27.4 Donation After Cardiac Death and Care of the Organ Donor (05.H–I)

Why donation is an intensivist topic, not a transplant-board topic

Quick Answer: Donation after brain death (DBD) occurs after BD/DNC. Donation after circulatory death (DCD) occurs after withdrawal of life-sustaining treatment and circulatory death. Keep death talk and donation talk apart; notify the OPO early; a designated requestor asks. Manage DBD donors as unstable ICU patients: MAP, oxygenation, euvolemia, diabetes insipidus (DI) with desmopressin (DDAVP) and/or vasopressin, and a conceptual hormone package (T3 or T4, vasopressin, corticosteroid). After DCD arrest, wait an institutional no-touch interval often 2–5 minutes (commonly taught as at least 2 and not more than 5). The treating physician, not the transplant team, declares death. Do not invent UNOS allocation scores.

Independent OpenExamPrep teaching in this section covers donation after circulatory death and care of the organ donor listed under Ethics, research, and practice-based learning in the ABPN Content Specifications. This is not an OPTN, UNOS, HRSA, ABIM, or ABPN product. How a given OPO writes MAP targets and thyroid-hormone doses is protocol, not a number you should fake on the examination. The scoring knowledge is the pathway, the separation of roles, and the refusal to abandon perfusion.

The dead-donor rule is the ethical floor: vital organs are recovered from a patient who has been determined dead, either by neurologic or by circulatory criteria. DCD is not a loophole around that rule. It is a different clock.

DBD versus DCD, and who is allowed to ask

DBD: catastrophic brain injury → BD/DNC determined as in the brain-death chapter → death is declared → organ support continues only as donor care if donation will proceed → recovery in the operating room with a beating heart and a ventilator. Families must hear that the patient has died before they hear about donation, as the 2023 BD/DNC communication recommendations emphasize: once death has occurred, continuation of therapies including the ventilator is not treatment of a living person unless donation is planned.

Controlled DCD: a living patient with a devastating injury who will not meet BD/DNC, or whose family has chosen WLST for other reasons → the WLST decision is independent of donation → OPO evaluates medical suitability and obtains authorization → typically move to an operating room or a nearby ICU → the treating team withdraws the ventilator and pressors → if circulation stops within the organ-specific time window, observe the no-touch interval, declare circulatory death, then the recovery team may begin. If the patient does not die within that window (often on the order of 60–90 minutes, varying by organ and center), the recovery is called off and the patient receives comfort care wherever planned. Kidneys tolerate longer waiting than livers or lungs; do not memorize a fake universal minute count as if OPTN published one number for every organ.

Uncontrolled DCD after unexpected arrest exists in some systems and is uncommon in many U.S. neuro ICUs. Do not make it the default story.

CMS hospital conditions of participation require timely OPO referral for individuals whose death is imminent or who have died. Referral is not the same as asking the family. Designated requestors, typically OPO staff trained for this conversation, make the request. Intensivists who blur “I’m sorry, he has died, and also we need the liver” coerce, even if they mean well.

Authorization: many people are on a first-person donor registry. State law on whether that authorization can be overridden by family varies. In practice, OPOs still work with families. Do not invent a single national override rule. The examination point is: someone with legal authority must authorize, and you are not that authority by default just because you run the unit.

The physician who declares death in DCD must not be part of the OPO or transplant recovery team. That firewall is in professional DCD statements (including ASA language on controlled DCD) and is the item you should be able to recite.

Allocation of recovered organs is performed through Organ Procurement and Transplantation Network (OPTN) systems operated with United Network for Organ Sharing (UNOS). Those systems use organ-specific match algorithms that have changed over time (kidney, liver, lung, and heart each have their own current framework). Do not invent a numeric allocation score, a points formula, or a “UNOS grade” to teach at the bedside. Your job is donor physiology and ethics, not running a match list.

Care of the donor: still a patient for the purpose of perfusion

Herniation and BD/DNC produce a catecholamine storm, then vasoplegia, diabetes insipidus, neurogenic pulmonary edema, hypothermia, and coagulopathy. If you treat the body as “already gone,” MAP collapses, the sodium rockets, the lungs flood or atelectasis, and organs are lost. Nursing care, suctioning, turning, bronchoscopy, antibiotics for the donor’s infection, and temperature control all continue.

Hemodynamics and oxygen. Follow the OPO protocol in front of you. Conceptual targets taught across donor-management reviews include an adequate MAP (many protocols use a floor in the 60–70 mm Hg region, sometimes higher for abdominal perfusion), euvolemia rather than drowning the lungs, and adequate PaO2 / PaO2:FiO2 especially if lungs are being considered. Lung-protective tidal volumes still matter. Do not invent a single national MAP that every OPO uses; do invent the idea that hypotension and hypoxemia are organ-losing events.

Diabetes insipidus. Posterior pituitary failure is common after BD/DNC. Suspect DI when urine output is huge (often >300 mL/h in adults), urine is dilute, and serum sodium is rising. Treat with DDAVP (desmopressin) and free-water replacement, and/or vasopressin infusion, which also supports vascular tone. Uncontrolled DI produces hypernatremia and hypovolemia that injure livers and kidneys you were trying to donate.

Hormone package, conceptually. Brain death can disrupt thyroid and adrenal axes and ADH. A commonly taught combined hormonal approach, historically associated with UNOS cardiac-donor pathways and observational organ-yield analyses, includes:

• Thyroid hormone — triiodothyronine (T3, liothyronine) or thyroxine (T4, levothyroxine); T3 is shorter-acting and often preferred in unstable donors when a protocol uses thyroid replacement.
• Vasopressin — DI plus vasodilatory shock.
• Corticosteroid — often methylprednisolone in donor protocols (anti-inflammatory effects on grafts are part of the rationale).
• Insulin — donor hyperglycemia is common; many protocols target a critical-care glucose band (a frequently cited range is about 120–180 mg/dL).

Evidence for the entire cocktail in every donor is mixed if you read randomized lung-donor trials against older observational UNOS analyses. The examination still expects you to recognize the cocktail conceptually and to treat DI and shock, not to recite a milligram dose as if it were ACLS. If the stem says “hormone replacement after BD/DNC,” think T3/T4 + vasopressin + steroid, plus DDAVP when the problem is DI.

Do not stop turning, warming, and ventilating because “they’re a donor.” That is the “already gone” error.

DCD wait time and the operating-room choreography

After pulselessness in controlled DCD, there is an obligatory observation period to show that circulation will not auto-resuscitate. U.S. professional statements (ASA statement on controlled DCD; similar Institute of Medicine and critical-care society language) commonly locate that interval at longer than 2 minutes and not more than 5 minutes. UNOS educational material likewise describes 2–5 minutes of sustained cessation before declaration, with state and hospital variation. Teach the range and the local policy, not a fake national second-count. Two minutes is the usual lower bound in those statements because auto-resuscitation after that interval is not supported by the DCD literature they cite; five minutes is the usual upper bound to limit warm ischemia.

Declaration uses circulatory and respiratory criteria required by law — typically absent pulse, pressure, and breathing, often confirmed with an arterial line. Then incision. Heparin and other antemortem DCD interventions (and evolving practices such as normothermic regional perfusion) require authorization and local policy; they are ethically debated and are not a national checklist you should invent. If a stem mentions them, the safe moves are: authorization, separation of the declaring team from the recovery team, and follow the institutional OPO protocol.

Worked bedside scenarios

BD/DNC is just determined. Urine output is 500 mL/h, sodium 158 mEq/L, MAP 52 mm Hg on a little phenylephrine, and someone has stopped the warmer “because they’re gone.” Start DDAVP or vasopressin, replace water, raise MAP per OPO protocol, restart temperature care, and notify the OPO if not already done. Do not add a donation ask to the death disclosure you are about to give.

A family chooses WLST for a devastating TBI that does not meet BD/DNC. They are open to donation. The OPO obtains authorization. In the OR, asystole occurs. The intensivist watches the agreed 2–5 minute no-touch window, declares circulatory death, and only then does recovery start. The transplant surgeon does not declare.

WLST for DCD begins. At 90 minutes the patient still has a pulse. The liver team stands down per protocol. Return to comfort care. That is a successful ethical process, not a failed intensivist.

A fellow tries to calculate “the UNOS score” to tell the family where the kidneys will go. Stop. Explain that allocation is an OPTN process after recovery. You can explain that organs are matched; you cannot invent the formula.

Exam traps

Asking for donation in the same sentence as the first death news. Letting the transplant surgeon declare DCD death. Starting recovery at 30 seconds of asystole because “warm ischemia.” Treating a DBD donor as a morgue case with no MAP or DI treatment. Inventing a numeric UNOS allocation score. Forgetting DDAVP/vasopressin in catastrophic DI. Calling DCD “brain death.” Skipping OPO notification because the family “seems too upset to donate.”