Survey of Canadian intensivists on physician non-referral and family override of deceased organ donation

Outcome analysis of brain-death referral to NOD-Lb: A retrospective chart review of a single hospital experience over 3 years

BACKGROUND

Organ donation shortage and in particular organ procurement is an international concern as the gap between the number of donors and recipients is steadily growing. Organ procurement is a chain of steps with donor identification and referral (ID&R) as the very first link in this chain. Failure of this step hinders the progress in the organ transplantation program.

OBJECTIVES

Our study was conducted to evaluate and highlight the gap between the national system and the practice at the identification and referral (ID&R) step of the organ procurement chain in a single tertiary-care academic health center in Beirut: the Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), and to appraise the literature for challenges at this step and for possible interventions for improvement based on the international experience.

MATERIALS AND METHODS

This retrospective study was a descriptive case series of ICU and ED deceased patients at a single tertiary-care university hospital in Beirut. Patients' characteristics were collected from medical records for all patients who died between 2017 and 2019 while in the ICU or the ED and shared with the National Organization for Organ and Tissue Donation and Transplantation (NOD-Lb), for each subject separately, to decide on the donor status. All data collected from the patient cohort was analyzed using R version 3.6.1. Wilcoxon signed-rank test, chi-squared, and fisher-exact tests were used to compare differences in clinical characteristics in terms of donor status when appropriate.

RESULTS

This study served as 3 years audit of a single hospital experience, and it demonstrates failure to make any referrals to NOD-Lb and zero actual organ and tissue donations over the study period. The review of 295 deceased subjects' charts demonstrates 295 missed alerts to NOD-Lb and the overall missing of 5 organ and tissue donors and 24 cornea donors assuming the organ procurement chain of steps will continue uninterrupted after ID&R.

CONCLUSION

The data gathered suggests the presence of an inefficient identification and referral system that is translated into a complete failure of reporting to NOD-Lb from LAUMC-RH. A systematic evidence-based approach to evaluate for the most cost-effective intervention to increase identification and referral rates is needed with a serious effort to examine and account for any inefficient implantation.

Development of the Nova Scotia Potential Donor Audit (PDA) Tool and 2020 Historic Performance Database: Lessons Learned From the First 1000 Medical Record Reviews

Background

Legislation and accountability frameworks are key components of high-performing deceased-donation systems. In 2021, Nova Scotia (NS), Canada, became the first jurisdiction in North America to enact deemed consent legislation and concurrently implemented mandatory referral legislation similar to that found in other Canadian provinces. Frontline financial resources were provided by the government to support the development of program infrastructure, including implementation of means to evaluate system performance.

Methods

The Organ Donation Program (ODP), in collaboration with other stakeholders, developed a Potential Donor Audit (PDA) tool and database for referral intake and manual performance audits. Medical record reviews of deaths in the year before legislative change were conducted to pilot and revise the PDA and evaluate missed donation opportunities.

Results

The NS PDA was piloted on 1028 patient deaths. Of 518 patients (50.4%) who met clinical triggers for referral to the ODP, 72 (13.9%) were referred (86.1% missed referral rate). One hundred sixty-three patients met the NS definition of a potential donor; 53 (32.5%) were referred (110 missed potential donors). Referral consent rates reached 71.7% (n = 38 of 53 approaches). The actualized donation rate reported by Canadian Blood Services was 29.9 donors per million population (n = 34 donors).

Discussion

We documented high rates of missed referrals and missed potential donors before the enactment of mandatory referral and deemed consent legislation.

Conclusions

The ODP has intentionally broadened clinical criteria for referral to shift the responsibility of identifying medically suitable potential donors from bedside clinicians to organ donation specialists. Lessons learned from our experience developing a PDA include the importance of early involvement of multiple stakeholders and ongoing modification of fields and workflow based on data availability and utility for clinical, educational, research, and reporting purposes.

Paediatric organ donation following neurological determinants of death in intensive care units in Saudi Arabia: a retrospective cross-sectional study

OBJECTIVES

The aim of this retrospective cross-sectional study was to assess the performance of paediatric organ donation in intensive care units following neurological determinants of death in Saudi Arabia.

DESIGN

Retrospective cross-sectional study.

SETTING

Paediatric intensive care units at three tertiary centres over 5 years.

PARTICIPANTS

423 paediatric deaths (<14 years) from January 2017 to December 2021.

PRIMARY OUTCOME

Patients were identified as either possible, potential, eligible, approached, consented or actual donors based on organ donation definitions from the WHO, Transplantation Society and UK potential donor audit.

SECONDARY OUTCOME

Secondary outcome was causative mechanisms of brain injury in possible donors. Demographics of the study cohort (age, sex, hospital length of stay (LOS), paediatric intensive care unit LOS, pre-existing comorbidities, admission type and diagnosis category) were compared between possible and non-possible donors. Demographics were also compared between patients who underwent neurological determination of death and patients who did not.

RESULTS

Among the 423 paediatric deaths, 125 (29.6%) were identified as possible donors by neurological criteria (devastating brain insult with likelihood of brain death, Glasgow Coma Score of 3 and ≥2 absent brainstem reflexes). Of them, 41 (32.8%) patients were identified as potential donors (neurological determination of death examinations initiated by the treating team), while only two became actual donors. The eligible death conversion rate was 6.9%. The reporting rate to organ procurement organisation was 70.7% with a consent rate of 8.3%. The most common causes of brain insult causing death were cardiac arrest (44 of 125 patients, 35.2%), followed by traumatic brain injury and drowning (31 of 125 patients, 24.8%), and intracranial bleeding (13 of 125 patients, 11.4%).

CONCLUSION

Major contributors to low actual donation rate were consent, donor identification and donor referral.

Organ Donation Organization Architecture: Recommendations From an International Consensus Forum

This report contains recommendations from 1 of 7 domains of the International Donation and Transplantation Legislative and Policy Forum (the Forum). The purpose is to provide expert guidance on the structure and function of Organ and Tissue Donation and Transplantation (OTDT) systems. The intended audience is OTDT stakeholders working to establish or improve existing systems.

Methods

The Forum was initiated by Transplant Québec and co-hosted by the Canadian Donation and Transplantation Program partnered with multiple national and international donation and transplantation organizations. This domain group included administrative, clinical, and academic experts in OTDT systems and 3 patient, family, and donor partners. We identified topic areas and recommendations through consensus, using the nominal group technique. Selected topics were informed by narrative literature reviews and vetted by the Forum's scientific committee. We presented these recommendations publicly, with delegate feedback being incorporated into the final report.

Results

This report has 33 recommendations grouped into 10 topic areas. Topic areas include the need for public and professional education, processes to assure timely referral of patients who are potential donors, and processes to ensure that standards are properly enforced.

Conclusions

The recommendations encompass the multiple roles organ donation organizations play in the donation and transplantation process. We recognize the diversity of local conditions but believe that they could be adapted and applied by organ donation organizations across the world to accomplish their fundamental objectives of assuring that everyone who desires to become an organ donor is given that opportunity in a safe, equitable, and transparent manner.

Organ and Tissue Donation Consent Model and Intent to Donate Registries: Recommendations From an International Consensus Forum

Consent model and intent to donate registries are often the most public facing aspects of an organ and tissue donation and transplantation (OTDT) system. This article describes the output of an international consensus forum designed to give guidance to stakeholders considering reform of these aspects of their system.

Methods

This Forum was initiated by Transplant Québec and cohosted by the Canadian Donation and Transplantation Program partnered with multiple national and international donation and transplantation organizations. This article describes the output of the consent and registries domain working group, which is 1 of 7 domains from this Forum. The domain working group members included administrative, clinical, and academic experts in deceased donation consent models in addition to 2 patient, family, and donor partners. Topic identification and recommendation consensus was completed over a series of virtual meetings from March to September 2021. Consensus was achieved by applying the nominal group technique informed by literature reviews performed by working group members.

Results

Eleven recommendations were generated and divided into 3 topic groupings: consent model, intent to donate registry structure, and consent model change management. The recommendations emphasized the need to adapt all 3 elements to the legal, societal, and economic realities of the jurisdiction of the OTDT system. The recommendations stress the importance of consistency within the system to ensure that societal values such as autonomy and social cohesion are applied through all levels of the consent process.

Conclusions

We did not recommend one consent model as universally superior to others, although considerations of factors that contribute to the successful deployment of consent models were discussed in detail. We also include recommendations on how to navigate changes in the consent model in a way that preserves an OTDT system's most valuable resource: public trust.

Nurse knowledge and attitudes towards organ donation and deemed consent: the Human Organ and Tissue Donation Act in Nova Scotia

PURPOSE

In April 2019, the Human Organ and Tissue Donation Act (HOTDA) in Nova Scotia was modified to incorporate a deemed consent model. In this study, we sought to understand intensive care unit (ICU) and emergency department (ED) nurses' knowledge of and confidence around organ donation and transplantation, experiences with organ donors and recipients, attitudes toward organ donation and deemed consent, and perceived opportunities and barriers to a deemed consent approach in view of the legislative change.

METHODS

We sent an electronic, self-administered survey to all ICU and ED nurses in Nova Scotia. The survey queried respondents on their knowledge of, experience with, and attitudes around organ donation and HOTDA, and opportunities and barriers to the implementation of HOTDA in clinical practice. Survey results were analyzed using descriptive statistics.

RESULTS

One-hundred and ninety-four nurses responded to the survey. Nearly all (98%) supported organ donation, with 86% having signed an organ donor card to donate organs and/or tissues after death. A considerable majority (89%) also supported the new legislation. Nevertheless, a minority of respondents (13%) believed that deemed consent legislation would be considered a violation of the general principles of freedom and autonomy. The three most identified topics for ongoing training were coordination of the donation process (70%), clinical management of donors (70%), and family issues in decision-making (70%).

CONCLUSION

Intensive care unit and ED nurses had positive attitudes toward organ donation, including deemed consent model. The findings should inform educational initiatives in Nova Scotia and beyond to optimize organ donation processes and outcomes.

Clinical evaluation and ancillary testing for the diagnosis of death by neurologic criteria: a cross-sectional survey of Canadian intensivists

PURPOSE

Trust in the deceased organ donation process relies on the expectation that the diagnosis of death by neurologic criteria (DNC) is accurate and reliable. The objective of this study was to assess the perceptions and approaches to DNC diagnosis among Canadian intensivists.

METHODS

We conducted a self-administered, online, cross-sectional survey of Canadian intensivists. Our sampling frame included all intensivists practicing in Canadian institutions. Results are reported using descriptive statistics.

RESULTS

Among 550 identified intensivists, 249 (45%) completed the survey. Respondents indicated they would be comfortable diagnosing DNC based on clinical criteria alone in cases where there is movement in response to stimulation (119/248; 48%); inability to evaluate upper/lower extremity responses (84/249; 34%); spontaneous peripheral movement (76/249; 31%); inability to evaluate both oculocephalic and oculo-caloric reflexes (40/249; 16%); presence of high cervical spinal cord injury (40/249; 16%); and within 24 hr of hypoxemic-ischemic brain injury (38/247; 15%). Most respondents agreed that an ancillary test should always be conducted when a complete clinical evaluation is impossible (225/241; 93%); when there is possibility of a residual sedative effect (216/242; 89%); when the mechanism for brain injury is unclear (172/241; 71%); and if isolated brainstem injury is suspected (142/242; 59%). Sixty-six percent (158/241) believed that ancillary tests are sensitive and 55% (132/241) that they are specific for DNC. Respondents considered the following ancillary tests useful for DNC: four-vessel conventional angiography (211/241; 88%), nuclear imaging (179/240; 75%), computed tomography (CT) angiography (156/240; 65%), and CT perfusion (134/240; 56%).

CONCLUSION

There is variability in perceptions and approaches to DNC diagnosis among Canadian intensivists, and some practices are inconsistent with national recommendations.

[Ethics of resuscitation and end of life decisions]

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Family veto in organ donation: the experiences of Organ and Tissue Donation Coordinators in Ontario

PURPOSE

In Ontario, an individual's registered wish for organ donation is legally valid consent following death. Family veto occurs when the deceased donor's substitute decision-maker (SDM) overrides this consent to donate, evoking a legal and ethical conflict. The objective of this study was to examine the experiences of Organ and Tissue Donation Coordinators (OTDCs) working with SDMs who vetoed a deceased donor's consent for organ donation.

METHODS

Qualitative focus groups were conducted with ten OTDCs in Ontario, Canada who reported experience with family veto. An interpretative phenomenological approach informed data analysis. Themes emerged through team consensus and were further refined through collaborative and reflexive engagement.

RESULTS

Four themes emerged regarding family veto: 1) the significance of the OTDC role, 2) emotional distress and the "understandable" family veto, 3) barriers contributing to family veto, and 4) strategies towards a culture of organ donation. Findings highlighted the importance of patient advocacy in the OTDC role, while revealing the emotional distress of experiencing family veto. OTDCs identified timing and healthcare providers' perceived ambivalence toward organ donation as critical barriers to family authorization. Value-positive language, role reframing, and increased education were offered as strategies to address these barriers and reduce family veto.

CONCLUSION

This study highlights important considerations about organ donation authorization processes in Ontario. Findings support practice changes towards reducing family veto and further research nationally. Collaborations with key stakeholders are warranted to align healthcare practices, donation policies, and education initiatives towards a shared goal of increasing organ donation.

European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions

These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.

Potential Heart, Liver, and Kidney Donation after Circulatory Determination of Death in a Neonatal Intensive Care Unit

BACKGROUND

Pediatric organ donation after circulatory determination of death (DCD) has increased in recent years; however, there are few data reporting the number of neonatal potential DCD organ donors and no Canadian-specific reports.

OBJECTIVE

The main objective of this study was to estimate the number of patients who may have become actual DCD organ donors from a single, tertiary neonatal intensive care unit (NICU) over 5 years.

METHODS

We reviewed all medical charts of newborns ≥2.5 kg, who died in our center's NICU from January 2013 to December 2017. We determined how many could have become actual organ donors after brain death (DBD) or DCD based on 3 sets of organ-specific eligibility criteria defined as conservative, standard, and liberal.

RESULTS

Of the 39 deceased patients, none met the criteria for DBD. Twenty-nine (75%) died after the withdrawal of life-sustaining therapies. According to the conservative criteria, 1 patient would have been eligible for kidneys and liver donation. Three patients met standard criteria for kidneys and 1 for liver. Eight patients would have been eligible donors for kidneys, 7 for liver, and 2 for heart according to liberal criteria. Only 2 patients were evaluated for DCD, and no organ donation was performed.

CONCLUSIONS

While uncommon, we identified potential DCD organ donors in the NICU population for kidney, heart, and liver transplants. The substantial variability in the number of potential donors depending on the selected eligibility criteria emphasizes the need for a standardized definition adapted to local capacities.

Survey of Canadian critical care physicians' knowledge and attitudes towards legislative aspects of the deceased organ donation system

PURPOSE

We surveyed Canadian critical care physicians who may care for patients who are potential organ donors to understand their attitudes and knowledge of legislation governing the deceased organ donation system.

METHODS

We used a web-based, self-administered survey that included questions related to opt-out consent and mandatory referral legislation. Potential participants were identified through membership lists of professional societies and manual searches. We designed our survey using standardized methods and administered it in February and March 2018.

RESULTS

Fifty percent (263/529) of potential participants completed the questionnaire. A majority (61%; 144/235) supported a change towards an opt-out consent model, and 77% (181/235) stated they believe it would increase donation rates. Asked if opt-out consent would change their practices, 71% (166/235) stated an opt-out model would not change how or if they approach families to discuss donation. Fifty-six percent (139/249) supported mandatory referral laws, while only 42% (93/219) of those working in provinces with mandatory referral correctly stated that such laws exist in their province. Respondents gave variable responses on who should be accountable when patients are not referred, and 16% (40/249) believed no one should be held accountable.

CONCLUSIONS

While a majority of critical care physicians supported opt-out consent and mandatory referral, many were neutral or against it. Many were unaware of existing laws and had variable opinions on how to ensure accountability. Efforts to increase understanding of how legislative models influence practice are required for any law to achieve its desired effect.

Patient-centred and family-centred care of critically ill patients who are potential organ donors: a qualitative study protocol of family member perspectives

INTRODUCTION

In a patient-centred and family-centred approach to organ donation, compassion is paramount. Recent guidelines have called for more research, interventions and approaches aimed at improving and supporting the families of critically ill patients. The objective of this study is to help translate patient-centred and family-centred care into practice in deceased organ donation.

METHODS AND ANALYSIS

This will be a national, qualitative study of family members of deceased organ donors in Canada. We will include family members who had been approached regarding an organ donation decision, including those who agreed and declined, at least 2 months and no later than 3 years after the patients' death. Data collection and analysis is ongoing and will continue until September 2020 to include approximately 250 participants. Family members will be identified and recruited from provincial organ donation organisation databases. Four experienced qualitative researchers will conduct telephone interviews in English or French with audio-recording for subsequent transcription. The research team will develop a codebook iteratively through this process using inductive methods, thus generating themes directly from the dataset.

ETHICS AND DISSEMINATION

Local research ethics boards (REB) at all participating sites across Canada have approved this protocol. The main REB involved is the Ottawa Health Science Network REB. Data collection began in August 2018. Publication of results is anticipated in 2021. Study findings will help improve healthcare provider competency in caring for potential organ donors and their families and improve organ donation consent rates. Findings will also help with the development of educational materials for a competency-based curriculum for critical care residents.