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Organ transplantation is established therapy for many patients with a variety of end-stage diseases. The survival benefits are remarkable, as are the improvements in quality of life. Unfortunately, the supply of donor organs remains insufficient to meet the need.Recently, through participation in the breakthrough collaboratives of the Health and Human Resources Administration, organ procurement organizations (OPOs) have become engaged in systems change through application of the principles of continuous improvement. So-called best practices are being shared by OPOs. This sharing, in turn, has created a level of synergy among OPO professionals and hospitals alike that is having a positive impact on the donor supply (Table 1).Clearly, reasons for optimism exist, but a stark reality must be confronted: there will never be a single solution to the donor dilemma. Organ donation is multifactorial, a fact that often eludes people who are consumed by the search for a “magic bullet.” Predictably, frustration eventually gives way to disillusionment. Thus, it should come as no surprise that aggressive efforts are being made to better use existing donors by expanding the traditional criteria for organ donation. In addition, concerted attempts are being made to redefine what constitutes a potential donor.In this article, we provide a general introduction to donation after cardiac death (DCD) relative to end-of-life care, distinguish among various concepts critical to understanding DCD, discuss a widely accepted critical pathway for managing donors after cardiac death, and quantify the outcomes of patients who have received organs from donors after cardiac death. Most important, our premise is that organ donation should be considered what it actually is: a pressing national public health crisis and an often-neglected aspect of end-of-life care.Since its inception, transplantation has raised many highly controversial public policy issues. Strangely, yet tragically, it takes a death to save a life. While one family grieves, another family rejoices. By its nature, organ donation is a complex socio-cultural phenomenon that is largely shaped by clinical considerations, many of which laypersons do not understand. In this regard, approach-avoidance behavior is the rule, not the exception. For most people, life is to be embraced, and death is to be avoided.Organ donation typically and unfortunately follows a tragic event for which families are unprepared. The circumstances surrounding conventional organ donation can be daunting for members of the care-giving team but are even more disconcerting if DCD is introduced without previous education or experience. Regardless, the introduction of organ donation to the grieving family of a patient translates into the need for additional resources for the caregiving team, resources that are both emotional and clinical.Fortunately, critical care medicine has evolved to a point where practitioners increasingly recognize their changing obligations to patients in life, dying, and death. From this perspective, the practitioners not only are responsible for treating disease and trauma but also are committed to managing a dying process that results in a dignified death.Currently, approximately 90% of patients who die in intensive care units (ICUs) do so after a decision to limit therapy.1 As a result, the treatment objective shifts from a curative to a palliative model of care, a shift that is directly relevant to DCD.DCD creates unfamiliar challenges for many critical care nurses. In DCD, organ donation is considered before an unequivocal pronouncement of death. Thus, when DCD is an option, critical care staff must have an in-depth knowledge of end-of-life decision making and must be committed to the goal of providing compassionate care.Communications between care-givers and patients’ families are already complex without introducing the possibility of DCD. Fortunately, the focus of a growing body of work is the provision of high-quality, compassionate, interdisciplinary care in these circumstances.Under the conditions described here, organ procurement professionals are most effective when they are “partnered in” as integral members of the end-of-life care team and are highly skilled in counseling patients’ families about opportunities for organ donation. In this role, organ procurement professionals serve as “dual advocates,” striking a delicate balance between their commitment to patients awaiting transplantation and their concern and care for patients’ families who are faced with the important end-of-life decision about organ donation. This dual advocacy is possible only if the procurement professional is sensitive to the needs of each donor patient, the donor patient’s family, and prospective transplant recipients.As a dual advocate, an organ procurement professional should make certain that grieving families are given the empowering opportunity of sparing other families from a similar grief. Through their gift of life, a patient’s family members can make the tragic death of their loved one meaningful and allow their loved one to leave behind a life-long legacy.DCD, also known as non–heartbeating organ donation, is not a novel concept; it is the very foundation of modern transplantation. Before the Harvard Committee report in 1968, which established acceptable criteria for the determination of death based on neurological findings, all deceased or cadaveric donors were pronounced dead on the basis of cessation of cardiopulmonary function.2Criteria for brain death gained acceptance in the 1970s. By the 1980s, every state had passed legislation enabling the recovery of organs from “brain-dead” patients maintained by using mechanical ventilation.Because of concerns about the quality of organs obtained after cardiac death and about the outcome of transplantation of these organs, interest in DCD diminished in the United States and elsewhere. However, in some countries, including Japan, which has continued to struggle with the concept of brain death, and some European countries, interest in the use of DCD has been sustained.The early 1990s saw a renewed interest among OPOs in pursuing DCD more routinely. This interest was the result of both dramatic increases in the number of patients on the transplant waiting list and recurring requests from patients’ family members who had made the decision to withdraw life support from their loved ones. Recognizing that withdrawal of life support meant imminent death, family members were requesting the opportunity to donate their loved ones’ organs as a way to bring meaning to the families’ losses and to help others.During the resurgence of DCD, a number of misinformed media reports created fear and trepidation in the donation and transplant community as well as in the general public. These reports led many healthcare professionals to question the practice of recovering organs after cardiac death. As a result of these concerns, the US Department of Health and Human Services asked the Institute of Medicine to review DCD procedures to ensure that interventions taken were in the best interest of the donor patient. The Institute of Medicine concluded that DCD is an ethically proper approach for recovering organs from a deceased patient for the purposes of transplantation.3,4 In addition, the ethics committee of the American College of Critical Care Medicine, Society of Critical Care Medicine published a position paper that not only indicated the ethical soundness of DCD but also offered a series of recommendations, including that donation of organs from infants and children after cardiac death should be offered routinely to patients’ families.5Approximately 95% of organ donations occur after the determination of brain death, which is defined as complete and irreversible loss of all brain and brain stem function. Upon determination of brain death, a patient is pronounced dead, and the time of death is established and recorded in the medical record. If the patient appears to be medically suitable for organ donation, and support is continued the patient’s family can be about potential opportunities for organ donation. If the patient’s to organ donation, these support systems in organ and and the recovery of organs in the to organ donation after brain death, DCD is defined as the recovery of organs after the pronouncement of death based on cessation of cardiopulmonary function. considered for DCD most often have a and neurological that not in brain death, and the patients’ family members have to withdraw patient who has a and for life support is being can be considered for most often only patients who have a neurological are the decision to withdraw life support has been the patient is to death most will occur a after withdrawal of life this is considered the acceptable between withdrawal of support and recovery of organs for organ If cessation of most will occur this and the patient to be medically suitable as an organ the patient’s family is about the possibility of organ donation. In to of the decision to withdraw life support must not be with the of opportunities for organ the patient’s to donation, support is continued through the similar to the in organ donation after brain death. the transplant the the patient is to the or a to the for the withdrawal of life support is in the of the caregiving team in the as it be in the critical care has the patient is pronounced dead on the basis of cardiopulmonary criteria by the or the death is the time of death is recorded in the medical record. The transplant team for a time to Institute of Medicine or to to and the recovery of the organ or organs to be the United organ donations after cardiac death can be into on the basis of the process and of the organ and donation most the conditions for organ recovery and is the of most both and are ethically in this article, we focus on DCD, which is the in the critical pathway for DCD of the Organ and for Organ and of both and the critical care of the Organ and for Organ a critical pathway for DCD. The of not only from OPOs but also from the American of American of Society of Critical Care Medicine, American Society of American and the of Organ The pathway and of to be taken in a also between the caregiving team and the OPO organ donors after cardiac death, potential donors after brain death, should be to an OPO when established clinical criteria or are as in donation after brain death, to an OPO is not with the for it is an opportunity to into with the and medical staff about the clinical of the potential The established clinical for to an OPO in patients is a of or on the DCD is possible for patients with all patients should be to an OPO when the patients’ families and have that will be of potential DCD donors are patients with as and patients who have through and are potential DCD donors are patients with cardiopulmonary as patients who have or who use for the decision to withdraw has been of these potential donors the in with the team, to medical and better for the potential family members when the decision is made to discuss organ donation. of potential donors after cardiac death is by the OPO in the as for potential donors after brain of organ donation not occur a patient’s and family have made a determination to As with organ donation after brain death, organ donation in the DCD should be offered only after the patient’s family has the of the clinical their family The about organ donation should not be by the it in all be by a However, the family members of a patient about organ donation before the of is and the for the patient to the of organ donation or the OPO to provide additional to the when a is made in the DCD a of the of the patient’s is potential donors after cardiac death, in to potential donors after brain death, a has often been before has about withdrawal of life support or organ donation. In these support must be maintained for organ in the event that organ donation is the of the patient or the patient’s the decision has been made to withdraw therapy and the OPO has the medical of a patient for organ donation, a determination must be made about the patient will die a time with donation. and after a patient is and all other use of are a that results in some to of from and withdrawal of support to pronouncement of death is considered with organ this time also be on the of the patient’s after withdrawal of life If the patient not the organ recovery not of the that the organs will not after the of DCD is with a patient’s family, the for donation must that additional time will be to a team on the for organ donation, and organs to many patients as potential DCD donors are not suitable the question of is is of about the clinical of a patient be but is often not In an to objective criteria for a patient is a suitable for DCD, a was by the of This is an of that is to the of continued and after and the and the to make the this that mechanical be for a the should be to the patient’s family, and should be and the of OPO had for DCD in which the was the basis of the with the patients were not considered potential for DCD. For the the an that die to the of DCD is with patients’ as well as with medical and it is important to that to of patients will not have in a time with organ donation, and in the team responsible for the patient will end-of-life on the were also but a of patients who have after The were in of potential donations were The policy of the of OPO is to a team for patients with on the of or are the of the patients’ the OPO recovery in in which the was or and organs were not each family was of the efforts and and each was an opportunity for the and medical staff of the of potential donors after cardiac death is similar to that for potential donors after brain death. However, patients suitable for DCD have not to brain death and have not the by brain death, their to be more In one of patients who organs after brain death only of who after cardiac death As even if a is in support of the organ systems should be maintained in potential donors after cardiac death to the for donation. a patient has been to be a suitable for DCD and the patient’s family has to donation, the should be The family should be that support must the team for the withdrawal of support and recovery of should be given to the this potential for DCD be brain dead, the treating team, not the is responsible for medical of these of a a and and of organ for and donation is similar to that for patients who donate organs after brain a patient is to be a suitable for DCD, a number of must be donation after brain death, in which death is on the basis of neurological criteria and all donors are to the withdrawal of support and of death in DCD occur in a number of before the donor is to the for organ The decision about where support will be should be based on the needs of the patient’s be in the with or without the family in in the or in a or to the should be with the family, including which organs or not be support is in the and additional to the after the patient organ be can be in all but use of organs from DCD donors is most organs are from patients who have had support in the medical and in the not be with the potential organ donor and not are being it is important for the OPO staff to discuss this in to the of withdrawal of life support and with withdrawal of support in the with the patient’s family in additional must be In this the and organ recovery should not be in the and only a number of people should be the responsible for life the patient’s family, an OPO staff and the who was for the patient. The patient or not be on the the family members should with and withdrawal of a should be to who will withdraw support and death. The who support should be in end-of-life care and be a of the OPO team or the transplant This be the patient’s or an an or an with end-of-life in end-of-life care, as well as and should not be on in addition, before withdrawal of life support and the with a patient’s family about the process of DCD, should be obtained for or procedures that are before The of that are not given in the care of a dying patient but the of a transplant should be with the patient’s This should a of potential to the The most before withdrawal of support are an and an of and of the solution to The patient’s family as well as medical and staff must that the of the of these and procedures is to organ after recovery and not to the death of the potential the of patients who donate organs after cardiac death are both the of and the of have DCD in infants and children have for approximately of all donations after cardiac death in the of the The in children in DCD are similar to in most and family members to be with their when life support is and some to be with the after organ the DCD is not to children and infants as a result, is being for use in The potential for DCD in children is In an of in a and that use of DCD had the potential to organ donation by in a single is obtained and are life support is by and the patient. the withdrawal of the the patient’s and are These will help the of to the is in the determination of death, an and are to the time of If use of an is not cardiac be and a of is before organ recovery can For most this is as by the Institute of and is to the patient for However, no recorded of have after a OPOs use as the to the of cardiac mechanical if this event the is to and after loss of the with of and not with the and of death by the who is life the recovery team can and the if withdrawal in the If withdrawal of support in the or in a the to the or after the in with the with organ recovery after the of the and the of of the organs with is The time from to the of of the organs with solution is also recorded as the time and is to help the determination as to which organs are suitable for organs after cardiac death be only or and organs as the and and are considered for donation patients are considered for both and donation. However, no and organs from patients more have been The recovery of organs also on the time from withdrawal of support to the of with If that time the not be and if it the not be In the of this time not However, a number of donors have a of relative after withdrawal of life and in this time be without additional to the are the only organs being the is similar to recovery in donation after brain death and after the are with solution the conventional solution by the of as in a of appears to the of in organs are being in to the the from that in donation after brain death. organs obtained after cardiac death, the organs must be and by using of This from procedures in donation after brain death, in which organs are in In DCD, the organs are after they are of has the in after the and are the is and all organs are the The and are and the and solution is into the and and into the If are being after the has the the to and the before the so that the can be and they are results of transplantation of from DCD donors have been similar to results with obtained after brain death. In an in of from the of of from deceased donors with of from non–heartbeating donors DCD The results no between the in survival of in which the with were not as and However, of from DCD donors had of and of from donors had of and loss from of obtained after cardiac death with of obtained after brain death. of from DCD donors had a of and a level the of not in of or and survival and and for obtained after brain no in and survival but a of and in of from In a more the of no in the relative of when from donors were with from DCD donors survival also not between the on the basis of these as well as all OPOs and donor hospitals should be the of DCD to patients’ families and all transplant should be using organs obtained after cardiac death for transplantation. the number of patients on national waiting are potential DCD donation have a impact on the number of patients in need of a series of from DCD donors was by in This series was by a of who received obtained after cardiac death with who received obtained after brain The of has an additional for a of of these organs from DCD As in the of was for from DCD donors no were in as by of and for a of in of organs from DCD the of had no in of and after transplantation also not between the In addition, survival not and survival were and for organs obtained after cardiac death and and for organs obtained after brain this the time time from the of with for organs from DCD donors was the time time from the of the to was similar for both for the and for the results that transplantation of from DCD donors results that are no from for from donors with brain death. from donors with brain death be in the United from DCD donors have the potential to the of the waiting list for if DCD donors are also considered as a for of from DCD donors is more complex of the of the and to and the of in patients in need of a In an early from the of on from no was in and survival or of between of from non–heartbeating donors and of from early reports were an of in of from from DCD donors with from donors with brain death and that as the number of from DCD donors certain to the after as well as the of of and and were in of from DCD as was use of in the In this the of was in from DCD donors and in of patients with the of was in of from DCD donors and the was However, the of not between the of and survival were in of from DCD donors and but when results from of from DCD donors were with in of from DCD donors more the of and survival were and the of had similar results in a in which they obtained after cardiac death with obtained after brain death. of and were and survival was in of from DCD but survival not between the a more by the of in which from DCD donors were with from donors for from through the were for survival and for survival for of from DCD DCD donor of or more was with a for loss was donor for the results of transplantation for from DCD donors using from donors time to or and time to and use of from DCD donors in as who have had previous procedures or addition, when from DCD donors are should be given to the a will from the transplant with the of dying on the waiting The to patients who are waiting for transplantation is based on to death in patients with In this the model for end-stage from to with be more for transplantation of from DCD patients with can and have of on the waiting from donors were by and has been published these but the of have of from DCD single and in were in the was the time of transplantation. The patient survival is patient was after transplantation of from a DCD transplantation of a obtained after cardiac death has been in a the of and the patient is after about this are results of transplantation of from DCD donors an of but a survival similar to that in of from donors with brain death. This in also appears to be for but the number of is for transplantation. The results of transplantation of from DCD donors are of transplantation of from donors with brain death, but with in donor and both and and improvements in the of donors and these results should improvements in and in to result in the outcomes of transplantation in a patients have been and be to is for many patients with a variety of end-stage diseases. Unfortunately, the supply of donor organs remains insufficient to meet have been taken to this more work remains to be is an that can help the between need and The concept is not it has as the clinical basis for modern transplantation. Unfortunately, recovering organs from DCD donors is and ethically DCD is considered ethically but if this approach to organ donation is to be on a it must be into the for end-of-life the we have can be all OPOs and donor hospitals should be the of DCD to patients’ and all transplant should be using organs obtained after cardiac death for transplantation. clinical practices and public will on the basis of with DCD.