Donation After Cardiocirculatory Determination of Death Requires “Timely” Rather Than “Early” Referral

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Krmpotic et al (1), in a recent issue of Critical Care Medicine, reviewed deaths following withdrawal of life-sustaining therapies (WLST) in Ontario and asserted that opportunities for donation after cardiocirculatory determination of death (DCD) were commonly lost because of “delayed referral.” The characteristics of these patients were not presented, making it difficult to confidently assess whether they truly could have been donors.
The process of obtaining consent, ruling out transmissible diseases, and allocating organs requires numerous hours, such that referral shortly before WLST makes DCD impossible. Strong collaborations between critical care and donation professionals are required to ensure that referrals occur within a manageable time frame. However, there are scenarios where DCD is clearly not possible, in which it may be entirely reasonable for critical care teams to exercise their professional judgment without missing true donation opportunities.
Since starting a regional DCD program, we have prospectively recorded reasons for nonreferral. Common examples include the following:
Although it is crucial to provide donation agencies with sufficient time to facilitate donation processes prior to WLST, there is also potential for referral to be “too early.” Many critical care professionals would contend that in-depth would contend that in-depth consideration of DCD by the healthcare team, without the family’s knowledge and prior to a definitive decision to proceed with WLST, is inappropriate. National guidelines in Canada recommend that consideration of DCD take place only “after a consensual decision to withdraw life-sustaining therapy” (6). Other international organizations have consistently made similar recommendations.
DCD requires “timely” referral, but caution is necessary in relation to “early” referral to avoid biasing subsequent discussions with families regarding possible WLST (7).
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