Donation After Cardiac Death (DCD)

by Reginald Burton, M.D.

The first time I heard about DCD, Donation after Cardiac Death, I was somewhat surprised. The idea of taking a non-brain dead patient to the OR, removing life support and then recovering organs seemed strange and maybe worse. The discussion at the donation committee left me quite unsure of how this would ever work. As the trauma director and active trauma surgeon at BryanLGH Medical Center , I was well aware of the importance of organ donation, and the lives saved by this last selfless act of a patient or family. Our trauma center has been verified for over 20 years, and our physicians and staff have excellent outcomes in treating major head injuries. If the injuries do progress to brain death, our staff does a great job in describing brain death to families so that they can understand that there are two types of death, cardiac death, and brain death. This process works seamlessly, and it is uncommon for families not to donate organs. I listened to the facts that were presented at the committee:

86,000 people on lists waiting for life-saving organs, one person dying every two hours while on the waiting list. There just aren’t enough organs to help these people. I was reminded that DCD was not new in that it was how organ donation started before brain death laws were in place. I was surprised to learn that most states already had DCD programs and that it was possible for families to request this in all states surrounding Nebraska . I also heard of the hope that DCD could provide by increasing available organs by 10%. I still remained skeptical as to whether this would ever work in Lincoln , Neb. BryanLGH Medical Center was chosen to collaborate with the Nebraska Organ Recovery System and participate in the National Organ Donation Collaborative. This collaborative was sponsored by HRSA and brought top organ donation hospitals from around the nation together to work on ways to increase organ donation. At these meetings I started to understand what DCD was all about. DCD donors are ventilated patients with do-not-resuscitate orders, where the family has decided to withdraw life support. The organ donation does not occur until after cardiac arrest. This is why it used to be called non-heart-beating donation.

Susan McVay-Dillon, a mother who had lost her son to a devastating head injury, presented her story at the collaborative. She told about how she came to realize that there was no possibility of his survival, and wanted to stop the agony and withdraw life support. She wept as she told of the agony she went through that long weekend, and how she kept thinking that if all her son needed to leave the hospital was a kidney, she would expect one to be available. She asked myriads of questions, and started to understand that if she expected an organ to be available when she needed one, she should also donate organs if she was able. Donation after cardiac death gave her the ability to donate her sonís organs. She was saddened at the collaborative to hear that this option was not available to all families, and challenged us not to rest until it was. I was convinced of the need for DCD.

The organ donation team at BryanLGH studied DCD protocols from around the nation and developed one for our hospital. The process took some time to ensure multidisciplinary involvement and conformity with other policies. During this time I met the Altepeters. Barry Altepeter was discharged from the army after completing his tour of duty in Iraq. Cindy and Adam, his mother and 13 year-old brother, decided to drive from Minnesota to Texas to pick him up and bring him home. Adam wanted to get back to Minnesota so he wouldnít miss Ox Cart Days, so they decided to drive all night to get back home. Unfortunately Barry fell asleep and rolled the car just outside Lincoln, Neb. Everyone in the car received major injuries, but Adam sustained a massive head injury that was not survivable. As the family gathered from Minnesota, Adamís condition worsened and brain death seemed imminent. Bruce Altepeter, Adamís father, realized the severity of the injury. ďI knew that he would never be able to be Adam Altepeter again.Ē He wanted to discuss organ donation. Adamís brainstem, however, did not completely die. No cranial nerve function was detectable, but Adam never completely lost his respiratory drive. The family watched helplessly as Adamís organ functions slowly began to deteriorate. Adamís father came to me and asked about DCD. He wanted to stop the agony, withdraw life support, and proceed with organ donation before Adamís organs failed. The hospital, however, did not yet have the policy in place to be able to allow DCD. Bruce continued to press. He again pled with me to do something so that they would be able to donate organs even though he was not completely brain dead. It finally dawned on meÖ.This was not about me or the staff and whether we were comfortable with DCD. It was about the intense need of a family to stop the suffering while allowing them to do the one good thing that could result from this horrible situation Ė organ donation. Bruce requested he be allowed to advocate for DCD so we arranged for him to record a plea to the hospital, and all hospitals that donít have policies for DCD. The next morning, Adam did proceed to brain death, and the family was able to donate his organs. The fatherís pleas continued to echo in our ears, and did not go unheeded. The team worked feverishly to finish the DCD protocol and pass it through the required hospital committees. The hospital board passed the protocol within one month of Adamís death.

As you can tell, education about Donation after Cardiac Death is essential so that all health care providers can come to understand the hope it can provide dying patients awaiting life saving organs, but more importantly, the humanity and comfort it can provide families in their grieving process.