impacts on emergency department staffing and space, the impacts on operating room capacity, costs required to implement educational programs and develop community consensus, as well as costs of in situ preservation equipment and personnel.

The committee recommends that HRSA, other federal agencies, states, and local entities fund demonstration projects to examine the feasibility of implementing donation programs focused on uncontrolled DCDD. These projects would best be developed within defined geographic areas with well-established EMS systems, particularly those served by a Level I trauma and transplant center, which is the principal receiving hospital for a single EMS system. The demonstration projects would involve the development of processes, in conjunction with hospital and prehospital personnel, to transport all patients with cardiac arrest, whether it is due to primary heart disease or secondary to trauma, to the emergency department of the hospital.

The hospital, OPO, and the EMS system must be well respected and trustworthy entities in the surrounding community that they serve. The single most important feature of the agreement reached about a DCDD protocol is that it meets with public approval and satisfies the community. Community input would be needed during all phases of the project; and public education, as well as professional education, would be important. Extensive stakeholder collaboration involving community members and hospital, OPO, and EMS staff would be needed to develop the protocols for postmortem cannulation and cooling, pending consent for donation from the next of kin. Whether or not such an agreement will also require legal sanction can be determined only by input from the various stakeholders. All organs would be considered appropriate for retrieval as circumstances permit, but the principal target would be kidney donation.

Demonstration projects would allow and enable exploration of the challenges and opportunities for uncontrolled DCDD and should be evaluated carefully. If deemed successful, donation programs focused on uncontrolled DCDD should be scaled up and disseminated to other cities and regions.

Organ quality is a primary determinant of the likelihood of successful organ transplantation. For this reason, potential organ donors are carefully assessed. In general, the suitability of organs for transplantation has traditionally been based on donor age, the circumstances of death, the absence