A 51-year-old man with poorly controlled hypertension and severe congestive heart failure was admitted with a devastating ganglionic hemorrhage. Soon after arrival he was intubated in the emergency department. About 2 hours after the onset of signs the patient had his eyes closed with no opening to temporomandibular pressure, fixed midsize pupils, absent corneal reflexes, minimal oculovestibular responses, but a good cough response after tracheal suctioning. He also had spontaneous extensor posturing and triple flexion responses with Babinski signs. The CT scan showed a large destructive ganglionic hemorrhage starting in the putamen and extending into the frontal lobe and diencephalon. There was trapping of the third ventricle and acute hydrocephalus. In a desperate and likely ineffective attempt to improve the neurologic condition, a ventriculostomy was placed, but the consulted neurosurgeon felt there was no benefit in removing the large hematoma with so many brainstem reflexes lost. Over the next hours more brainstem reflexes disappeared, and only a faint cough reflex and a breathing drive remained, as evidenced by triggering of the ventilator.
The family understood very well that there was no chance to salvage him and they were told that he might progress further and become brain-dead within several hours. The family brought up his previously expressed strong desire for organ donation if something major would happen to him. However, 24 hours after admission to the neurological intensive care unit, the neurologic examination has remained unchanged. The family would still like to donate his organs after withdrawal of support.
What do you do now?
Catastrophic neurologic injury is often quite obvious even within hours after presentation. In such extreme cases, acute neurosurgical intervention or other measures to reduce increased intracranial pressure are futile. In these acute circumstances with rapid onset of coma, neurologists and neurosurgeons try to identify “a point of no return,” and that is mostly defined by the degree of destruction, by the involvement of crucial structures maintaining awareness (i.e., the diencephalon), and by persistent upper brainstem dysfunction. Clinically this translates into no pupillary light responses, no corneal responses, and no oculocephalic responses. The lower part of the brainstem (lower pons and medulla oblongata) is often still functioning, as made clear by the presence of a motor response to a noxious stimulus, a cough response to tracheal suctioning, and the patients’ preserved ability to trigger a ventilator.
In these situations when there is no hope for recovery, withdrawal of intensive care support will rapidly come up during a family conference, and often the decision is to provide palliative care after extubation.
It is easy to see that something good may come out of such a deep distress, and we should agree with the family, that if feasible, organ donation should be explored. Two clinical scenarios are expected. First, a considerable proportion of these patients will eventually progress to loss of all brainstem function and can be officially declared brain-dead and be therefore legally deceased. Organ donation can then be discussed, and the procedures are well established. But, if the patient does not meet the clinical criteria for brain death, the patient could potentially become a candidate for donation after withdrawal of life support. This procedure is known as donation after cardiac death protocol (abbreviated “DCD protocol”). It requires two important decisions: to establish with certainty the presence of a hopeless situation and when to withdraw life-support measures. Proponents of a DCD protocol have claimed a significant increase in donation rates, but the increase has still been less conspicuous than hoped for.
A DCD procurement protocol is more complicated and restricted than a brain death procurement protocol. Important differences between the two protocols are shown in Table 31.1.
TABLE 31.1 Differences between a Donation after Cardiac Death (DCD) and Donation after Brain Death (DBD) Protocols
| Variables | DCD | DBD |
| Preconditions | No confounders and irremediable cause | No confounders and irremediable cause |
| Clinical findings | Devastating neurologic injury and often loss of upper brainstem function. | Coma, absent brainstem reflexes, no motor response and apnea |
| Eligibility Determination | Preferably an independent physician | Attending physician (may need confirmation by another physician) |
| Organ recovery | 5 minutes circulatory arrest after patient extubation in the operating room | Immediately after arrival |
| Organ/tissue | All those consented except heart (lungs rarely procured) | All those consented |
| Triage | May return to ICU for palliative care if patient breathes after extubation | Morgue |
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