Implementing donation after cardiac death protocols.

As organ transplantation becomes increasingly successful and the demand for organs outnumbers available organs, the transplantation community has revived the transplantation process of donation after cardiac death (DCD). In DCD donation, organ procurement begins once the donor's cardiopulmonary function ceases. This is in contrast to the more common practice of donation after brain death (DBD), where organ procurement begins once the donor is declared brain dead--even while the donor's cardiopulmonary function is artificially supported to perfuse and maintain the donor's organs. In January 2007, the Joint Commission required hospitals, in coordination with their Organ Procurement Organizations (OPO),* either to create donation after cardiac death policies or document efforts to formulate the policies and justifications for opting out. As DCD practice grows, legal and ethical issues surface. This article will discuss these legal and ethical issues, including determining a donor's death based on the irreversible cessation of cardiopulmonary function, procedures conducted on the donor for the benefit of the donee, informed consent and the surrogate decisionmaker, choosing appropriate DCD candidates, and conflicts of interest. This article will summarize general recommendations for donor candidate selection, consent and approval, withdrawal of life-sustaining measures, criteria for determining death, organ recovery, and financial considerations.