DCD in the United Kingdom - Critical Care Canada Forum · DCD in the United Kingdom ... National Clinical Leed for Organ Donation, NHS Blood and ... DBD donor pathway, 2016-17 % o

DCD in the United Kingdom

Dr Paul Murphy

Consultant in Neuroanaesthesia and Critical Care, Leeds, UK

National Clinical Leed for Organ Donation, NHS Blood and Transplant

The Black Mountains, South Wales

DCD in the United KingdomWhere we are, how we got there and where we

are going

• Current status

– Donor and transplant numbers

– Transplant outcomes

• Implementation of the UK

programme

– Overcoming the obstacles

• Challenges and opportunities

DCD in the United KingdomWhere we are, how we got there and where we

are going

The Black Mountains, South Wales

Deceased donation in the United KingdomBackground

• UK-wide service

– NHS Blood and Transplant

• UK-wide network of donation leads

– Hospital clinicians

– Specialist nurses

– Donation Committee Chairs

• Potential donor audit

– All ICU and ED deaths up to age of 80 years

• Consent

– Opt-in: England, Northern Ireland and Scotland

– Opt-out: Wales

– Opt-in / opt-out register

Deceased donation in the United KingdomBackground

• UK-wide service

– NHS Blood and Transplant

• UK-wide network of donation leads

– Hospital clinicians

– Specialist nurses

– Donation Committee Chairs

• Potential donor audit

– All ICU and ED deaths up to age of 80 years

• Consent

– Opt-in: England, Northern Ireland and Scotland

– Opt-out: Wales

– Opt-in / opt-out register

DCD in the United KingdomBackground

• Launched in 2003

• Maastricht III

– Organ retrieval after death that follows planned withdrawal of life sustaining

treatment

– 80% deaths on ICU in UK follow planned treatment withdrawal

• Diagnose death after 5 minutes asystole

• Current prohibition on ante mortem interventions

– Heparin

– Femoral cannulation

• Organ retrieval

– Rapid laparotomy / cooling as standard

– Increasing interest in in situ and ex situ organ resuscitation

Current statusDCD donors in UK, 2002-17

Actu

al D

CD

do

no

rs

Current statusDeceased donors in UK, 2002-17

21.8 donors

pmp

12.9

8.9

Actu

al deceased d

onors

Deceased donors, transplants and the

transplant waiting list 2007-2017

809 899 959 1010 10881212 1320 1282 1364 1413

23812552 2645 2695

29123112

35143342

35313712

6476

69437026

78007997

78777655 7636

7288

6389

0

1000

2000

3000

4000

5000

6000

7000

8000

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

Nu

mb

er

Donors

Transplants

Transplant list

Kidney transplantation in UKContribution of DCD

Long term renal replacement therapy in UK

0

100

200

300

400

500

600

Dialysis

Transplant

Long term renal replacement therapy in UK

Organ Donation and Transplantation in Canada:

System Progress Report 2006–2015

10.8

5.9 8.4

8.310.0

8.0

12.5

9.4

8.87.9 11.4

5.8

Variation in DCD numbers in the UK

10.8

5.9 8.4

8.310.0

8.0

12.59.4

8.87.9 11.4

5.8

Variation in DCD numbers in the UK

Source of DCD donorsBy donation potential of UK hospitals

www.odt.nhs.uk/statistics-and-

reports/annual-activity-report/

In last 24 months,

209 / 232 donor

hospitals in UK had

at least 1 actual

DCD donor

Hospitals with > 12

potential donors /

year

Hospitals with 6 - 12

potential donors / year

Hospitals with

3 – 5 potential

donors / year

Hospitals with < 3

potential donors /

year

DCD in the UK 2007

• Lawfulness

– Alteration in end of life care

– Ante mortem interventions

• Conflict of interest

– Public acceptability

• Diagnosis of death

– Dead donor rule

– Post mortem interventions

Implementation of DCDOrgan Donation Taskforce report

Donation should not be viewed as something

optional, something to be inflicted upon

patients and families after end of life care for

the benefit of a third party.

2008

Implementation of DCDOrgan Donation Taskforce report

Donation should not be viewed as something

optional, something to be inflicted upon

patients and families after end of life care for

the benefit of a third party.

Rather, it should be considered to be a

fundamental component of end of life care

and not denied to patients because they are

dying in the wrong place or in the wrong way.

2008

X

Implementation of DCDLegal guidance

• In many cases, actions that can facilitate

DCD most successfully will be in the

person’s best interests.

– Blood sampling

– Maintenance of physiological stability

– Delayed treatment withdrawal

– Altered location of treatment withdrawal2009

Implementation of DCDProfessional guidance

• Death can be confirmed after 5 minutes of

complete and continuous absence of

cardio-respiratory function

• Death is confirmed by demonstrating the

absence of neurological function

(respiration, consciousness and brain-

stem reflexes) after 5 minutes of

continuous asystole.2010

Implementation of DCDUK Donation Ethics Committee

Principle 1: Where donation is likely to be a

possibility, full consideration should be given to the

matter when caring for a dying patient.

Principle 2: If it has been established that further life-

sustaining treatment is not of overall benefit to the

patient, and it has been further established that

donation would be consistent with the patient’s

wishes, values and beliefs, consideration of donation

should become an integral part of the patient’s care

in their last days and hours

2011

UK organ donor pathways 2016-17

%o

fp

ote

nt i

ald

on

ors

0

10

20

30

40

50

60

70

80

90

Potentialdonors1

Neurologicaldeath testsperformed(DBD only)

Neurologicaldeath

confirmed(DBD only)

Contraindications Familyapproach

Consent/authorisation

Donation

DBD, 819 donated (46% of potential donors)DCD, 565 donated (10% of potential donors, 13% of those not contraindicated)

14% 1%4%

8%

31%

11%

23%

57%

42%

46%

http://www.odt.nhs.uk/statistics-and-reports/annual-activity-report/

DBD donor pathway, 2016-17

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fp

ote

nt i

ald

on

ors

0

10

20

30

40

50

60

70

80

90

100

Potentialdonors1


Neurologicaldeath

confirmed(DBD only)



Donation

Figure 13.3

1

1

1

819 of 1780 potential DBD donors donated (46% conversion)

14% 1%4%

8%

31%11%

1775 potential

DBD donors

819 actual

DBD donors

DCD donor pathway, 2016-17

%o

fp

ote

nt i

ald

on

ors

0

10

20

30

40

50

60

70

80

90

100

Potentialdonors1


Neurologicaldeath

confirmed(DBD only)



Donation

Figure 13.3

1

565 of 5650 potential donors donated (10% conversion)

23%

57%

42%

46%

5522 potential

DCD donors

565 actual

DCD donors

DCD donor pathway, 2016-17

%o

fp

ote

nt i

ald

on

ors

0

10

20

30

40

50

60

70

80

90

100

Potentialdonors1


Neurologicaldeath

confirmed(DBD only)



Donation

Figure 13.3

1

565 of 5650 potential donors donated (10% conversion)

23%

57%

42%

46%

5522 potential

DCD donors

565 actual

DCD donors

UK donation balance sheet, 2016-17

DBD DCD

Potential donors 1775 5522

Family approaches 1329 1815

Consents 917 1055

Attendances by abdominal retrieval teams 841 911

Actual donors 819 565

Organs retrieved 3100 1601

Transplants 2714 1287

Transplants / family approach 2.04 0.71


DBD DCD



Consents 917 1055







DBD DCD



Consents 917 1055







DBD DCD



Consents 917 1055






UK family consent rates

Reasons for family refusal

http://www.odt.nhs.uk/statistics-

and-reports/potential-donor-

audit/

Family refusal in DCD

Duration of the DCD pathway

Referral ApproachWithdrawal of life sustaining

treatment

Retrieval operation

startTransplant

Timing of treatment withdrawal

10.8

5.9 8.4

8.310.0

8.0

12.59.4

8.87.9 11.4

5.8

Audit of diagnosis of death in DCD

• N = 68, single regional team, Apr 2015 – Feb 2016

• No record in donor care file = 13

• Documented compliance with professional guidance

– 5 minutes observation – 64%

– Pupillary light reflex – 93%

– Supra-orbital pressure – 59%

– Corneal reflex – 30%

• Documented non-compliance with professional

guidance

– 3 patients observed for ONE minute

– 3 patients observed for TWO minutes

– 1 patient observed for THREE minutes Chris Booth, Salford

North West OD Team

Organ utilisation from DCD donors

DCD donors

• 42% of all donors

• 41% of kidneys

• 24% of livers

• 19% of lungs

• 35% of all

transplants

Annual activity report 2016/17

http://www.odt.nhs.uk/uk-transplant-registry/annual-activity-report/

Organ utilisation from DCD donorsLiver

Ischaemic cholangiopathy Normothermic regional perfusion

Organ utilisation from DCD donorsHeart

Retrieval / tx

centre

Direct

procurement

Normothermic

Regional

Perfusion

Survival to

discharge1

Harefield 6 - 4 / 6

Papworth 14 18 29 / 31

Manchester 3 - 2 / 2

Total 20 21 35 / 39

1Two recently transplanted patients are excluded

Strengths• Sound professional

framework

• 41% of all deceased

donors, 32% of transplants

• Expands possibility of

donation to more patients /

hospitals

Opportunities• Improved organ utilisation

• Reperfusion technologies

• DCD heart

transplantation

Threats• Uncontrolled lengthening

of pathway

• Variation in how death is

diagnosed

Weaknesses• Resource intensive

• Fewer donor organs

• Harder on some families

• Frustrating for staff

DCD in the UK

DCD in the United Kingdom - Critical Care Canada Forum · DCD in the United Kingdom ... National Clinical Leed for Organ Donation, NHS Blood and ... DBD donor pathway, 2016-17 % o

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