The median time that elapsed from the time of collapse to the time of the pronouncement of death was 53 minutes for these 244 patients with cardiac arrest, 73 percent of whom were pronounced dead within 60 minutes. Thus, 73 percent (178/244) of the patients with cardiac arrest were pronounced dead within an hour of collapse. If one allows a 10-minute hands-off period with an absent heartbeat after the pronouncement of death and the cessation of CPR, the transplantation team would be left with 50 minutes, on average, to perform cannulation and cooling of the kidneys (which is well within the requisite window of total warm ischemia time).

Thus, 178 of 2,329, or about 7.6 percent (95 percent confidence interval, 6.6 to 8.7 percent), of all patients with out-of-hospital cardiac arrests could theoretically meet the criteria for donor eligibility. If one then applies the lower limit of the confidence interval to the American Heart Association figure of 335,000 cardiac arrest deaths in the United States each year, the result is a conservative estimate of about 22,000 decedents who meet the Modified Madrid Criteria for uncontrolled DCDD kidney donation each year. This is significantly higher than the current pool of 10,500 to 16,800 eligible donors for whom death is determined by neurologic criteria (Guadagnoli et al., 2003; Sheehy et al., 2003) and does not include potential controlled DCDD donors.

NEXT STEPS FOR DCDD

Because the vast majority of Americans die as a result of the loss of circulatory function, many individuals who during their lifetimes expressed a desire to be an organ donor are not currently able to have that wish carried out upon their death for merely technical reasons and not medical reasons of exclusion. A well-established DCDD program would meet their end-of-life wishes. DCDD is not widely practiced in the United States, and at present the circumstances for its use are largely limited to controlled situations in which artificial ventilation is withdrawn. The committee believes that a concerted effort is needed to implement DCDD in uncontrolled situations and thereby provide the opportunity for organ donation to a greater number of people. In addition to the current focus on increasing the number of controlled DCDD donors, the committee believes that the possibility of uncontrolled DCDD should be fully explored to see if this might be realistic, particularly in urban areas with extensive trauma and emergency care systems.

It is important to acknowledge the challenges and the level of effort that will be needed to ensure that DCDD is a feasible option. Trust in the healthcare system is the prime consideration. Patients and their families must have complete confidence that all emergency and resuscitative efforts



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