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

609 611 624 637 652 705780

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<45) •  Long term dialysis •  Renal malignancy (prior kidney

tumours of low grade and previously excised would not exclude donation)

•  Kidney transplant (> 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

637 652 705 781

74 60 5863

373 436507

539

466 486567

614

0

500

1000

1500

2000

2010/11(34.8%)

2011/12(33.4%)

2012/13(34.0%

2013/14(33.9%)

Non-­‐proceeding  DCD

Actual  DCD

Non-­‐proceeding  DBD

Actual  DBD

34% of all attendances result in no organs being retrieved in 2013/14

Controlled DCD – resource implications

The burden of DCD on retrieval teams

637 652 705 781

74 60 5863

373 436507

539

466 486567

614

0

500

1000

1500

2000

2010/11(34.8%)

2011/12(33.4%)

2012/13(34.0%

2013/14(33.9%)

Non-­‐proceeding  DCD

Actual  DCD

Non-­‐proceeding  DBD

Actual  DBD

34% of all attendances result in no organs being retrieved in 2013/14

For every one potential DBD family we approach we get two organs For every two potential DCD families we approach we get one organ

Controlled DCD – outcomes

Contribution of DCD to organ transplantation in the UK, 2012-13

living DBD DCD % total

Kidney1 1068 1167 749 25

Liver 31 637 136 17

Lung 0 153 34 18

Pancreas

0 33 5 13

Heart - 145 0 0

1Includes kidney and pancreas

Controlled DCD – outcomes

Kidney transplant outcomes for DBD/DCD donors

Graft survival

% g

raft

surv

ival

40

50

60

70

80

90

100

years post-transplant0 1 2 3 4 5

% p

atie

nt s

urvi

val

40

50

60

70

80

90

100

years post-transplant0 1 2 3 4 5

DCD DBD Patient survival

Controlled DCD – outcomes

DBDDCD

3 year patient survival

% p

atie

nt s

urvi

val

50

60

70

80

90

100

Years since transplant0.0 0.5 1.0 1.5 2.0 2.5 3.0

3 year transplant survival

% tr

ansp

lant

sur

viva

l

50

60

70

80

90

100

Years since transplant0.0 0.5 1.0 1.5 2.0 2.5 3.0

Liver transplant outcomes for DBD/DCD donors

Controlled DCD – key elements of the pathway

Summary

•  MC III DCD embedded into UK donation and transplantation

•  Not restricted to patients dying of acute brain injury

•  The needs of the donor families are rather different compared to DBD

•  Very resource intensive