Emerging Ethical Considerations of Donation After Circulatory Death: Getting to the Heart of the Matter.

C ontrolled donation after circulatory death (DCD) poses unique challenges in both logistics and ethics. After withdrawal of supportive treatment, often mechanical ventilation and vasopressors, respiratory distress, and movements consistent with discomfort are commonly observed. A situation arises, which conflicts between facilitating the individual’s autonomous wish to donate their organs, the right for a dignified death, and the responsibility to optimize the quality of the organs donated. Best practice must reflect equally each of these ethical perspectives. Tracking the outcomes of potential DCD donors after withdrawal of support provides a valuable and overarching perspective on the nature of these challenges. We commend the authors in this issue’s feature article for their efforts and insights, as provocative as they may be. As the authors point out, there have been many reports, including their own, attempting to predict whether DCD donors will expire in a timely manner consistent with organ donation. However, it is worth noting that none of these tools have gained universal acceptance. The area under the receiver operating characteristic curve as an estimate of the predictive capacity of these models generally varies from 0.68 to 0.81. Those models with a C-statistic less than 0.7 offer prediction that is only slightly better than chance alone. Moreover, even those with very good predictive capacity (C-statistic>0.8) still can suffer from poor discrimination, particularly in the center of the distribution, which is often where most patients fall. In the setting of DCD donation, where the consequences of an inaccurate prediction is the loss of organs for transplant, the decision is often taken by a Medical Director with substantial experience regarding DCD as opposed to singular application of a decision support tool or unilateral Organ Procurement Organization (OPO) policy. Limited ability to predict the time of death reliably has led to suggestions that the DCD procedure should be used for every potential donor to avoid the loss of transplantable organs. However, this approach is troublesome for grieving families, and resource intensive for hospitals, OPOs, and transplant centers. The present study is valuable but requires further refinement. Unfortunately, the authors did not provide data regarding the prospective or retrospective application of their own University of Wisconsin DCD tool. Further valuable insights into which prospective DCD donors are likely to expire according to a particular timeline for targeted application of their suggested conversion of DCD into living donors might alleviate some concerns regarding implementation of this provocative strategy. The success of DCD depends on appropriate policies for the withdrawal of life-sustaining treatments including the discontinuation of mechanical ventilation and vasopressor agents. In addition, specific protocols for the timing of interventions, such as the use of anticoagulant medications (eg, heparin), the mandatory waiting period, declaration of death, and organ recovery are necessary to reduce variability and improve outcomes. In the US, the Organ Procurement and Transplantation Network and the Joint Commission have required all hospitals to have a DCD policy in place as of January 1, 2007. However, there is still considerable interhospital variation in the policies governing DCD recovery, both in the US and worldwide. This can lead to ethical issues and disagreements even among experienced practitioners. Indeed, if a unified protocol was introduced throughout the US, it is likely that DCD outcomes, including the prediction of organ recovery, would improve significantly. Quite apart from calling for a more streamlined national approach to these policies, the basic principle of better alignment of outcome metrics (patient and graft survival vs organs transplanted per donor) for transplant centers and OPOs is vital to successful expansion of DCD. This is logistically complicated elsewhere but the circumstances of the single center OPO at the University of Wisconsin make this far more likely. Alternatively, we must guard against premature involvement of either the transplant team or OPO personnel during the DCD withdrawal process. Extreme caution must be taken particularly with increasing utilization of OPO-based surgical suites for donor procedures to ensure transparency and preserve the public trust.