validate the UNOS criteria. A total of 533 patients were enrolled. A total of 28 were excluded from this report due to age <18 years or failure to include time of death. Of 505 (95%) patients, 227 (45%) died within 60 min, 134 (27%) in 1–6 h and 144 (29%) >6 h after withdrawal of LST. A total of 29%, 52%, 65% and 82% of patients with 0,1,2 and 3 UNOS DCD criteria, respectively, died within 60 min of withdrawal of LST. The data validate the UNOS criteria. Patients with no criteria might be excluded from consideration for DCD. Those with more than one criterion are reasonable candidates, while those with a single criterion should be considered if a 50% failure rate for DCD is acceptable.     

The Life-Years Saved by a Deceased Organ Donor

Understanding the additional life-years given to patients by deceased organ donors is necessary as substantial investments are being proposed to increase organ donation. Data were drawn from the Scientific Registry of Transplant Recipients. All patients placed on the wait-list as eligible to receive or receiving a deceased donor solid organ transplant between 1995 and 2002 were studied. The benefit of transplant was determined by the difference in the expected survival experiences of transplant recipients and candidates expecting transplant soon. An average organ donor provides 30.8 additional life-years distributed over an average 2.9 different solid organ transplant recipients, whereas utilization of all solid organs from a single donor provides 55.8 additional life-years spread over six organ transplant recipients. The relative contribution of the different organs to the overall life-year benefit is higher for liver, heart and kidney, and lowest for lung and pancreas. The life-year losses from unprocured and unused organs are comparable to suicide, congenital anomalies, homicide or perinatal conditions and half that of HIV. Approximately 250,000 additional life-years could be saved annually if consent for potential deceased donors could be increased to 100%. Therefore, increasing organ donation should be considered among our most important public health concerns.     

Living Anonymous Liver Donation: Case Report and Ethical Justification

Most living organ donations are from genetically or emotionally related donors. Although some transplant centers are willing to accept donations from living anonymous kidney donors (LAKDs), very few centers will accept donations from living anonymous liver donors (LALDs). The difference in acceptance rates is primarily due to the greater risk in liver donation, which is estimated to be 10-fold that of the risk in kidney donation. We present a case of donation from a LALD, the first reported in Canada. There are currently no established standards for LALDs. Our criteria for the ethical acceptability of LALDs require such donors to be physically healthy, mentally competent, altruistic, highly motivated, well-informed and able to give voluntary consent to donation. Another major ethical criterion is that the likely psychological benefit to the LALD balances the physical risks. Our case demonstrates that transplants from LALDs are medically successful and ethically justified under certain conditions.     

A Multicenter Study on Long‐Term Outcomes After Lung Transplantation Comparing Donation After Circulatory Death and Donation After Brain Death

The implementation of donation after circulatory death category 3 (DCD3) was one of the attempts to reduce the gap between supply and demand of donor lungs. In the Netherlands, the total number of potential lung donors was greatly increased by the availability of DCD3 lungs in addition to the initial standard use of donation after brain death (DBD) lungs. From the three lung transplant centers in the Netherlands, 130 DCD3 recipients were one‐to‐one nearest neighbor propensity score matched with 130 DBD recipients. The primary end points were primary graft dysfunction (PGD), posttransplant lung function, freedom from chronic lung allograft dysfunction (CLAD), and overall survival. PGD did not differ between the groups. Posttransplant lung function was comparable after bilateral lung transplantation, but seemed worse after DCD3 single lung transplantation. The incidence of CLAD (p = 0.17) nor the freedom from CLAD (p = 0.36) nor the overall survival (p = 0.40) were significantly different between both groups. The presented multicenter results are derived from a national context where one third of the lung transplantations are performed with DCD3 lungs. We conclude that the long‐term outcome after lung transplantation with DCD3 donors is similar to that of DBD donors and that DCD3 donation can substantially enlarge the donor pool.     

Organ Donation and Utilization in the United States: 1998–2007

Organ transplantation remains the only life-saving therapy for many patients with organ failure. Despite the work of the Organ Donation and Transplant Collaboratives, and the marked increases in deceased donors early in the effort, deceased donors only rose by 67 from 2006 and the number of living donors declined during the same time period. There continues to be increases in the use of organs from donors after cardiac death (DCD) and expanded criteria donors (ECD). This year has seen a major change in the way organs are offered with increased patient safety measures in those organ offers made by OPOs using DonorNet^©. Unfortunately, the goals of 75% conversion rates, 3.75 organs transplanted per donor, 10% of all donors from DCD sources and 20% growth of transplant center volume have yet to be reached across all donation service areas (DSAs) and transplant centers; however, there are DSAs that have not only met, but exceeded, these goals. Changes in organ preservation techniques took place this year, partly due to expanding organ acceptance criteria and increasing numbers of ECDs and DCDs. Finally, the national transplant environment has changed in response to increased regulatory oversight and new requirements for donation and transplant provider organizations.     

The Use of Donation After Cardiac Death Allografts Does Not Increase Recurrence of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) recurrence in patients undergoing liver transplantation (LT) with donation after brain death (DBD) and donation after cardiac death (DCD) allografts has not previously been investigated. Rates and patterns of HCC recurrences were investigated in patients undergoing DBD (N = 1633) and DCD (N = 243) LT between 2003 and 2012. LT for HCC was identified in 397 patients (340 DBD and 57 DCD). No difference in tumor number (p = 0.26), tumor volume (p = 0.34) and serum alphafetoprotein (AFP) (p = 0.47) was seen between the groups. HCC recurrence was identified in 41 (12.1%) patients in the DBD group and 7 (12.3%) patients in the DCD group. There was no difference in recurrence‐free survival (p = 0.29) or cumulative incidence of HCC recurrence (p = 0.91) between the groups. Liver allograft was the first site of recurrence in 22 (65%) patients in the DBD group and two (37%) patients in the DCD group (p = 0.39). LT for HCC with DBD and DCD allografts demonstrate no difference in the rate of HCC recurrence. Previously published differences in survival demonstrated between recipients with HCC receiving DBD and DCD allografts despite statistical adjustment can likely be explained by practice patterns not captured by variables contained in the SRTR database.     

Effect of Population Aging on the International Organ Donation Rates and the Effectiveness of the Donation Process

This study analyzed the effect of population aging on organ donation for transplants in 43 countries and on the effectiveness of the donation process by comparing the results between Spain and the United States. The percentage of the population aged 65 or over accounted for 33% of the difference in the donation rates between the countries and for 91% of the variation in the rates after age adjustment. However, the level of aging of the Spanish (16.5%) and American (12.3%) populations failed to account for the percentages of deceased donors 65 or over (28% vs. 10%), due to the different age-specific donation rates, much higher in Spain above 50 years. These differences lead to a higher effectiveness of the process in the United States (3.1 transplanted organs per donor vs. 2.5 in Spain), though at lower rates of transplant per million population (73 vs. 87). We conclude that older populations have a greater donation potential as donation rates are strongly associated with population aging. It should therefore be mandatory to adjust donation rates for age before making comparisons. Additionally, effectiveness decreases with older donors, so age should be considered when establishing standards relating to organ donation and effectiveness of the process.     

A Hierarchical Communication Model of the Antecedents of Health Care Professionals’ Support for Donations after Cardiac Death

Using structural equation modeling, the direct and indirect impact of five variables on the support of donation after cardiac death from the perspective of health care professionals were investigated: knowledge, trust in the transplant team, whether patients are in a state of irreversibility, whether health care professionals participate in a patient's death, and perceptions about the brain death versus cardiac death donation process. In total, 10/15 relationships posited in the model had significant pathways. The results provide insight into sequential communication strategies for generating support for donations after cardiac death.     

Donation after Cardiac Death: Community Views about ‘Decent’ Intervals

Donation after cardiac death (DCD) offers an alternative pathway to donation for some donors. Successful recovery of organs for transplantation following DCD requires that organ recovery surgery commence as soon as possible after death has occurred. This limits the amount of time that family and friends can spend with the donor prior to surgery. The aim of this study was to identify community views about the timing of organ recovery in DCD. Data were collected from two sources in South Australia: 32 members of the public participated in four focus groups, and 2693 adults participated in a representative population survey. Respondents were asked their views about a decent interval to wait after death prior to organ recovery surgery. Focus group participants identified a tension between preserving organ viability and allowing families time with the deceased. Of the survey respondents, 45.2% selected a timeframe compatible with potentially viable donations; 34.1% selected a timeframe incompatible with viable donations; and 20.8% gave an indeterminate answer. These findings provide information about public perceptions of DCD, can be used to inform educational campaigns about DCD and serve as a baseline for evaluating such campaigns, and identify a number of areas for further investigation.