Donation after cardiac death: how best to address ethical concerns.

Although the issue is not resolved in certain centers, clear guidelines are available and accepted, enabling Canadian centers to function with reasonable confidence. The Table provides an example of criteria for death after cardiac arrest recommended for DCD. Surveys of seriously ill hospitalized patients demonstrate that important elements in end-of-life (EOL) care are trust and confidence in the treating physician, avoidance of unwanted life support, effective and honest communication. 4 In this article we focus on the controversy that is of most concern to neurologists: the way end of life care decisions may be affected by the availability of DCD. Specifically, how accurate is the prediction of survival, how objective and uniform is the decision to withdraw life-sustaining therapy (WSLT), and how uniform and satisfactory is the withdrawal of support. Prognosis and the decision to withdraw life-sustaining treatments One of the principle obstacles to DCD development has been a concern about real and perceived conflicts of interests between providing care for a dying patient and providing the option of donation before death has been established. 5,6 The fact is that most deaths in neonatal, pediatric and adult Post mortem organ donation falls into two broad categories based on the criteria used for the determination of death. When procurement occurs after death determination using neurologic criteria, it is termed " donation after brain death " (DBD). When procurement follows death determined using absence of respiration, circulation, and responsiveness, it is termed " donation after cardiac (or cardiopulmonary, or cardiocirculatory) death, known as DCD. Donation after brain death is now an accepted form of organ donation, with criteria that have become quite uniform since the landmark Canadian forum on the neurologic determination of death in April 2003. 1 Non beating heart organ donation or DCD has been gaining in acceptance, and is now practiced in several countries and provides the potential for increased kidney, liver and lung transplantation. Prior to brain death criteria, the historical source of transplantable organs in Canada was from donors after cardiac arrest, without much initial success. While tissue donation (eg. heart valves, cornea, bone) has traditionally occurred after cardiac death in Canada, the acceptance of DCD for solid organ donation has been variable given the circumstances and time constraints related to minimizing ischemic organ injury after cardiac arrest. Despite thorough debate in the literature, a Canadian forum on DCD in 2005 and reviews by the Institute of …