MPH DCD Ethics Next Speaker Sponsored by DCD Ethics Alexandra K Glazier JD MPH VP amp General Counsel New England Organ Bank Chair OPTNUNOS Ethics Faculty Boston University School of Law ID: 295977
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Alexandra K. Glazier, JD, MPHDCD Ethics
Next Speaker:
Sponsored bySlide2
DCD EthicsAlexandra K. Glazier, JD MPHVP & General Counsel New England Organ Bank
Chair, OPTN/UNOS EthicsFaculty, Boston University School of LawSlide3
US DCD Donors: 2000 - 2012Slide4
LCNW DCD Donors by Year2013 Total Projected From 9 MonthsSlide5
The origins of DCDThe first transplantations from deceased donors were DCD
The establishment of brain death criteria in 1968 from Harvard report changed the course of donationHistorical ethical and legal uncertainty of withdrawal of supportSlide6
The origin of DCD controversyWithdrawal of support is a component of DCD
VoluntarinessDeath declaration and recovery of organs occur within very short time frame
Dead donor ruleSlide7
The origin of DCD controversyWithdrawal of support
Constitutional right Ethically supported by autonomy
Based on medical determination of futility Slide8
The origin of DCD controversyDeath declaration and recovery of organs occur within very short time frame
Is the Dead Donor Rule met? Slide9
DEAD DONOR RULEThe recovery of donated organs shall not cause the donor’s deathSlide10
DEAD DONOR RULE Ethical PrinciplesRespect for personsBeneficence
Public trustSlide11
DEAD DONOR RULE Legal basis?
HOMICIDE Slide12
DEAD DONOR RULEThe donor must be declared consistent with medical and legal standards prior to the recovery of vital organsSlide13
Declaring Death in DCDThe Uniform Determination of Death Act (UDDA)
State law UDDA establishes 2 criteria for death declarationIrreversible cessation of circulatory function
or Irreversible cessation of whole brain function Slide14
Declaring Death in DCD“irreversible” is understood as “permanent”
Circulation will not be restoredBrain function will not be restored Slide15
Declaring Death in DCDDonation after Circulatory Death (DCD)
The patient’s circulation has permanently ceasedWill not auto-resuscitateWaiting period after
asystole prior to declarationWill not artificially be resuscitated
Context of planned withdrawalSlide16
Declaring Death in DCDAdheres to the Dead Donor rule
The patient is declared consistent with UDDA prior to the recovery of organsThe UAGA prohibits a member of the transplant team from declaring deathPotential conflict of interest avoidedSlide17
Timing of the Discussion and Authorization for DCDThe
dead donor rule does not preclude discussion of or consent to donation prior to deathSeparating out the withdrawal decision from the donation decision
Respect for personsBeneficenceAvoid undue pressureSlide18
Discussion and Authorizing DCD“Decoupling”
Institute of Medicine (IOM) reportThe decision to withdraw should be made independent of and prior to donation discussion
Ethical firewall
Context of surrogate consent for bothSlide19
First Person Authorization and DCDThe UAGA governs donation after deathRegardless of how death is declared
Donor designation authorizes donation after deathRegardless of how death is declaredSlide20
First Person Authorization and DCDAuthorizing donation does NOT also authorize withdrawal of support
Surrogate consent for withdrawal of requiredWithdrawal must be done in way that allows DCDTimeframe and mannerSlide21
Legal Constructs in DCD
Anatomical
HealthCare
Decision
Gift
Withdrawal of Support
Donation
Death Declared
AsystoleSlide22
CaseA 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. Slide23
Which of the following should happen next:
If the family agrees to donation they should sign the authorization formThe 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