The author recounts his experience with an uDCD program that ran for three years at the Washington Hospital I Center in Washington, D.C. in the 1990s. Challenges, I benefits, and lessons learned are considered in depth. A I primary focus is the importance of community education, Organ Procurement Organization support, and the need for immediate in-situ preservation of organs.

As of January 1, 2008, over 98,000 people are waiting for organ transplants in the United States of America. Of those, nearly 75,000 are waiting for a kidney. In this calendar year, fewer than 15,000 will receive a kidney transplant from a deceased donor. The average waiting time for a deceased donor kidney now exceeds five years in virtually all metropolitan areas. Sadly, nearly as many people die waiting as there are deceased donors each year, despite monumental efforts by the (...) entire transplant community to increase both the number of organ donors and the number of organs recovered from each donor. The imbalance between demand and supply has led to considerable efforts to expand the criteria for what is considered an acceptable organ donor by the Organ Procurement and Transplant Network, thereby hoping somewhat to assuage the shortfall of donor organs. So-called Expanded Criteria Donors may be older than 50, have history of hypertension, or have died from intracerebral hemorrhage and/or have impaired renal function. ECDs now make up nearly 40% of the donor population. (shrink)

The gap between the number of organs available for transplant and the number of individuals who need transplanted organs continues to increase. At the same time, thousands of transplantable organs are needlessly overlooked every year for the single reason that they come from individuals who were declared dead according to cardio pulmonary criteria. Expanding the donor population to individuals who die uncontrolled cardiac deaths will reduce this disparity, but only if organ preservation efforts are utilized. Concern about potential legal liability (...) for temporary preservation of organs pending a search for family members appears to be one of the impediments to wider use of donation in cases of uncontrolled cardiac death in states without statutes explicitly authorizing such action. However, we think that the risk of liability for organ preservation under these circumstances is de minimis, and that concerns about legal impediments to preservation should yield to the ethical imperative of undertaking it. (shrink)

In this paper, we assume that organ donation policy in the United States will continue to be based on an opt-in model, requiring express consent to donate, and that families will continue to have the prerogative to make donation decisions whenever the deceased person has not recorded his or her own preferences in advance. The limited question addressed here is what should be done when a potential donor dies unexpectedly, without any recorded expression of his or her wishes at hand, (...) while a family decision is being sought. (shrink)

“I think there’s a big strong belief in [...] the community … and maybe it’s in the world at large that somehow the doctors are more concerned about harvesting the organs than what’s best for the patient.”1 In the past 45 years, organ and tissue recovery and transplantation have moved from the occasional and experimental to a standard of care for end-stage organ failure; receiving an organ transplant is for many the only opportunity for increased quantity and/or quality of life. (...) The increasing prevalence of diseases such as viral hepatitis, diabetes, and hypertension has significantly increased the incidence of end-organ failure. Additionally, surgical advances have permitted less stringent qualification criteria, so that people of advanced age or patients who may be in a physiologically fragile state are now eligible to be organ recipients. These changes have created a significant demand for organs. (shrink)

In this short article, we articulate a position that organ recovery from uncontrolled DCD — primarily patients who have suffered a cardiac arrest — is unlikely to result in a significant number of organs, and this small gain must be balanced against significant risk of unduly influencing resuscitation provider decision-making, and jeopardizing public trust in the propriety of organ donation and transplantation.

Presumed consent alone will not solve the organ shortage, but it will create an ethical and legal context that supports organ donation, respects individuals who object to organ donation, relieves families from the burden of decision making, and can save lives.