ICU/ED/OR Corner: Two types of organ donation, two different processes

Donation after brain death

Donation after brain death is defined as a deceased donor who has suffered complete and irreversible cessation of the entire brain, including brain stem, is mechanically ventilated and still has a beating heart.

Upon a nurse’s or physician’s assessment, these patients will no longer have any neurological (brain stem) reflexes indicated by:

• Loss of pupils

• Loss of corneal reflex

• Loss of cough upon endotracheal tube suctioning

• Loss of gag upon stimulation

• Loss of pain reflex OR posturing

• Loss of respiratory effort

• Absence of any seizure activity or legitimate electroencephalogram activity

At this time, the attending physician should complete an assessment to confirm the diagnosis of death by neurologic criteria (brain death). This assessment typically includes a clinical exam and an apnea test in accordance with the American Academy of Neurology guidelines and your facility’s policy on brain death. One of the following ancillary tests may also be included:

• EEG

• Cerebral blood flow test or nuclear flow study

• Four-vessel angiography

• Transcranial Doppler

Once brain death is confirmed, this becomes the legal time of death on the death certificate. The patient will remain on artificial/mechanical support if they are an authorized donor. MTN’s clinical team then assumes care of the patient after authorization and through the time of organ procurement. Eligible, stable donors will be transferred to MTN’s Donor Care and Surgical Recovery Unit in the Kansas City metro once all hospital-based procedures have been completed. MTN’s clinical coordinator will continue to respond on-site following authorization to begin the transfer process with the assistance of the bedside nurse.

Donation after circulatory death (DCD)

Donation after circulatory death (DCD) is defined as organ donation in patients who do not meet brain death criteria and are anticipated to reach asystole within 120 minutes of withdrawal of ventilatory support. This timeframe may be extended in specific cases. DCD can only occur after a family has made a firm decision to withdraw mechanical and pharmacological support. These donor heroes will remain at the hospital for organ recovery.

• Prior to shifting to comfort care, the patient must meet certain eligibility criteria upon assessment by MTN.

• Following eligibility determination, MTN will collaborate with hospital physicians and staff members to determine next steps for the organ donation discussion with the patient’s family.

• Following authorization for DCD, the hospital’s attending physician continues direct care for the patient while collaborating with MTN.

• Organ procurement occurs following pronouncement of circulatory standstill after ventilatory support is withdrawn, provided the patient expires within the necessary timeframes.

• DCD is less common than donation after brain death, occurring in about 40% of MTN’s organ case activity.

Please remember to call MTN at 800-366-6791 within one hour or less (per your hospital policy) when your patient meets ANY of the following criteria:

• Mechanically ventilated with a severe brain injury OR a devastating illness

• Glasgow Coma Scale ≤ 5

• Not expected to survive terminal extubation (e.g., pulmonary disease, high cord injury or ALS)

• Family or medical team has initiated discussion of a shift toward comfort care decisions