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Organ Donation and Transplantation 757

are bagged with sterile ice and perfusion fluid and trans- time, whether or not the potential donor proceeds to
ported by the retrieval teams to the transplanting hospi- donation. 1
tals. The donor’s surgical wound, from the sternal notch
to the pubis, is closed by the surgeons in a routine manner DONATION AFTER CARDIAC DEATH
and dressed with a surgical dressing. If the donor is not
a coroner’s case, the remaining lines, catheter and drains Donation after cardiac death (DCD) (also known as non-
are removed according to local policy, the patient is heart-beating donor [NHBD]) provides a solid organ
washed, and arrangements are made to transfer the donation option for a patient who has not progressed
patient to a location for family viewing or to the mor- and is not likely to progress to brain death. Prior to brain
tuary. Musculoskeletal tissue and retinal retrieval can death legislation, donation after cardiac death was the
occur after the solid organ retrieval in theatre or later in source of cadaveric kidneys for transplant. 69,70 Four cate-
the mortuary. 66,67 gories of potential DCD donors have been identified
(known as the Holland–Maastricht categories): 71,72
DONOR FAMILY CARE 1. dead on arrival (uncontrolled)
Supportive care of a donor family begins from the time 2. failed resuscitation (uncontrolled)
their family member is admitted to hospital and contin- 3. withdrawal of support (controlled)
ues beyond organ retrieval. In addition to personal factors 4. arrest following brain death (uncontrolled).
such as cultural background, family dynamics, coping DCD programs around the world are being re-established,
skills and prior experiences with loss that may influence with successful retrieval and transplant of kidneys, livers
the grieving process, the family of an organ and tissue and lungs. The Australian Organ and Tissue Authority
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donor will be dealing with a number of unique factors. has developed a national DCD protocol that outlines an
Death of their family member was possibly sudden and ethical process that respects the rights of the patient and
unexpected; brain death can be difficult to understand ensures clinical consistency, effectiveness and safety for
when people look as if they are asleep rather than dead; both donors and recipients. Since 2005 there has been a
1
having the option of organ donation may mean making steady increase in DCD donors each year, particularly in
a decision on behalf of the person if his/her wishes were New South Wales, Victoria, Queensland and South Aus-
not known; and the process of organ donation means tralia. Since 1989 there have been 131 donors in Australia
they will not be with the person when their heart stops. 68 17
and six donors in New Zealand. The first multiorgan
DCD was performed in South Australia in 2006.

IDENTIFICATION OF A POTENTIAL
Practice tip DCD DONOR
An opportunity for staff debriefing or operational reviews of Using lessons learnt from multiorgan donor programs,
the donation and retrieval process is important, particularly in the aims of a successful DCD program are to maintain
regional or rural settings where cases may be infrequent and dignity for the donor at all times, provide the donor
the community is smaller. family with support and information, and limit warm
ischaemia time (time from withdrawal of ventilation
and treatment to confirmation of death to commence-
ment of infusion of cold perfusion fluid and/or organ
Donor families benefit from emotional and physical retrieval). Longer warm ischaemia time potentiates the
support throughout and after the organ donation process. risk of irreparable hypoxic damage to the organ. As
73
In critical care units, this support can include open visit- noted above, Maastricht category 3 is the only option that
ing times, privacy for meetings, clear and precise infor- can be controlled and possibly regulate warm ischaemia
mation and regular contact with the attending clinical time. A potential category 3 DCD donor is a person ven-
team and the Donatelife donor coordinator. After organ tilated and monitored in critical care about whom a deci-
retrieval, ongoing care can include contact with a bereave- sion has already made that further treatment is no longer
ment specialist, written material, telephone support, of benefit, and current interventions are to be withdrawn.
private or group counselling, and correspondence from Clinical suitability assessment for organ retrieval repli-
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recipients. Most Australian and New Zealand organ cates a multiorgan donor, with medical, surgical and
donation agencies have cost-free structured aftercare and social history, virology and organ function information
follow-up programs with these features (see Online collected. Legal requirements of the consent-seeking
resources). Involvement of trained personnel with a donor process also reflect those of a multiorgan donor. Potential
family through this process can positively influence the donor families are informed that retrieval may not occur
family’s grief journey. 51 due to a number of factors, including the length of time
from treatment withdrawal to cardiac standstill. 73,74
The National Donor Family Support Service operates
through the DonateLife Network and is a nationally con-
sistent program of support that provides cadaveric organ RETRIEVAL PROCESS ALTERNATIVES
and/or tissue donor families. All families whose next of Withdrawal of treatment for a potential category 3 DCD
kin are identified as possible donors are offered end-of- patient can occur in critical care or in the operating
life support including bereavement counselling at the theatre, depending on which organs are planned for