The dying process is a natural part of life, and while difficult and sad, can also present opportunities for new beginnings through organ and tissue donation. When possible, the opportunity to donate organs after death should be integrated into good end of life care. A growing number of organ donations in Canada are resulting from “donation after circulatory death” (DCD) a type of donation that can occur in situations where a person is no hope of recovery and life support therapy will be removed, but they do not meet stringent testing criteria for brain death. Physicians and the public are generally supportive of DCD, but ethical and logistical concerns continue to hinder its uptake. Some of these concerns include: the inability to predict which donors will die within a time frame that enables them to proceed to donation, the lack of consensus on the definition of circulatory death and how to diagnose it, and disagreement about how long to wait, after circulation stops, before organ procurement can begin. Each time delay increases the amount of time that organs remain without oxygen and risks the potential for organ damage. Currently the wait time to declare death and proceed to organ procurement is 5 minutes. However, some critics of DCD cite the possibility of autoresuscitation, or spontaneous resumption of circulation without intervention, as a reason to delay the time to organ procurement after arrest of circulation. Our team’s reviews of scientific literature have shown that evidence is not sufficient to draw final conclusions on these controversies.
research program lead by Sonny Dhanani from Children's Hospital of Eastern Ontario
and the University of Ottawa
under the umbrella of the Canadian Critical Care Trials Group aims to provide much needed information about the physiology of death after withdrawal of life sustaining therapy in the ICU, helping to inform DCD practice and thereby ultimately increasing organ donation rates in Canada.
In 2014, the DePPICt study team published the results of the pilot study in Critical Care Medicine. The pilot study recruited 41 out of a goal of 45 patients, had a consent rate of 87%, and recorded 73% protocol compliance. The landmark pilot study was able to show feasibility of examining the natural history of the dying process following withdrawal of life sustaining therapies in Canadian ICUs by recording and analyzing the vital signs of dying patients. You can read the Critical Care Medicine article by clicking here
In 2014, the DePPICt team received funding as part of the Canadian National Transplant Research Program
for a larger study: “Death Prediction and Physiology after Removal of Therapy (DePPaRT)”. The DePPaRT study, which is currently underway, will recruit 500 patients at 13 sites across Canada, and several sites internationally including in the Czech Republic and the United Kingdom. The DePPaRT study will document the physiology of the dying process and will also aim to develop a tool that will allow doctors to predict how long it will take patients to die after the removal of life sustaining therapy. A qualitative component of the study will investigate the decision-making surrounding consent for organ donation and how family members felt when their loved ones became organ donors or were unable to proceed to donation. Results from both the quantitative and qualitative aspects of this study will be invaluable in supporting DCD policies across Canada. By providing the evidence required to address many of the current concerns regarding DCD, the DePPaRT study will help to ensure an increase in the uptake in DCD practice across Canada, which in turn will provide more organs for patients who desperately need them.
The DePPaRT study represents another example of the contribution of research from the CCCTG that improves the care of critically ill patients with the potential to impact the healthcare system.