1. Alexandra K. Glazier, JD, MPH DCD Ethics Next Speaker: Sponsored by

2. DCD Ethics Alexandra K. Glazier, JD MPH VP & General Counsel New England Organ Bank Chair, OPTN/UNOS Ethics Faculty, Boston University School of Law

3. US DCD Donors: 2000 - 2012

4. LCNW DCD Donors by Year 2013 Total Projected From 9 Months

5. The origins of DCD  The first transplantations from deceased donors were DCD  The establishment of brain death criteria in 1968 from Harvard report changed the course of donation  Historical ethical and legal uncertainty of withdrawal of support

6. The origin of DCD controversy  Withdrawal of support is a component of DCD ○ Voluntariness  Death declaration and recovery of organs occur within very short time frame ○ Dead donor rule

7. The origin of DCD controversy  Withdrawal of support Constitutional right Ethically supported by autonomy Based on medical determination of futility

8. The origin of DCD controversy  Death declaration and recovery of organs occur within very short time frame Is the Dead Donor Rule met?

9. DEAD DONOR RULE The recovery of donated organs shall not cause the donor’s death

10. DEAD DONOR RULE  Ethical Principles Respect for persons Beneficence Public trust

11. DEAD DONOR RULE  Legal basis? HOMICIDE

12. DEAD DONOR RULE The donor must be declared consistent with medical and legal standards prior to the recovery of vital organs

13. Declaring Death in DCD  The Uniform Determination of Death Act (UDDA)  State law  UDDA establishes 2 criteria for death declaration Irreversible cessation of circulatory function or Irreversible cessation of whole brain function

14. Declaring Death in DCD  “irreversible” is understood as “permanent” Circulation will not be restored Brain function will not be restored

15. Declaring Death in DCD  Donation after Circulatory Death (DCD)  The patient’s circulation has permanently ceased Will not auto-resuscitate ○ Waiting period after asystole prior to declaration Will not artificially be resuscitated ○ Context of planned withdrawal

16. Declaring Death in DCD Adheres to the Dead Donor rule The patient is declared consistent with UDDA prior to the recovery of organs The UAGA prohibits a member of the transplant team from declaring death ○ Potential conflict of interest avoided

17. Timing of the Discussion and Authorization for DCD  The dead donor rule does not preclude discussion of or consent to donation prior to death  Separating out the withdrawal decision from the donation decision  Respect for persons  Beneficence  Avoid undue pressure

18. Discussion and Authorizing DCD  “Decoupling”  Institute of Medicine (IOM) report  The decision to withdraw should be made independent of and prior to donation discussion  Ethical firewall  Context of surrogate consent for both

19. First Person Authorization and DCD  The UAGA governs donation after death Regardless of how death is declared  Donor designation authorizes donation after death Regardless of how death is declared

20. First Person Authorization and DCD  Authorizing donation does NOT also authorize withdrawal of support  Surrogate consent for withdrawal of required  Withdrawal must be done in way that allows DCD Timeframe and manner

21. Legal Constructs in DCD Anatomical HealthCare Decision Gift Withdrawal of Support Donation Death Declared Asystole

22. Case A 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.

23. Which of the following should happen next: If the family agrees to donation they should sign the authorization form The 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