Alexandra K. Glazier, JD, MPHDCD Ethics

Next Speaker:

Sponsored by

DCD Ethics

Alexandra K. Glazier, JD MPHVP & General Counsel New England Organ Bank

Chair, OPTN/UNOS EthicsFaculty, Boston University School of Law

0

200

400

600

800

1000

1200

117168 189

268

391

564645

793848

920 9411055

1105

US DCD Donors: 2000 - 2012

LCNW DCD Donors by Year

2013 Total Projected From 9 Months

2009 2010 2011 2012 20130

5

10

15

20

25

30

35

40

45

12

19

36

41

36

The origins of DCD The first transplantations from deceased donors

were DCD

The establishment of brain death criteria in 1968 from Harvard report changed the course of donation

Historical ethical and legal uncertainty of withdrawal of support

The origin of DCD controversy

Withdrawal of support is a component of DCD

○Voluntariness

Death declaration and recovery of organs occur within very short time frame

○Dead donor rule

The origin of DCD controversy

Withdrawal of support

Constitutional right

Ethically supported by autonomy

Based on medical determination of futility

The origin of DCD controversy

Death declaration and recovery of organs occur within very short time frame

Is the Dead Donor Rule met?

DEAD DONOR RULE

The recovery of donated organs shall not cause the donor’s death

DEAD DONOR RULE

Ethical PrinciplesRespect for personsBeneficencePublic trust

DEAD DONOR RULE

Legal basis?

HOMICIDE

DEAD DONOR RULE

The donor must be declared consistent with medical and legal standards prior to the

recovery of vital organs

Declaring Death in DCD The Uniform Determination of Death Act (UDDA)

State law

UDDA establishes 2 criteria for death declaration

Irreversible cessation of circulatory function or

Irreversible cessation of whole brain function

Declaring Death in DCD

“irreversible” is understood as “permanent”

Circulation will not be restored

Brain function will not be restored

Declaring Death in DCD Donation after Circulatory Death (DCD)

The patient’s circulation has permanently ceased

Will not auto-resuscitate○ Waiting period after asystole prior to declaration

Will not artificially be resuscitated○ Context of planned withdrawal

Declaring Death in DCD

Adheres to the Dead Donor rule

The patient is declared consistent with UDDA prior to the recovery of organs

The UAGA prohibits a member of the transplant team from declaring death○ Potential conflict of interest avoided

Timing of the Discussion and Authorization for DCD

The dead donor rule does not preclude discussion of or consent to donation prior to death

Separating out the withdrawal decision from the donation decision Respect for persons Beneficence Avoid undue pressure

Discussion and Authorizing DCD

“Decoupling” Institute of Medicine (IOM) report The decision to withdraw should be made independent of and prior to

donation discussion

Ethical firewall

Context of surrogate consent for both

First Person Authorization and DCD

The UAGA governs donation after death

Regardless of how death is declared

Donor designation authorizes donation after death

Regardless of how death is declared

First Person Authorization and DCD

Authorizing donation does NOT also authorize withdrawal of support

Surrogate consent for withdrawal of required

Withdrawal must be done in way that allows DCD

Timeframe and manner

Legal Constructs in DCD

Anatomical

HealthCareDecision

Gift

Withdrawal of Support DonationDeath DeclaredAsystole

Case

A patient is referred to the OPO for potential DCD. The OPO confirms that the patient is a registered donor. After the decision to withdraw is made the family is approached about donation.

Which of the following should happen next:

If the family agrees to donation they should sign the authorization form

The family should be informed that the donor has given legal permission for donation and be provided info about the DCD process

If the family agrees to donation then they should be informed that the donor gave permission for donation but since the patient has not yet died they need to sign the authorization form