Organ Donation After Cardiac Death

There was a time when organ donation after cardiac (or circulatory) death ("DCD") was controversial. Then it wasn't (at least not as much). We may be returning to that earlier time once more.

DCD protocols were developed as a way of obtaining transplantable organs without waiting for brain death to occur. Considering the 103,000+ backlog of transplant candidates on national waiting lists, DCD seemed like an innovative way to increase the supply of organs.

The protocol called for taking away life-support, waiting for spontaneous respirations and cardiac function to stop, waiting a little longer to ensure that the donor's heart didn't spontaneously restart ("autoresuscitation), and declaring death. All of these steps take place in an operating room where a transplant team is ready to remove the decedent's organs while they are still relatively "fresh."

Criticisms were mostly focused on the waiting periods, which -- if too short -- might result in taking vital organs from a patient who wasn't really dead. With the encouragement of the transplant field's regulatory body -- the United Network for Organ Sharing (UNOS) -- the practice has established a solid footing and currently accounts for 43% of deceased donors, 7,200 donors in total.

If there's a problem with DCD, it is the persistent reports of DCD donors being declared dead and turning out not to be. As recently as this week, The New York Times ran a long story with the striking headline, "Doctors Were Preparing to Remove Their Organs. Then They Woke Up". Experts say that if the protocol is carried out properly, this should never happen. So what's the explanation? The agency that oversees the federal Organ Procurement and Transplant Network is the Health Resources and Services Administration (HRSA), which conducted a review of cases in Kentucky. As reported by the Times: 

Now, a federal investigation has found that officials at the nonprofit in charge of coordinating organ donations in Kentucky ignored signs of growing alertness not only in that patient but also in dozens of other potential donors.

The investigation examined about 350 cases in Kentucky over the past four years in which plans to remove organs were ultimately canceled. It found that in 73 instances, officials should have considered stopping sooner because the patients had high or improving levels of consciousness.

The results of that investigation has led HHS to start a process of "reforming" the OPTN:

[HHS] announced a major initiative to begin reforming the organ transplant system following an investigation by its Health Resources and Services Administration (HRSA) that revealed disturbing practices by a major organ procurement organization.“Our findings show that hospitals allowed the organ procurement process to begin when patients showed signs of life, and this is horrifying,” Secretary Kennedy said. “The organ procurement organizations that coordinate access to transplants will be held accountable. The entire system must be fixed to ensure that every potential donor’s life is treated with the sanctity it deserves.”

The headline of this press release is apparently intended to alarm: HHS Finds Systemic Disregard for Sanctity of Life in Organ Transplant System (boldface in original). The question this leaves open is whether HHS is going to adopt measures to ensure compliance with the existing DCD protocol or take steps to scrap DCD altogether. (Wait until RFK, Jr. is told about Nomothermic Regional Perfusion!) Stay tuned . . . .