Organ donations and unused potential donations in traumatic brain injury, subarachnoid haemorrhage and intracerebral haemorrhage

Factors affecting organ donation rate during devastating brain injuries: a 6-year data analysis

OBJECTIVES

The discrepancy between organ donation rate and the number of patients waiting transplantation has been a common problem in Turkey. Intracerebral hemorrhage (ICH), traumatic brain injury (TBI), anoxic encephalopathy, stroke, and brain tumors comprise the majority of the causes of brain death. This study thus aimed is to analyze potential brain deaths and factors associated with organ donation among such patients.

MATERIAL AND METHODS

Medical records of 629 intensive care unit (ICU) patients with potentially devastating cerebral lesions from 01/2013 to 12/2018 were retrospectively analyzed. Clinical characteristics and the prevalence of consent for organ donation were then assessed.

RESULTS

Although possible brain death was considered in 102 patients, 21 (18%) died before diagnostic tests could be performed. Accordingly, the 81 potential organ donors had a donor conversion rate (DCR) of 30%. Causes of non-organ retrieval among potential donors included refusal of consent by relatives (89.5%), indecision of the family regarding donation or no relatives present (7%), and medical unsuitability for donation (3.5%).

CONCLUSIONS

Our findings showed that refusal by the family was the most common reason for failure of deceased organ donations. To maximize the number of procured organs, transplant communities need to focus on increasing awareness regarding brain death and organ donation and establish strategies to increase consent obtained from the families.

Is informed consent required for the diagnosis of brain death regardless of consent for organ donation?

In the half-century history of clinical practice of diagnosing brain death, informed consent has seldom been considered until very recently. Like many other medical diagnoses and ordinary death pronouncements, it has been taken for granted for decades that brain death is diagnosed and death is declared without consideration of the patient's advance directives or family's wishes. This essay examines the pros and cons of using informed consent before the diagnosis of brain death from an ethical point of view. As shared decision-making in clinical practice became increasingly indispensable, respect for the patients' autonomous wishes regarding how to end their lives has a significant role in deciding how death is diagnosed. Brain death, as a fully technologically controlled death, may require a different ethical framework from the old one for traditional cardiac death. With emerging and proliferating options in end-of-life care for those who suffer from catastrophic brain injury, the traditional reasoning that 'death gives no choice, hence no consent' requires another examination. Patients facing imminent brain death now have options other than undergoing the diagnostic workup for brain death, such as donation after circulatory death and withdrawal of life-sustaining treatment with maximum comfort measures for death with dignity. Nevertheless, just as in the debate over opt-in versus opt-out organ donation policies, informed consent before the diagnosis of brain death faces fierce opposition from consequentialists urging the expansion of the donor pool. This essay examines these objections and provides constructive replies along with a proposal to accommodate this morally required consent.

Criteria to Identify a Potential Deceased Organ Donor: A Systematic Review

OBJECTIVES

To systematically review the global published literature defining a potential deceased organ donor and identifying clinical triggers for deceased organ donation identification and referral.

DATA SOURCES

Medline and Embase databases from January 2006 to September 2017.

STUDY SELECTION

All published studies containing a definition of a potential deceased organ donor and/or clinical triggers for referring a potential deceased organ donor were eligible for inclusion. Dual, independent screening was conducted of 3,857 citations.

DATA EXTRACTION

Data extraction was completed by one team member and verified by a second team member. Thematic content analysis was used to identify clinical criteria for potential deceased organ donation identification from the published definitions and clinical triggers.

DATA SYNTHESIS

One hundred twenty-four articles were included in the review. Criteria fell into four categories: Neurological, Medical Decision, Cardiorespiratory, and Administrative. Distinct and globally consistent sets of clinical criteria by type of deceased organ donation (neurologic death determination, controlled donation after circulatory determination of death, and uncontrolled donation after circulatory determination of death) are reported.

CONCLUSIONS

Use of the clinical criteria sets reported will reduce ambiguity associated with the deceased organ donor identification and the subsequent referral process, potentially reducing the number of missed donors and saving lives globally through increased transplantation.

Acute Tubular Injury is Associated With Severe Traumatic Brain Injury: in Vitro Study on Human Tubular Epithelial Cells

Acute kidney injury following traumatic brain injury is associated with poor outcome. We investigated in vitro the effects of plasma of brain injured patients with acute tubular kidney injury on kidney tubular epithelial cell function. we performed a prospective observational clinical study in ICU in a trauma centre of the University hospital in Italy including twenty-three ICU patients with traumatic brain injury consecutively enrolled. Demographic data were recorded on admission: age 39 ± 19, Glasgow Coma Score 5 (3–8). Neutrophil Gelatinase-Associated Lipocalin and inflammatory mediators were measured in plasma on admission and after 24, 48 and 72 hours; urine were collected for immunoelectrophoresis having healthy volunteers as controls. Human renal proximal tubular epithelial cells were stimulated with patients or controls plasma. Adhesion of freshly isolated human neutrophils and trans-epithelial electrical resistance were assessed; cell viability (XTT assay), apoptosis (TUNEL staining), Neutrophil Gelatinase-Associated Lipocalin and Megalin expression (quantitative real-time PCR) were measured. All patients with normal serum creatinine showed increased plasmatic Neutrophil Gelatinase-Associated Lipocalin and increased urinary Retinol Binding Protein and α1-microglobulin. Neutrophil Gelatinase-Associated Lipocalin was significantly correlated with both inflammatory mediators and markers of tubular damage. Patient’ plasma incubated with tubular cells significantly increased adhesion of neutrophils, reduced trans-epithelial electrical resistance, exerted a cytotoxic effect and triggered apoptosis and down-regulated the endocytic receptor Megalin compared to control. Plasma of brain injured patients with increased markers of subclinical acute kidney induced a pro-inflammatory phenotype, cellular dysfunction and apoptotic death in tubular epithelial cells.

Identification of potential organ donors after aneurysmal subarachnoid hemorrhage in a population-based neurointensive care in Eastern Finland

BACKGROUND

To analyze the organ donation action in population-based neurointensive care of acute aneurysmal subarachnoid hemorrhage (aSAH) and to seek factors that would improve the identification of potential organ donors (PODs) and increase the donor conversion rate (DCR) after aSAH.

METHODS

The Kuopio Intracranial Aneurysm Database, prospective since 1995, includes all aSAH patients admitted to the Kuopio University Hospital (KUH) from its defined Eastern Finnish catchment population. We analyzed 769 consecutive acute aSAH patients from 2005 to 2015, including their data from the Finnish Transplantation Unit and the national clinical registries. We analyzed PODs vs. actual donors among the 145 (19%) aSAH patients who died within 14 days of admission. Finland had implemented the national presumed consent (opt-out) within the study period in the end of 2010.

RESULTS

We retrospectively identified 83 (57%) PODs while only 49 (34%) had become actual donors (total DCR 59%); the causes for non-donorship were 15/34 (44%) refusals of consent, 18/34 (53%) medical contraindications for donation, and 1/34 (3%) failure of recognition. In 2005-2010, there were 11 refusals by near relatives with DCR 52% (29/56) and only three in 2011-2015 with DCR 74% (20/27). Severe condition on admission (Hunt and Hess grade IV or V) independently associated with the eventual POD status.

CONCLUSIONS

Nearly 20% of all aSAH patients acutely admitted to neurointensive care from a defined catchment population died within 14 days, almost half from cardiopulmonary causes at a median age of 69 years. Of all aSAH patients, 11% were considered as potential organ donors (PODs). Donor conversion rate (DCR) was increased from 52 to 74% after the national presumed consent (opt-out). Implicitly, DCR among aSAH patients could be increased by admitting them to the intensive care regardless of dismal prognosis for the survival, along a dedicated organ donation program for the catchment population.

Organ donation by patients with and without trauma in a Canadian province: a retrospective cohort analysis

BACKGROUND

People who experience trauma represent a large pool of potential organ donors. Our objective was to describe organ donation by patients with and without trauma in Nova Scotia.

METHODS

We performed a retrospective cohort study of all patients with trauma in the Nova Scotia Trauma Registry who were injured between Apr. 1, 2009, and Mar. 31, 2016, and died in hospital, as well as all potential organ donors captured in the Nova Scotia Legacy of Life Donor Registry over the same period. We compared characteristics of the 2 groups with respect to organ donation and identified reasons for nondonation.

RESULTS

Overall, 940 patients were included in the analysis, of whom 689 (73.3%) had experienced trauma. Patients with trauma accounted for 37.2% (48/129) of donors. A total of 274 (39.8%) of the patients with trauma were identified as potential organ donors, and 48 (7.0%) donated organs. Only 108 (39.4%) of the 274 were referred to the Legacy of Life Program. The conversion rate (proportion of potential donors who went on to donate an organ) was 84.2% (48/57) among patients with trauma and 83.5% (81/97) among those without trauma. Donation after circulatory death occurred in 8 patients (17%) with trauma and 13 (16%) of those without trauma. Family refusal (28/60 [47%]) and medical unsuitability (16/60 [27%]) were the most common reasons for nondonation among patients with trauma.

INTERPRETATION

In Nova Scotia, 40% of patients with trauma who died in hospital were potential organ donors, yet only 39% of these patients were referred for donation. More work is required to improve organ donation within the trauma population.

Barriers toward organ donation in a Danish University Hospital

BACKGROUND

In Denmark, organ donation-rates are below the average in the western countries. We investigated the donor potential and identified barriers toward organ donation in a Danish university hospital.

METHODS

All patients who died in Aalborg University Hospital in 2012 were retrospectively identified. Patients with a CT- or MRI-proven deadly brain-lesion were eligible for inclusion.

RESULTS

Eighty-five patients with deadly brain-lesions were included, and of these 47 patients died in the intensive care unit (ICU). Older age and diagnosis of brain-hemorrhage and infarction were associated with admission to general ward (GW). In 62.4% of the patients the potential of becoming a donor was not identified. No donations occurred from patients dying from intracerebral hemorrhage or brain-infarction although they represented 44.7% of the potential donors.

DISCUSSION

This study reveals a huge, unrecognized donation potential at our hospital. About 30% was lost because they were never admitted to the ICU. After primary admission to the ICU, 15.3% of the potential donors were lost because they were transferred to the GW. In patients who died in the ICU 17.6% of the patients were not evaluated as potential donors. The relatives refused donation in 17.6% of cases.

CONCLUSION

It would be possible to raise the donation rate considerably if patients with donation potential are intubated and admitted to the ICU. When active treatment is considered withdrawn, possibility of organ donation should be evaluated, and the next of kin be approached by experienced staff.

Interhospital Transfer of Neurosurgical Patients to a High-Volume Tertiary Care Center: Opportunities for Improvement

BACKGROUND

Neurosurgical indications for patient transfer include absence of local or available neurosurgical coverage, subspecialty or interdisciplinary requirements, and family preference. Transfer of patients to regional centers will increase with further centralization of medical care.

OBJECTIVE

To report the transfer records of a large tertiary care center to identify trends, failures, and opportunities to improve interhospital transfer of neurosurgical patients.

METHODS

All consecutive, prospectively documented requests for interhospital patient transfer to the adult neurosurgical service of Emory University Hospitals were retrospectively identified from a centralized transfer center database for a 1-year study period.

RESULTS

Requests for neurosurgical care constituted 1323 of the 9087 calls (14.6%); 81.1% of these requests were accepted, and a total of 984 patients (74.4%) arrived at our institutions. Patients arrived from 133 unique facilities throughout a catchment area of 66 287 sq miles. Although the median travel time for transfer patients was 36 minutes, the median interval between the request and patient arrival was 4 hours 2 minutes. The most frequent diagnoses were intracranial hemorrhage (31.8%), subarachnoid hemorrhage (31.2%), and intracranial tumor (15.2%). The overall diagnostic error rate was 10.3%. Only 42.5% of patients underwent neurosurgical intervention, and 57 patients admitted to intensive care were immediately transitioned to a lower level of care.

CONCLUSION

Interhospital transfer requires a coordinated effort among hospital administrators, physicians, and staff to make complex decisions that govern this important and costly process. These data suggest common failures and numerous opportunities for improvement in transfer efficiency, diagnostic accuracy, triage, and resource allocation.

Maternal organ donation and acute injuries in surviving children

PURPOSE

The purpose of this study is to test whether maternal deceased organ donation is associated with rates of subsequent acute injuries among surviving children after their mother's death.

METHODS

This is a longitudinal cohort analysis of children linked to mothers who died of a catastrophic brain event in Ontario, Canada, between April 1988 and March 2012. Surviving children were distinguished by whether their mother was an organ donor after death. The primary outcome was an acute injury event in surviving children during the year after their mother's death.

RESULTS

Surviving children (n=454) had a total of 293 injury events during the year after their mother's death, equivalent to an average of 65 events per 100 children per year and a significant difference comparing children of mothers who were organ donors to children of mothers who were not organ donors (21 vs 82, P<.001). This difference in subsequent injury rates between groups was equal to a 76% relative reduction in risk (95% confidence interval, 62%-85%).

CONCLUSIONS

Deceased organ donation was associated with a reduction in excess acute injuries among surviving children after their mother's death. An awareness of this positive association provides some reassurance about deceased organ donation programs.

Fatal gunshot wound to the head: the impact of aggressive management

BACKGROUND

Patients with fatal gunshot wounds (GSWs) to the head often have poor outcomes but are ideal candidates for organ donation. The purpose of this study was to evaluate the effects of aggressive management on organ donation in patient with fatal GSWs to the head.

METHODS

A 5-year review of all patients at a trauma center with GSWs to the head was performed. The primary outcome was organ donation after fatal GSW to the head.

RESULTS

A total of 98 patients with fatal GSWs to the head were identified. The rate of potential organ donation was 70%, of whom 49% eventually donated 72 solid organs. Twenty-five percent of patients were not considered eligible for donation as a result of disseminated intravascular coagulopathy. The T4 protocol lead to significant organ procurement rates (odds ratio, 3.6; 95% confidence interval, 1.3 to 9.6; P = .01). Failures to organ donation in eligible patients were due to lack of family consent and cardiac arrest.

CONCLUSIONS

Organ donation after fatal GSW to the head is a legitimate goal. Management goals should focus on early aggressive resuscitation and correction of coagulopathy.

Subarachnoid hemorrhage causing cardiopulmonary arrest: resuscitation profiles and outcomes

Aneurysmal subarachnoid hemorrhage (SAH) is a common cause of cardiopulmonary arrest (CPA). The outcomes of SAH patients presenting with CPA are extremely poor, and long-term survivors have occasionally been reported, but the circumstances under which SAH-CPA patients achieve long-term survival are unclear. Neurosurgeons will have to determine whether a SAH-CPA patient is brain-dead or not more often after enactment of the revised Organ Transplantation Act. Prediction of survival length may be important not only to neurosurgeons, but also to the transplantation team. A retrospective study was conducted to elucidate how often brainstem function was recovered in resuscitated SAH-CPA patients and whether the recovery was associated with longer survival. Among 315 patients with non-traumatic SAH admitted to our institution during 6 years, 35 (11%) presented with CPA. Ventricular fibrillation (VF) as initial cardiac rhythm was rare, observed only in 1 patient. The survival length ranged from 1 to 15 days (mean 3.5 ± 0.7 days), and none achieved long-term survival. Return of brainstem function, represented by spontaneous respiration and/or reactive pupils, was observed in 6 patients (17%), but was only partial and transient. Cardiac arrest to return of spontaneous circulation interval tended to be shorter in patients with transient recovery of the brainstem function than in those without recovery. However, the survival length was not significantly different between the two groups. In addition to the 35 SAH-CPA patients, another 44 SAH patients lost both brainstem reflexes and spontaneous respiration within 72 hours of admission. As a result, 79 (25%) of the 315 SAH patients were considered to have sustained fatal, irreversible brain damage. Review of previous experience suggests that SAH-CPA patients may survive only if the cause of cardiac arrest is VF and not brainstem damage/respiratory arrest. Approximately one-third of resuscitated SAH-CPA patients may die within 24 hours of arrival, for whom the declaration of brain death may be difficult.

The incidence of potential missed organ donors in intensive care units and emergency rooms: a retrospective cohort

PURPOSE

There is a shortage of organ donors in Canada. The number of potential organ donors that are not referred to organ procurement organizations in Canada is unknown.

METHODS

We conducted a retrospective cohort study of all deaths in ICUs and emergency rooms not referred to the Human Organ Procurement and Exchange Program in four hospitals between 1 January 2008 and 31 December 2010. The primary outcome was the number of normal and expanded criteria heart-beating donors and circulatory death (DCD) donors.

RESULTS

Of 2,931 deaths, 64 patients were identified as having a high probability for progression to heart-beating donation (Glasgow Coma Score of 3 and three or more absent brainstem reflexes) and 130 patients were assessed for possible DCD donation. The number of potential abdominal and lung heart-beating donors ranged from 3.2 to 7.5 and 0.5 to 2.7 per million population. The number of potential DCD abdominal and lung donors ranged from 3.9 to 6.5 and 2.7 to 4.3 per million population. Potential heart-beating abdominal (p = 0.04) and lung (p = 0.06) donors increased after legislation mandating donation discussion. Non-pupillary brainstem reflexes were documented in fewer than 60 % of records. Life-sustaining treatment was withdrawn in 19 of 46 (41.3 %) cardiac arrest patients not requiring high doses of vasoactive drugs within 24 h.

CONCLUSION

The number of heart-beating or DCD organ donors represented by missed referrals may represent up to 7.5 donors per million population. Improved documentation of brainstem reflexes and encouraging referral of patients suffering cardiac arrest to ICU specialists may improve donor numbers.

Organ donation after death in Ontario: a population-based cohort study

BACKGROUND

Shortfalls in deceased organ donation lead to shortages of solid organs available for transplantation. We assessed rates of deceased organ donation and compared hospitals that had clinical services for transplant recipients (transplant hospitals) to those that did not (general hospitals).

METHODS

We conducted a population-based cohort analysis involving patients who died from traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage or other catastrophic neurologic conditions in Ontario, Canada, between Apr. 1, 1994, and Mar. 31, 2011. We distinguished between acute care hospitals with and without transplant services. The primary outcome was actual organ donation determined through the physician database for organ procurement procedures.

RESULTS

Overall, 87,129 patients died from catastrophic neurologic conditions during the study period, of whom 1930 became actual donors. Our primary analysis excluded patients from small hospitals, reducing the total to 79,746 patients, of whom 1898 became actual donors. Patients who died in transplant hospitals had a distribution of demographic characteristics similar to that of patients who died in other large general hospitals. Transplant hospitals had an actual donor rate per 100 deaths that was about 4 times the donor rate at large general hospitals (5.0 v. 1.4, p < 0.001). The relative reduction in donations at general hospitals was accentuated among older patients, persisted among patients who were the most eligible candidates and amounted to about 121 fewer actual donors per year (adjusted odds ratio 0.58, 95% confidence interval 0.36-0.92). Hospital volumes were only weakly correlated with actual organ donation rates.

INTERPRETATION

Optimizing organ donation requires greater attention to large general hospitals. These hospitals account for most of the potential donors and missed opportunities for deceased organ donation.

Prediction of evolution toward brain death upon admission to ICU in comatose patients with spontaneous intracerebral hemorrhage using simple signs

The aim of the study was to identify the predictors of brain death (BD) upon admission to the intensive care unit (ICU) of comatose patients with spontaneous intracerebral hemorrhage (ICH). Patients admitted in our ICU from 2002 to 2010 for spontaneous ICH and placed under mechanical ventilation were retrospectively analyzed. Of the 72 patients, 49% evolved to BD, 39% died after withdrawal of life support, and 12% were discharged alive. The most discriminating characteristics to predict BD were included in two models; Model 1 contained ≥3 abolished brainstem responses [adjusted odds ratios (OR) = 8.4 (2.4, 29.1)] and the swirl sign on the baseline CT-scan [adjusted OR = 5.0 (1.6, 15.9)] and Model 2 addressed the abolition of corneal reflexes [unilateral/bilateral: adjusted OR = 4.2 (0.9, 20.1)/8.8 (2.4, 32.3)] and the swirl sign on the baseline CT-scan [adjusted OR = 6.2 (1.9, 20.0)]. Two scores predicting BD were created (sensitivity: 0.89 and 0.88, specificity: 0.68 and 0.65). Risk of evolution toward BD was classified as low (corneal reflexes present and no swirl sign), high (≥1 corneal reflexes abolished and swirl sign), and intermediate. Simple signs at ICU admission can predict BD in comatose patients with ICH and could increase the potential for organ donation.

Incidence, predisposing factors, management and survival following cardiac arrest due to subarachnoid haemorrhage: a review of the literature

INTRODUCTION

The prevalence of cardiac arrest among patients with subarachnoid haemorrhage [SAH], and the prevalence of SAH as the cause following out-of-hospital cardiac arrest [OHCA] or in-hospital cardiac arrest [IHCA] is unknown. In addition it is unclear whether cardiopulmonary resuscitation [CPR] and post-resuscitation care management differs, and to what extent this will lead to meaningful survival following cardiac arrest [CA] due to SAH.

AIM

We reviewed the literature in order to describe; 1.The prevalence and predisposing factors of CA among patients with SAH 2.The prevalence of SAH as the cause of OHCA or IHCA and factors characterising CPR 3.The survival and management of SAH patients with CA.

MATERIAL AND METHODS

The following sources, PubMed, CinAHL and The Cochrane DataBase were searched using the following Medical Subheadings [MeSH]; 1. OHCA, IHCA, heart arrest and 2. subarachnoid haemorrhage. Articles containing relevant data based on the abstract were reviewed in order to find results relevant to the proposed research questions. Manuscripts in other languages than English, animal studies, reviews and case reports were excluded.

RESULTS

A total of 119 publications were screened for relevance and 13 papers were included. The prevalence of cardiac or respiratory arrest among all patients with SAH is between 3-11%, these patients commonly have a severe SAH with coma, large bleeds and evidence of raised intracerebral pressure on computed tomography scans compared to those who did not experience a CA. The prevalence of patients with SAH as the cause of the arrest among OHCA cases vary between 4 to 8% among those who die before hospital admission, and between 4 to 18% among those who are admitted. The prevalence of SAH as the cause following IHCA is low, around 0.5% according to one recent study. In patients with OHCA survival to hospital discharge is poor with 0 to 2% surviving. The initial rhythm is commonly asystole or pulseless electrical tachycardia. In IHCA the survival rate is variable with 0-27% surviving. All survivors experience brief cardiac arrests with short latencies to ROSC.

CONCLUSION

Cardiac arrest is a fairly common complication following severe SAH and these patients are encountered both in the pre-hospital and in-hospital setting. Survival is possible if the arrest occurs in the hospital and the latency to ROSC is short. In OHCA the outcome seems to be uniformly poor despite initially successful resuscitation.

Sequential improvements in organ procurement increase the organ donation rate

PURPOSE

Organ demand exceeds availability of transplantable organs. Organ procurement continues to suffer from failures to identify potential donors, inability to obtain consent for donation, as well as failures to retrieve certain organs as donor demographics change. The purpose of this article is to propose how sequentially introduced measures can increase organ donation rates as well as improve organ procurement.

METHODS

We analysed the effect of stepwise improvements in the organ procurement process patients in a university-based surgical intensive care unit over a 20-year period. We related newly introduced measures in the organ retrieval process with changes in donation rates. We specifically targeted these three main steps in the donation process: donor identification, conversion of potential donors to actual donors, and organ protection during the procurement process. Finally, we assessed the effect of the same measures on organ procurement after introduction in other hospitals of the same organ procurement region.

RESULTS

Introduction of quality improvement steps increased all of the observed parameters. The number of organ donors was stabilised due to a better identification of potential donors, a major increase in conversion from potential to actual donors, and an increase in extended criteria donor. Improvements in organ protection led to higher rates of organs transplanted per donor and increased recovery of lungs and hearts despite increasing donor age. The same measures were introduced successfully in other hospitals in our organ procurement region.

CONCLUSION

Sequential improvements in organ procurement can increase the yield of retrieved organs. The same measures can be applied to other hospitals and lead to comparable improvements in organ donation.

Donation after cardiocirculatory death: a call for a moratorium pending full public disclosure and fully informed consent

Many believe that the ethical problems of donation after cardiocirculatory death (DCD) have been "worked out" and that it is unclear why DCD should be resisted. In this paper we will argue that DCD donors may not yet be dead, and therefore that organ donation during DCD may violate the dead donor rule. We first present a description of the process of DCD and the standard ethical rationale for the practice. We then present our concerns with DCD, including the following: irreversibility of absent circulation has not occurred and the many attempts to claim it has have all failed; conflicts of interest at all steps in the DCD process, including the decision to withdraw life support before DCD, are simply unavoidable; potentially harmful premortem interventions to preserve organ utility are not justifiable, even with the help of the principle of double effect; claims that DCD conforms with the intent of the law and current accepted medical standards are misleading and inaccurate; and consensus statements by respected medical groups do not change these arguments due to their low quality including being plagued by conflict of interest. Moreover, some arguments in favor of DCD, while likely true, are "straw-man arguments," such as the great benefit of organ donation. The truth is that honesty and trustworthiness require that we face these problems instead of avoiding them. We believe that DCD is not ethically allowable because it abandons the dead donor rule, has unavoidable conflicts of interests, and implements premortem interventions which can hasten death. These important points have not been, but need to be fully disclosed to the public and incorporated into fully informed consent. These are tall orders, and require open public debate. Until this debate occurs, we call for a moratorium on the practice of DCD.

Religious and ethnic influences on willingness to donate organs and donor behavior: an Australian perspective

CONTEXT

Globally, the demand for donated organs outstrips supply, meaning that there are both practical and theoretical reasons for examining factors that are predictive of individuals' willingness to donate their organs upon their death.

OBJECTIVES

To determine whether individuals of different religious denominations living in Australia have different views on organ donation, whether donation attitudes differ significantly across ethnic groups, and whether factors identified in international research are predictors of willingness to donate and actual donor behavior in this population.

PARTICIPANTS

Data for this study were collected from students at an Australian university from a range of religious and ethnic backgrounds, and their friends and relatives (N = 509). Intervention-Participants were administered the Organ Donation Attitude Scale, as well as additional attitudes and knowledge measures.

MAIN OUTCOME MEASURES

Self-reported "willingness to donate" and "donor behavior".

RESULTS

Our findings complemented those reported in comparable countries, with females, younger Australians, and those with high knowledge levels being more willing to donate than males, older persons, and those with low knowledge. Persons who described themselves as having stronger religious beliefs (particularly Buddhist and Islamic) held less favorable attitudes toward donation, had lower knowledge levels, and were more likely to oppose donation.

CONCLUSIONS

Although this study established that attitudes toward, knowledge about, and predictors of organ donation in Australia are similar to those reported elsewhere, donation rates remain low. Further in-depth research examining the impact of religion and culture on attitudes, beliefs, and behavior is essential when exploring strategies to improve organ donation rates in highly multicultural societies such as Australia.

Is organ donation from brain dead donors reaching an inescapable and desirable nadir?

The brain dead patient is the ideal multiorgan donor. Conversely, brain death (BD) is an undesirable outcome of critical care medicine. Conditions that can lead to the state of BD are limited. An analysis showed that a (aneurysmal) subarachnoid hemorrhage, traumatic brain injury, or intracerebral hemorrhage in 83% precede the state of BD. Because of better prevention and treatment options, we should anticipate on an inescapable and desirable decline of BD. In this article, we offer arguments for this statement and discuss alternatives to maintain a necessary level of donor organs for transplantation.

Religious and Ethnic Influences on Willingness to Donate Organs and Donor Behavior: An Australian Perspective

Context

Globally, the demand for donated organs outstrips supply, meaning that there are both practical and theoretical reasons for examining factors that are predictive of individuals' willingness to donate their organs upon their death.

Objectives

To determine whether individuals of different religious denominations living in Australia have different views on organ donation, whether donation attitudes differ significantly across ethnic groups, and whether factors identified in international research are predictors of willingness to donate and actual donor behavior in this population.

Participants

Data for this study were collected from students at an Australian university from a range of religious and ethnic backgrounds, and their friends and relatives (N = 509).

Intervention

Participants were administered the Organ Donation Attitude Scale, as well as additional attitudes and knowledge measures.

Main Outcome Measures

Self-reported “willingness to donate” and “donor behavior.”

Results

Our findings complemented those reported in comparable countries, with females, younger Australians, and those with high knowledge levels being more willing to donate than males, older persons, and those with low knowledge. Persons who described themselves as having stronger religious beliefs (particularly Buddhist and Islamic) held less favorable attitudes toward donation, had lower knowledge levels, and were more likely to oppose donation.

Conclusions

Although this study established that attitudes toward, knowledge about, and predictors of organ donation in Australia are similar to those reported elsewhere, donation rates remain low. Further in-depth research examining the impact of religion and culture on attitudes, beliefs, and behavior is essential when exploring strategies to improve organ donation rates in highly multicultural societies such as Australia.

Donor conversion rates depend on the assessment tools used in the evaluation of potential organ donors

Purpose

It is desirable to identify a potential organ donor (POD) as early as possible to achieve a donor conversion rate (DCR) as high as possible which is defined as the actual number of organ donors divided by the number of patients who are regarded as a potential organ donor. The DCR is calculated with different assessment tools to identify a POD. Obviously, with different assessment tools, one may calculate different DCRs, which make comparison difficult. Our aim was to determine which assessment tool can be used for a realistic estimation of a POD pool and how they compare to each other with regard to DCR.

Methods

Retrospective chart review of patients diagnosed with a subarachnoid haemorrhage, traumatic brain injury or intracerebral haemorrhage. We applied three different assessment tools on this cohort of patients.

Results

We identified a cohort of 564 patients diagnosed with a subarachnoid haemorrhage, traumatic brain injury or intracerebral haemorrhage of whom 179/564 (31.7%) died. After applying the three different assessment tools the number of patients, before exclusion of medical reasons or age, was 76 for the IBD-FOUR definition, 104 patients for the IBD-GCS definition and 107 patients based on the OPTN definition of imminent neurological death. We noted the highest DCR (36.5%) in the IBD-FOUR definition.

Conclusion

The definition of imminent brain death based on the FOUR-score is the most practical tool to identify patients with a realistic chance to become brain dead and therefore to identify the patients most likely to become POD.

Fatal gunshot wounds to the head: a critical appraisal of organ donation rates

BACKGROUND

Patients sustaining fatal gunshot wounds to the head are often young, without associated comorbidities, and are potentially ideal transplantation candidates.

METHODS

A 5-year review of a level I trauma center's prospective database was performed for all patients sustaining fatal gunshot wounds to the head. Demographic, physiologic, anatomic, and laboratory variables were collected.

RESULTS

Sixty-eight patients were identified, of whom 10 (14.7%) were organ donors. Of 25 admitted to the intensive care unit who eventually did not become donors, 15 (60%) were due to lack of consent.

CONCLUSIONS

Despite frequent intensive care unit admissions, organ donation is infrequent following fatal gunshot wounds to the head, primarily because of lack of consent. Improved communication with next of kin could improve organ recovery and reduce futile care in this group.

Higher refusal rates for organ donation among older potential donors in the Netherlands: impact of the donor register and relatives

BACKGROUND

The availability of donor organs is considerably reduced by relatives refusing donation after death. There is no previous large-scale evaluation of the influence of the Donor Register (DR) consultation and the potential donor's age on this refusal in The Netherlands.

METHODS

This study examines 2101 potential organ donors identified in intensive care units between 2005 and 2008 and analyzes the association of DR consultation and subsequent refusal by relatives and the relationship with the potential donor's age.

RESULTS

Of the 1864 potential donor cases where the DR was consulted, the DR revealed no registration in 56%, 20% registration of consent, and 18% objection. In the other 6.5% of cases, where the DR indicated that relatives had to decide, the relatives' refusal rate was significantly lower than in the absence of a DR registration (46% vs. 63%). In 6% of the cases where the DR recorded donation consent, relatives still refused donation. DR registration, objection in the DR, and the relatives' refusal rate if the DR was not decisive increased with donor age.

CONCLUSIONS

Despite the introduction of a DR, relatives still play an equally important role in the final decision for organ donation. The general public should be encouraged to register their donation preferences in the DR and also to discuss their preferences with their families. The higher refusal rate of older potential donors means that this group should receive more information about organ donation, especially because the cohort of available donors is ageing.

Lack of association between decompressive craniectomy and conversion to donor status

There has been a recent resurgence in the use of decompressive craniectomy (DC) following severe brain injury. The aim of this study was to evaluate any association between DC and solid organ donation. We performed a retrospective, single-center, cohort study involving referrals to the local organ procurement organization, excluding those with anoxic brain injury. Of subjects referred, 64 (53%) were deemed eligible for donation and 29 (24%) converted to donor status. DC was performed with similar frequency in donors and non-donors (41% vs. 29%; p = 0.23). Patients with DC had similar odds of donation as those without DC (odds ratio 1.70, 95% CI 0.72-4.03), including after adjustment for age and Glasgow Coma Scale score (odds ratio 1.31, 95% CI 0.53-3.24). The most common reason eligible patients failed to convert to donor status was failure to pursue organ procurement because of the belief that the patient would not progress to neurological death or be a candidate for donation following cardiac death. Decompressive craniectomy was not uncommon among referrals to organ procurement organizations who ultimately become solid organ donors. Continued communication between the organ donation coordinators and the treating team has potential to decrease missed opportunities for organ donation.

Imminent brain death: point of departure for potential heart-beating organ donor recognition

PURPOSE

There is, in European countries that conduct medical chart review of intensive care unit (ICU) deaths, no consensus on uniform criteria for defining a potential organ donor. Although the term is increasingly being used in recent literature, it is seldom defined in detail. We searched for criteria for determination of imminent brain death, which can be seen as a precursor for organ donation.

METHODS

We organized meetings with representatives from the field of clinical neurology, neurotraumatology, intensive care medicine, transplantation medicine, clinical intensive care ethics, and organ procurement management. During these meetings, all possible criteria were discussed to identify a patient with a reasonable probability to become brain dead (imminent brain death). We focused on the practical usefulness of two validated coma scales (Glasgow Coma Scale and the FOUR Score), brain stem reflexes and respiration to define imminent brain death. Further we discussed criteria to determine irreversibility and futility in acute neurological conditions.

RESULTS

A patient who fulfills the definition of imminent brain death is a mechanically ventilated deeply comatose patient, admitted to an ICU, with irreversible catastrophic brain damage of known origin. A condition of imminent brain death requires either a Glasgow Coma Score of 3 and the progressive absence of at least three out of six brain stem reflexes or a FOUR score of E(0)M(0)B(0)R(0).

CONCLUSION

The definition of imminent brain death can be used as a point of departure for potential heart-beating organ donor recognition on the intensive care unit or retrospective medical chart analysis.

Donor conversion and organ yield in traumatic brain injury patients: missed opportunities and missed organs

BACKGROUND

The purpose of this study was to define donation patterns and lost donor opportunities in severe traumatic brain injury (TBI) patients.

METHODS

The trauma registry was queried for all deaths after severe TBI in 2004; this was cross matched with the regional organ procurement organization database and subjected to post hoc statistical analysis.

RESULTS

One hundred thirty-five patients met criteria for inclusion. Forty percent had isolated TBI. Forty-two patients (31%) were eligible for deceased donation. Seventeen eligible patients (40%) did not convert to donation, 15 from family declining. Twenty-five eligible patients (60%) donated 85 organs (yield 3.4 organs/donor). Yield was similar in both isolated TBI (3.2) and patients with head injuries (3.5). Ineligible patients had higher admission Glasgow Coma Scale scores, lower head Abbreviated Injury Scale scores, and were more likely to develop cardiovascular or pulmonary dysfunction (p < 0.05). Of the 25 donors, 48% did not donate hearts and 84% did not donate lungs, despite the absence of chest trauma in the majority of patients.

CONCLUSION

Less than one-third of severe TBI patients were identified as eligible organ donors and only 40% actually donated. Half of all donors fail to donate hearts and over 80% fail to donate lungs. Within this population, opportunities may exist to improve both donor conversion and organ yield.

In defense of the reverence of all life: Heideggerean dissolution of the ethical challenges of organ donation after circulatory determination of death

During the past 50 years since the first successful organ transplant, waiting lists of potential organ recipients have expanded exponentially as supply and demand have been on a collision course. The recovery of organs from patients with circulatory determination of death is one of several effective alternative approaches recommended to reduce the supply-and-demand gap. However, renewed debate ensues regarding the ethical management of the overarching risks, pressures, challenges and conflicts of interest inherent in organ retrieval after circulatory determination of death. In this article, the author claims that through the engagement of a Heideggerean existential phenomenological and hermeneutic framework what are perceived as ethical problems dissolve, including collapse of commitment to the dead donor rule. The author argues for a revisioned socially constructed conceptual and philosophical responsibility of humankind to recognize the limits of bodily finitude, to responsibly use the capacity of the transplantable organs, and to grant enhanced or renewed existence to one with diminished or life-limited capacity; thereby making the locus of ethical concern the donor-recipient as unitary ''life.'' What ethically matters in the life-cycle (life-world) of donor-recipient is the viability of the organs transplanted; thereby granting reverence to all life.