How to Define Death: Variation in Donation After Circulatory Death Policies

Abstract

Organ transplantation utilizes a shared and scarce resource. In order to best utilize this resource, a network of organ procurement organizations, hospitals and individuals must work together. National societies make recommendations for policies that govern organ transplantation recoveries, however at each tier of the network there is room for variability. Donation after circulatory death (DCD) policies are one example of organ transplantation policies that are not standardized. The American Society of Transplantation Surgeons defines death in DCD recoveries as "irreversible cessation of cardiac and respiratory function." However, many individual hospitals have policies that may differ from this practice of observing pulseless electrical activity (PEA) for the ASTS recommended wait time of 2 minutes. In this study, we examined the DCD protocols of 50 adult hospitals representing a single OPO within Michigan. We hypothesized there would be institutional variance in the definition of death, the provider who can declare death and maximum wait time for the donor to expire after extubation until organ recovery is no longer pursued. We found that there was substantial variation in how each hospital defined death, with the most common definition being asystole. Most hospitals require a physician to declare death in DCD and the minutes to expire range from 60 to 120 minutes. Given that the difference between PEA and asystole may result in time lost and organs to become nonviable, we recommend that standard policies are created and there is increased education to physicians and designees that declare death in DCD recoveries.