Critical Care · Year 4 · from Critical Care
Case 3: Organ Donation After Circulatory Death
Clinical Image
Source: Wikimedia Commons - Organ Donation - Public Domain
Case Presentation
A 34-year-old woman suffers a devastating anoxic brain injury after prolonged cardiac arrest from a drug overdose. After 72 hours, multimodal prognostication (absent brainstem reflexes, absent N20 on somatosensory evoked potentials, diffuse cerebral edema on CT, persistently elevated neuron-specific enolase) indicates no meaningful chance of neurologic recovery. However, she does not meet brain death criteria as she has some brainstem function (cough reflex present). Her family, after a goals of care discussion, decides to withdraw life-sustaining treatment. The primary team notifies the organ procurement organization (OPO) per hospital protocol. The OPO representative, separate from the treatment team, approaches the family about donation after circulatory death (DCD). The family learns she had registered as an organ donor. They consent to DCD donation. A detailed protocol is followed: the patient is taken to the operating room, life support is withdrawn, and she is pronounced dead 15 minutes after circulatory arrest (as per institutional protocol requiring 2-5 minutes of observation). Organ procurement proceeds immediately. Her kidneys and liver are successfully transplanted into three recipients. Her family later reports that knowing she helped others provided comfort in their grief.
Key Learning Points
- Donation after brain death (DBD) occurs when the patient is declared dead by neurological criteria; donation after circulatory death (DCD) occurs after withdrawal of life support and declaration of death by circulatory criteria
- The treating team should notify the OPO of potential donors; trained OPO representatives should approach families about donation to "decouple" donation from care decisions
- DCD requires that the decision to withdraw life support be made independently of and prior to any discussion of donation
- Warm ischemia time (time from withdrawal to death to organ procurement) is critical in DCD; organs may not be viable if death does not occur within 60-90 minutes of withdrawal