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  • Controlled DCD The clinical pathway

    Dr Paul Murphy National Clinical Lead for Organ Donation NHS Blood and Transplant, UK

    1 Swedish Inquiry into organ donation and transplantation. April 2014

  • Controlled DCD background

    Background Key elements of the pathway Specific issues

    Identification of potential DCD donors Family consent Resources

    Contribution of DCD to transplantation in the UK

    Objectives

  • Controlled DCD background

    Maastricht Classification of DCD

    Definition Where

    I Dead on arrival Spain, France, Italy

    II Unsuccessful resuscitation

    III Cardiac arrest awaited after withdrawal of life support in patients who are not brain dead Belgium, United Kingdom, Netherlands, Australia, USA, New Zealand IV Cardiac arrest after brain death

    MC I, II, uncontrolled

    MC III, IV: controlled

  • Controlled DCD background

    609 611 624 637 652705

    780

    200288

    335373

    436

    507

    540

    0

    200

    400

    600

    800

    1000

    1200

    1400

    2007-8 2008-9 2009-10 2010-11 2011-12 2012-13 2013-14

    Num

    ber

    DBD DCD

    809

    1320

    Deceased donors up to 2013-14

  • Controlled DCD background

    International donation rates, 2012

    0 5 10 15 20 25 30 35 40

    Germany

    Denmark

    Sweden

    Netherlands

    Australia

    Ireland

    United Kingdom

    Italy

    Austria

    Norway

    Portugal

    France

    Belgium

    Spain

    Croatia

    deceased donors pmp, 2012

    DBD donorsDCD donors

  • Controlled DCD key elements of the pathway

    The Maastricht Category III DCD Pathway

    Irreversible loss of circulatory function

    Permanent loss of consciousness and respiration

    Biochemical collapse and decomposition

    ischaemia

    Organ retrieval

    Organ retrieval after death that follows planned withdrawal of life-sustaining treatments

  • Controlled DCD key elements of the pathway

    Death on ICU

    lack of overall benefit from further treatments

    withdrawal

    asystole

    Multi-organ failure Intolerable disability

    diagnosis of death

    last offices

    As many as 70% of ICU deaths in the UK follow the planned limitation or withdrawal of cardio-respiratory support

  • Controlled DCD key elements of the pathway

    Impact of DCD on the end of life care

    lack of overall benefit

    withdrawal

    asystole

    Multi-organ failure Intolerable disability

    diagnosis of death

    last offices

    lack of overall benefit

    delayed withdrawal

    asystole

    Referral and initial assessment Approach family Continued support Detailed donor assessment and offering Arrival of retrieval team

    Expedient diagnosis of death Transfer to theatre Perfusion / retrieval Last offices

    ?

    death death and donation

  • Controlled DCD key elements of the pathway

    DCD pathway Key considerations

    End of life care has to be adjusted if DCD is to be possible

    Donation considered before death Assessment who can donate? Family approach

    Requires delay in treatment withdrawal ? Physiological instability

    Altered management of death Location of treatment withdrawal Rapid diagnosis of death Rapid transfer to theatre

    Organ ischaemia and stand down of retrieval

  • Controlled DCD key elements of the pathway

    50% of DCD retrievals in the UK are stood down.

    DCD pathway Key considerations

    Donation considered before death Assessment Family approach

    Requires delay in treatment withdrawal ? Physiological instability

    Altered management of death Location of treatment withdrawal Rapid diagnosis of death Rapid transfer to theatre

    Organ ischaemia and stand down of retrieval

  • Controlled DCD identification of potential donors

    Who can be a DCD donor?

    Organ Donation Taskforce

    In the context of a catastrophic neurological injury, when no further treatment options are available or appropriate and there is no intention to confirm death by neurological criteria, the DTC should be notified when a decision has been made by a consultant to withdraw active treatment and this has been recorded in a dated, timed and signed entry in the case notes. This notification should take place even if the attending clinical staff believe that death cannot be diagnosed by neurological criteria, or that donation after cardiac death might be contra-indicated or inappropriate.

  • Controlled DCD identification of potential donors

    Who can donate?

    10.4

    16.2

    12.4

    25.9

    3.2

    5.6

    26.3

    3.5

    4.2

    6.2

    27.5

    7.8

    8.0

    42.8

    0 5 10 15 20 25 30 35 40 45

    Other Miscellaneous

    Other Medical Disease

    Primary Respiratory Disease

    Hypoxic Brain Injury

    Trauma (including head injury)

    Other CVA (thrombotic or unclassified)

    Intracranial haemorrhage (non traumatic)

    Dia

    gnos

    tic c

    ateg

    orie

    s

    Percentage

    Actual DCDs %

    Potential DCDs %

    UK Potential Donor Audit (October 2009 March 2012) 7504 patients referred as potential DCD donors 877 actual DCD donors

  • Controlled DCD identification of potential donors

    Absolute contra-indications to DCD (all organs)

    Age >85 years Any cancer with evidence of spread outside affected organ (including lymph

    nodes) within 3 years of donation (however, localised prostate, thyroid, in situ cervical cancer and non-melanotic skin cancer are acceptable)

    Melanoma (except completely excised Stage 1 cancers) Choriocarcinoma Active haematological malignancy (myeloma, lymphoma, leukaemia) Definite, probable or possible case of human TSE, including CJD and vCJD,

    individuals whose blood relatives have had familial CJD, other neurodegenerative diseases associated with infectious agents

    TB: active and untreated HIV disease (but not HIV infection)

    http://www.odt.nhs.uk/transplantation/guidance-policies/

  • Controlled DCD identification of potential donors

    Organ-specific contra-indications to DCD Liver Acute hepatitis (Serum AST or

    ALT>1000 IU/L if of liver origin) Cirrhosis Portal vein thrombosis Kidney Chronic kidney disease (CKD stage

    3B and below, eGFR 6 months previously)

    Pancreas Insulin dependent diabetes

    (excluding ICU associated insulin requirement)

    Pancreatic malignancy Lungs donor age >65 years; DBD donor

    age >70 years Intra-thoracic malignancy Significant, chronic destructive or

    suppurative lung disease (those with controlled asthma are suitable donors)

    Chest X-ray evidence of major pulmonary consolidation

    http://www.odt.nhs.uk/transplantation/guidance-policies/

  • Controlled DCD family consent

    What do families need?

    Confidence that treatment withdrawal and donation are independent

    Likelihood that donation will be possible

    Minimal delays in treatment withdrawal

    0

    10

    20

    30

    40

    50

    60

    70

    80

    2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14

    fam

    ily c

    onse

    nt ra

    te (%

    )DBDDCD

  • Controlled DCD family consent

    20

    30

    40

    50

    60

    70

    80

    2005

    /6

    2006

    /7

    2007

    /8

    2008

    /9

    2009

    /10

    2010

    /11

    2011

    /12

    2012

    /13

    2013

    /14

    Fam

    ily c

    onse

    nt ra

    te (%

    )

    Consent rate when coordinator involved

    Consent rate when coordinator not

    involved

    Impact of coordinator on family consent

  • Controlled DCD family consent

    Time intervals for the DCD pathway

    Time interval Median (hours)

    Referral to family consent

    3.5

    Family consent to arrival of retrieval team(s)

    7.7

    Arrival of retrieval teams to treatment withdrawal

    1.0

    Referral to treatment withdrawal

    13.8

    Speeding up the DCD pathway is a key objective for future interventions in the UK

  • Controlled DCD family consent

    Reasons for family refusal

  • Controlled DCD resource implications

    MC III DCD in UK, 2012-13 %

    of p

    oten

    tial D

    CD

    don

    ors

    0 10 20 30 40 50 60 70 80 90

    100

    Potential donors 1

    Neurological death tests performed

    Neurological death

    confirmed Contraindications Family

    approach Consent/

    authorisation Donation

    Potential DCD donor: a patient who had treatment withdrawn and death anticipated within 4 hours Conversion rate 14%

    6517

    3114

    1816

    931 449

  • Controlled DCD resource implications

    Consented donors in UK

    0

    50

    100

    150

    200

    250

    300

    350

    400

    450

    500

    Oct 09 - Mar 10

    Apr 10 - Sep 10

    Oct 10 - Mar 11

    Apr 11 - Sep 11

    Oct 11 - Mar 12

    Apr 12 - Sep 12

    Num

    ber o

    f pot

    entia

    l don

    ors

    whe

    re c

    onse

    nt fo

    r do

    natio

    n ob

    tain

    ed fr

    om fa

    mily

    Quarter

    Consents by quarter

    DBD

    DCD

  • Controlled DCD resource implications

    The burden of DCD on retrieval teams