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A Mixed-Methods Analysis of Variation

Armand H. Matheny Antommaria, MD, PhD; Karen Trotochaud, RN, MN, MA; Kathy Kinlaw, MDiv; Paul N. Hopkins, MD, MSPH; Joel Frader, MD, MA

JAMA. 2009;301(18):1902-1908.

Context  Although authoritative bodies have promulgated guidelines for donation after cardiac death (DCD) and the Joint Commission requires hospitals to address DCD, little is known about actual hospital policies.

Objective  To characterize DCD policies in children's hospitals and evaluate variation among policies.

Design, Setting, and Participants  Mixed-methods analysis of policies collected between November 2007 and January 2008 from hospitals in the United States, Puerto Rico, and Canada in 2 membership categories of the National Association of Children's Hospitals and Related Institutions.

Main Outcome Measures  Status of DCD policy development and content of the policies based on coding categories developed in part from authoritative statements.

Results  One hundred five of 124 eligible hospitals responded, a response rate of 85%. Seventy-six institutions (72%; 95% confidence interval [CI], 64%-82%) had DCD policies, 20 (19%; 95% CI, 12%-28%) were developing policies; and 7 (7%; 95% CI, 3%-14%) neither had nor were developing policies. We received and analyzed 73 unique, approved policies. Sixty-one policies (84%; 95% CI, 73%-91%) specify criteria or tests for declaring death. Four policies require total waiting periods prior to organ recovery at variance with professional guidelines: 1 less than 2 minutes and 3 longer than 5 minutes. Sixty-four policies (88%; 95% CI, 78%-94%) preclude transplant personnel from declaring death and 37 (51%; 95% CI, 39%-63%) prohibit them from involvement in premortem management. While 65 policies (89%; 95% CI, 80%-95%) indicate the importance of palliative care, only 5 (7%; 95% CI, 2%-15%) recommend or require palliative care consultation. Of 68 polices that indicate where withdrawal of life-sustaining treatment can or should take place, 37 policies (54%; 95% CI, 42%-67%) require it to occur in the operating room and 3 policies (4%; 95% CI, 1%-12%) require it to occur in the intensive care unit.

Conclusions  Most children's hospitals have developed or are developing DCD policies. There is, however, considerable variation among policies.

Author Affiliations: Departments of Pediatrics (Dr Antommaria) and Internal Medicine (Dr Hopkins), University of Utah School of Medicine, Salt Lake City; Center for Ethics, Emory University, Atlanta, Georgia (Mss Trotochaud and Kinlaw); and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois (Dr Frader).

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RELATED LETTER

Policies of Children’s Hospitals on Donation After Cardiac Death
Yorick J. de Groot and Erwin J. O. Kompanje
JAMA. 2009;302(8):844.
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THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Policies of Children's Hospitals on Donation After Cardiac Death
de Groot and Kompanje
JAMA 2009;302:844-844.
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