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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. LCNW DCD Donors by Year. - PowerPoint PPT Presentation
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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
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US DCD Donors: 2000 - 2012
LCNW DCD Donors by Year
2013 Total Projected From 9 Months
2009 2010 2011 2012 20130
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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