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IOM report calls for professional, public education efforts to gain acceptance for uncontrolled DCDD.

There are approximately 22,000 potential uncontrolled donation after circulatory determination of death (DCDD) donors annually in the US and but the practice is still in its infancy and will require demonstration projects and data gathering before transplant programs and the public will embrace the practice, according to a report released in March by the Institute of Medicine (IOM).

The report -- Moving Forward in Increasing Organ Donation: Opportunities and Barriers to Uncontrolled DCDD in Major Metropolitan Cities - was developed by a group of transplant professionals who gathered in Washington, DC last December to address the feasibility of DCDD and whether it is equally feasible to donate organ after neurologic determination of death (DNDD).

The group's finding was a cautious "yes" provided well-planned local pilot projects and data gathering are conducted to get local transplant programs and the general public to "buy-in" to DCDD, which represents the largest number of untapped donors in the US.

"I believe that the IOM report on organ donation last year (Organ Donation: Opportunities for Action published in 2006) combined with a follow-up meeting is enough to provide sanctions for local groups to begin demonstration projects," James DuBois, PhD, DSc, who co-chaired the December meeting, told Transplant News. DuBois is an assistant professor at the St. Louis University Center for Health Care Ethics, in St. Louis, MO.

Donation after circulatory determination of circulatory death is termed "uncontrolled" when death is due to unexpected or sudden circulatory-respiratory arrest.

Controlled DCDD donors currently account for only 5.5% of the deceased donors in the US. Neurological determination of death (DNDD) donors account for approximately 23,000 transplanted organs from just over 7,500 donors and there were approximately 7,000 living donations of single organs in 2006, the report stated.

In the report DuBois said that controlled DCDD raises issues regarding the withdrawal of ventilation, determination of the length of waiting time following circulatory arrest, and the use of heparin. However, he pointed out, these issues are non-existent with uncontrolled DCDD, as the donor is not on a ventilator, and medical professionals don't attempt to resuscitate them.

DuBois also raised the question of making the consent issue moot. He argued that in the absence of statutes explicitly permitting preservation, it could be best to start with individuals who have a signed donor card and/or have joined registries. He also favored changing the system to explicitly let people opt out of donation which would create a situation where only the organs of those opting out would not be preserved.

Here are some of the general findings and questions raised in the report:

*Areas of consideration relevant to uncontrolled DCDD include, what should the professional standards beprofessional considerations.

*What criteria are necessary to respect the dead donor ruleethical considerations.

*What criteria are necessary to preserve the public trust that resuscitation is the first prioritypublic considerations.

*What legal criteria are compatible with organ donationlegal considerations.

*Does "the law" currently impede this ethically permissible activity, either because it clearly requires explicit consent before preservation can be undertaken or because legal uncertainty about the issue deters doctors and hospitals from undertaking preservation in the absence of explicit consent?

*One question that needs to be resolved is whether community education needs to focus on uncontrolled DCDD or whether focus groups and town hall meetings should focus on the trust issues that are connected with organ donation in general.

*It is important to gain buy-in from those entities providing medical care to the community. It will also be important to work with leaders and change agents in the community, such as religious groups and African American women.

*Washington, DC is at a high state of readiness with the resources, desire and experience to conduct uncontrolled DCDD. Use of the regional trauma center infrastructure and routing pre-hospital triage through the trauma centers rather than the emergency departments was discussed.

*The next steps could focus on implementing pilot programs on uncontrolled DCDD in states that have organ donor registries. Success in locating individual hospitals that are enthusiastic about involvement will be a critical element.

The full report is available online at: www.iom.edu/organdonation. Scroll to bottom of the page and click on: December 20, 2006 Meeting Summary-Moving Forward in Increasing Organ Donation: Uncontrolled DCDD.
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Publication:Transplant News
Date:Apr 1, 2007
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