Cadaveric donor organ transplantation is one of the greatest feats of modern medicine. Transplant recipients enjoy significant improvements in their quality of life and life expectancy. However, the demand for donor organs far out stripe their availability resulting in prolonged waiting times for transplants.
The number of donation after brain death (DBD) donors has always been very limited. In order to increase the donor pool, multiple strategies have been deployed over the decades. The use of organs from donation after circulatory death (DCD) has proven to be an important strategy in many countries, significantly increasing the number of cadaveric donor organs available for transplantation. In general, the outcomes of DCD transplants are comparable to DBD transplants for most organs.
Most of the advances have been in the area of "controlled" DCD donors. These are patients on life support with very severe neurological injuries or disorders in whom treatment is deemed futile and it would be in the patient's best interest to discontinue life support. The patient or their surrogate had expressed a wish to donate organs after death and consent signed. Life supporting treatment is then withdrawn when eventual circulatory arrest can be anticipated. After mechanical asystole and a mandatory period of observation to confirm no spontaneous return of the circulatory or respiration, death is certified and the donor organs can be retrieved for transplantation.
Public support for DCD organ donation is remarkably high in many Western countries. However, there is no universal agreement in many aspects of the DCD process. Should interventions that do not directly benefit the patient be permissible before confirmation of death? This can range from non-invasive investigations such as a transthoracic echocardiogram to giving the patient full-dose systemic anticoagulation and the insertion of perfusion cannulae. Where should withdrawal of life supporting treatment (WLST) take place? This could range from the Intensive Care Unit bed space to the operating room. When would the potential donor organs start to become ischaemic? What, if any, "comfort therapy" is appropriate? How long should the mandatory observation period be after circulatory arrest? How long should the retrieval teams wait for circulatory arrest before standing down? Once death has been certified, which retrieval technique is acceptable? These and other controversies remain and will be discussed.
