Donors After Cardiac Death: Validation of Identification Criteria (DVIC) Study for Predictors of Rapid Death

Abstract

Donation after cardiac death (DCD) is uncommon in part because clinicians cannot prospectively identify patients who are likely to die within 60 min of withdrawal of life-sustaining treatments (LST). UNOS criteria exist but have not been validated. Consecutive patients electively withdrawn from LST at five university-affiliated hospitals were prospectively enrolled. Demographic and treatment characteristics were collected. Chi-square was used to determine risk for death within 60 min and validate the UNOS criteria. A total of 533 patients were enrolled. A total of 28 were excluded from this report due to age <18 years or failure to include time of death. Of 505 (95%) patients, 227 (45%) died within 60 min, 134 (27%) in 1-6 h and 144 (29%) >6 h after withdrawal of LST. A total of 29%, 52%, 65% and 82% of patients with 0,1,2 and 3 UNOS DCD criteria, respectively, died within 60 min of withdrawal of LST. The data validate the UNOS criteria. Patients with no criteria might be excluded from consideration for DCD. Those with more than one criterion are reasonable candidates, while those with a single criterion should be considered if a 50% failure rate for DCD is acceptable.

Time to Death after Terminal Withdrawal of Mechanical Ventilation: Specific Respiratory and Physiologic Parameters May Inform Physician Predictions

“…Comorbidities were based on identification of the condition in the We also noted performance of a spontaneous breathing trial within the 24 hours prior to withdrawal. For neurologic status, we abstracted the lowest Glasgow Coma Scale (GCS) score (range [2][3][4][5][6][7][8][9][10][11][12][13][14][15] 18 within the 24 hours prior to withdrawal. For hemodynamic status, we recorded the two lowest mean arterial pressure (MAP mmHg) values that were documented for >30 minutes during the 24 hours prior to ventilator discontinuation, then averaged those values for a final estimate.…”

“…[1][2][3] Discussions surrounding withdrawal of lifesustaining therapies often include family members of critically ill patients, and experts in end-of-life care recommend that these conversations address essential components of the dying process, including expected time to death. 4,5 Studies evaluating time to death after terminal withdrawal of lifesustaining measures in adults suggest that 45% to 76% of deaths occur within 60 minutes, [6][7][8][9][10][11][12][13] and the majority of patients die within 24 hours.…”

“…The majority of studies evaluating time to death after withdrawal of life-sustaining measures have assessed time to death as a dichotomous outcome (death within 60 minutes versus death occurring after this time). [6][7][8][9][10][11][12]15,16 Utilization of time to death in a continuous fashion may better identify independent predictors of time to death after withdrawal of life-sustaining measures. Improved predictive capability may enhance communication with family members about the dying process and thus improve end-of-life care for patients and their family members.…”

A few realistic questions raised by organ retrieval in the intensive care unit

“…This period may range from a few minutes to many hours or days, depending on the level of life support engaged at the time of the decision for WhWd, and how withdrawal is achieved. Because circulatory arrest must occur after a short period, only the withdrawal of life-sustaining cardiopulmonary support for highly-dependent patients [high inspired oxygen fraction (FiO 2 ), non-triggered modes of ventilation, inotrope/vasoactive drug use] is compatible with post-mortem organ donation (26,(28)(29)(30)(31)(32). Any patient in whom the elective WhWd measure is not withdrawal of life-sustaining treatment should therefore be definitively excluded from any intention to retrieve organs.…”

“…Removal of the endotracheal tube (extubation) is more often associated with progression to organ donation than terminal weaning without extubation (12). Death within one or two hour(s) of withdrawal usually correlates with severe brain injuries (low Glasgow Coma Scale, absence of brainstem reflexes) (30)(31)(32)(35)(36)(37)(38), high dependence on mechanical ventilation (non-triggered mode, high FiO 2 , high positive expiratory pressure) (28-32,36,38,39), use of inotrope drugs (29,30,35,39), young age (28,35,40), underlying diseases (37,39), and physiological anomalies (high severity index scores, low blood pressure, low pH on arterial blood gas analysis) (37,38,40,41). Under Maastricht III conditions, the removal of organs must be scheduled before withholding/ withdrawal implementation and starts as soon as death is certified.…”