GROWING DCD IN ONTARIO

Michael Sharpe MD

Department of Anesthesia and Perioperative Medicine

CCDT - DCD Canadian Forum

• Discussion with the ‘experts’; best practice; legal and ethical framework for policy development

• strong majority support for proceeding with DCD in Canada

• guidance for programs developing DCD protocols

“Donation After Cardiocirculatory Death: A Canadian Forum

Report and Recommendations” CMAJ 2006;10:175:S1

www.giftoflife.on.ca

(Feb 2005)

Schulich School of Medicine & Dentistry The University of Western Ontario

DCD - Rationale

• growing disparity between supply and demand

• appropriate patients / families who wish to donate

– not candidates for NDD

– good candidates for DCD

• significant source of organs: Canadian estimates 10-34%

• experience

– pre NDD

– other jurisdictions

Schulich School of Medicine & Dentistry The University of Western Ontario

DCD Who are the candidates?

• Family and physician elect to withdraw support

• Patients with severe neurological injury

– Intracranial hemorrhage, stroke, anoxia, trauma

• Patients without neurological injury

– Degenerative neuromuscular diseases

– End-stage cardiopulmonary diseases

– High spinal cord injury

• Do not meet the criteria for brain death

• No chance for survival off the ventilator

Schulich School of Medicine & Dentistry The University of Western Ontario

3 K,L 015 K

2 K

N = 20 DCD Donors

St.Michael’sUHNNorth YorkSick KidsSunnybrook

Hamilton

LHSC

Kitchener

Ottawa

Windsor

ThunderBay

Niagara Health

N = 69 DCD Donors

Total DCD Donors – 214

June 2006-Sep 2012

DCD Donors in Ontario

0

5

10

15

20

25

30

35

40

45

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

10

16

35 35

41 41

36

DCD

Ontario DCD Donors by Cause of Death

CAUSE OF DEATH DONOR COUNT % OF TOTAL

ANOXIA / HYPOXIA 87 40.7%

CEREBROVASCULAR ACCIDENT (STROKE) 12 5.6%

CNS INFECTION 1 0.5%

GUNSHOT 1 0.5%

HEAD TRAUMA - NOT MOTOR VEHICLE ACCIDENT 23 10.7%

MOTOR VEHICLE ACCIDENT 36 16.8%

MYOCARDIAL INFARCTION 2 0.9%

OTHER 5 2.3%

OVERDOSE 5 2.3%

RUPTURED CEREBRAL ANEURYSM 2 0.9%

SPONTANEOUS INTRACRANIAL HEMMORRHAGE 38 17.8%

2 0.9%

Grand Total 214 100.0%

June 2006-Sep 2012

0%

5%

10%

15%

20%

25%

30%

35%

40%

All Donors (1013) NDD Donors (852) DCD Donors (161)

35%37%

20%18%

15%

37%

12% 11%

17%

11%12%

5%

10% 10% 11%

ICH Anoxia / Hypoxia MVA CVA (Stroke) Head Trauma (Not MVA)

Donors by Cause of Death, 2007 – 2011

(Four Most Common Causes Shown)

Organs Transplanted from Ontario DCD Donors

June 2006-Sept 2012

ORGANTRANSPLANTED ORGAN

COUNT*

Kidney-Both 8

Kidney-Left 188

Kidney-Right 179

Liver 76

Lung Both 36

Lung-Left 8

Lung-Right 3

Pancreas-Islets 1

Pancreas-Whole 8

Grand Total 507*Includes accepted out of province offers

TGLN COMPARED TO U.S. OPOs

Decision to extubate or wean ventilator dependant

patient, or limit or withdraw therapy to support blood

pressure as part of WLS

Mandatory referral to TGLN for donation

Registered consent decision look-up by TGLN

Mandatory approach involving TGLN for organ/ tissue

donation

WLS as per hospital protocol

Medical suitability for organ

donation?

(assessed by TGLN)

Trillium Gift of Life Network

Mandatory Referral and Approach Withdrawal of Life Support Algorithm

Yes

No

This algorithm is for situations with

ventilator dependant patients,

when a decision is made to:

Extubate or wean ventilator as

part of WLS

Limit therapy to support blood

pressure (shifting to end of life

focus)

Withdraw therapy supporting

blood pressure

Call TGLN at the time of death for

mandatory TGLN approach for tissue when

eligible

Consent for donation?

No Consent

October 17, 2012

Post Mortem Care

Donation Process

Consent

DCD in Ontario

.1. Significant contributor to the solid organ pool available for transplantation

2. Eligibility criteria a moving target: discuss all potential cases with OPO prior to withdrawal of support

3. With experience extended criteria are gradually being applied with comparable results to NDD outcomes

4. Early identification of potential donors : Mandatory Ask Algorithm

Schulich School of Medicine & Dentistry The University of Western Ontario