Next Speaker:
Alexandra K. Glazier, JD, MPH
DCD Ethics
Sponsored by
DCD Ethics
Alexandra K. Glazier, JD MPH
VP & General Counsel New England Organ Bank
Chair, OPTN/UNOS Ethics
Faculty, Boston University School of Law
US DCD Donors: 2000 - 2012
1200
1105
1055
1000
793
800
645
564
600
391
400
200
0
268
117
168 189
848
920 941
LCNW DCD Donors by Year
45
41
40
36
36
35
30
25
19
20
15
12
10
5
0
2009
2010
2011
2012
2013 Total Projected From 9 Months
2013
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 Principles
Respect for persons
Beneficence
Public 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
Gift
HealthCare
Decision
Withdrawal of Support
Asystole
Death Declared
Donation
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