6.1 Understanding DCD
Introduction
This section contains general information about DCD in New Zealand. It is included in this document for the benefit of staff in all hospitals. DCD is only undertaken in hospitals that have been credentialed for this process.
What is DCD?
DCD is organ donation occurring after death has been determined by cessation of circulation.
In New Zealand DCD is confined to circumstances where death occurs after intensive therapies have been withdrawn from a patient in ICU.
Who can be a DCD donor?
A patient:
- on ventilatory support in ICU irrespective of diagnosis or age
- from whom intensive therapies will be withdrawn in the near future
- and who is anticipated to die soon after withdrawal of intensive therapies.
Which organs can be donated?
In New Zealand lungs, liver, kidneys and tissues can be donated in a DCD process.
What is the process for DCD?
DCD is considered only after the treating team and the family have agreed that intensive therapies should be withdrawn in the near future. The decision to withdraw intensive therapies must be based on an agreement that continuing them is not in the patient’s best interest.
Potential DCD donors are then referred to the donor coordinator to determine suitability for DCD. The ODNZ medical specialist and the senior ICU doctor (intensivist, ICU fellow or anaesthetist) discuss the clinical details and together determine whether death is likely to occur within the required timeframe for DCD.
After ODNZ has determined that DCD is possible, donation is discussed with the family. The consent of the coroner is obtained when required.
The donor coordinator organises the organ donation, including where withdrawal will take place (most commonly in the ICU, occasionally in an OT or in a room adjacent to OT). The donor coordinator liaises with the OT coordinator and ICU staff to organise a suitable OT time.
The donor surgical team(s) and donor coordinator travel to the hospital. On arrival at the hospital the donor coordinator facilitates a planning meeting with the ICU and OT staff and donor surgical team(s).
At this meeting all details are discussed including location of withdrawal of therapies, whether family members will be present and the roles of those involved. The Authority for Organ and Tissue Removal Form is checked at this meeting. Donor ABO, infectious serology and COVID-19 results are checked also.
Following the planning meeting, the OT is set up including the preparation of slush ice and perfusion fluids. When the OT set-up is complete and the surgeons are gowned and gloved, the donor coordinator notifies the ICU staff that withdrawal of intensive therapies can now take place.
If intensive therapies are withdrawn in the ICU or a room outside the OT, the patient is transferred to the OT within a few minutes of death.
If intensive therapies are to be withdrawn in the OT, the patient (accompanied by the senior ICU doctor and ICU nurse) is transferred to the OT table and prepared and draped. The OT staff leave the OT but remain gowned and gloved. The ICU staff withdraw intensive therapies and continue to care for the patient until death has been determined.
Wherever withdrawal of intensive therapies takes place, death is determined by a senior ICU doctor according to the criteria in the ANZICS Statement.
When the patient dies in OT, the ICU staff leave the OT before the OT staff re-enter and commence the donor surgery.
Organ donation commences as soon as possible after determination of death. It is important to minimise the time interval from death until cold perfusion of the organs to be donated.
If lung donation is planned, the thoracic anaesthetist immediately re-intubates the patient prior to transfer to the OT table, unless the patient is already on the OT table.
If death does not occur within the required timeframe, DCD is abandoned and care of the patient is continued in the ICU. Tissue donation can still be facilitated following death.
6.2 OT procedures for DCD
The donor coordinator will inform the theatre coordinator that the donation will be DCD not DBD.
OT staff
Two circulating nurses are required for DCD.
A local anaesthetic technician is required if lung donation is planned but is not required if only abdominal organ donation is planned.
A local hospital anaesthetist is not required for DCD donor surgery. A cardiothoracic anaesthetist is part of the thoracic donor surgical team if lung donation is planned. A respiratory physician is often also part of the DCD donor surgical team and will perform bronchoscopy on the donor before lung donation.
It is important for the staff who will be involved in the DCD process to be present at the planning meeting to ensure they understand the details of the DCD process and their role. Additional staff are not permitted to observe the donor surgery.
OT set-up
The OT set-up is similar to DBD donor surgery but no diathermy machine is required. The set-up, including preparation of the slush ice and the perfusion fluids, is completed before withdrawal of intensive therapies
6.3 Sequence of events in DCD
A patient on ventilatory support in ICU in whom intensive therapies are likely to be withdrawn.
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Family and treating team agree to the withdrawal of intensive therapies.
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ODNZ is contacted to discuss the potential for DCD.
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Blood is taken for the Donor Blood Pack and the donor coordinator arranges transport.
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The agreement of the coroner is obtained when required.
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Donor information is obtained and required documentation is completed
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Donor coordinator organises the organ donation.
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OT is set up for donor surgery.
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Planning meeting for all staff involved.
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Withdrawal of intensive therapies in ICU, OT or room adjacent to OT.
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Death is determined and documented.
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Donor surgery commences immediately.
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After the surgery is completed, the family may wish to spend time with their relative.