Single-centre experience of donation after cardiac death

To the Editor: We congratulate Coulson and colleagues for sharing their single-centre experience of donation after cardiac death (DCD).1 Our recently published Queensland DCD data2 reflect their experience and highlight the efficacy of DCD in augmenting the pool of donors with organs available for transplantation. The number of Australian DCD organ donors is increasing. There were 19 in 2007 and 86 in 2009. In 2011, of the 337 total donors, 26% (86) were DCD donors, providing 19% (195) of the total 1041 organs transplanted in Australia.3

Concerns about DCD reducing the number of organ donations after brain death (DBrD) were not supported by Coulson and colleagues. They reported that brain death occurred in four patients while being considered for DCD. These patients provided 17 of a total of 62 organs.1 In the absence of an institutional DCD service, these patients were unlikely to have donated, as they were likely to have been given palliative care after withdrawal of cardiorespiratory support (WCRS). This shows that both pathways for organ donation from deceased patients can coexist and complement each other.

Clinicians may find the process of DCD more challenging, as it involves active WCRS based on the futility of ongoing care to facilitate organ donation, as opposed to DBrD which is essentially a consideration once a patient has died. Coulson and colleagues describe a case in which a patient being considered for DCD returned to reasonable functional survival.1 Such occurrences within a small group of patients may justify some apprehension about DCD. We must ensure that these events do not recur by careful selection of candidates for DCD, as positive public perception and participation are key to the success of transplantation programs. More objective guidelines are required to establish futility of care and the prognoses of patients before withdrawing cardiorespiratory support for DCD. Equally, that case highlights the need for continued regulation of DCD practices worldwide to ensure that societal expectations from organ transplantation can be met while maintaining highest moral and ethical standards.

We agree with Coulson and colleagues that all hospitals in Australia must investigate their potential for DCD. If implemented more widely, DCD will not only expand the donor pool, but will also fulfil the wishes of the many potential donors and their families. Our experience2 and that of Coulson and colleagues1 highlight how DCD programs can be successfully implemented in an appropriately resourced institution.