End-of-Life Issues in Cardiac Critical Care: The Option of Organ Donation

Barriers to the identification of possible organ donors among brain-injured patients admitted to intensive care units

Background

Improving organ donation rates requires better detection of possible organ donors, which in turn necessitates identifying barriers preventing the identification of possible organ donors. The objectives of this study were to determine the actual rate of possible deceased organ donors among nonreferred cases and to identify barriers to their identification as possible donors.

Methods

This retrospective observational study used 6 months of data collected from two intensive care units (ICUs). Possible organ donors were defined as patients with a Glasgow Coma Scale score <5 and evidence of severe neurological damage. Barriers that led to the nonidentification of these patients as possible organ donors were also identified.

Results

Fifty-six of 819 patients admitted to the ICUs during the study period were detected as possible organ donors, representing a 6.83% possible organ donor detection rate. Nonclinical barriers to the identification of possible organ donors were found to be more significant than clinical barriers (55% vs. 45%, respectively). The most significant nonclinical barrier was an unknown reason, despite patients being medically suitable for deceased organ donation and fulfilling the criteria for possible organ donor classification. Unresolved sepsis was the main clinical barrier.

Conclusions

The significant rate of unreferred possible deceased organ donors found in this study reveals the need to increase awareness and knowledge among clinicians of the proper detection of possible donors at an early stage to avoid the loss of possible deceased organ donors, and thereby increase the deceased organ donation rate in Malaysian hospitals.

Brain Death and Its Prediction in Out-of-Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management

Evolution toward brain death (BD) in out-of-hospital cardiac arrest patients with targeted temperature management (TTM) provides opportunities for organ donation. However, knowledge regarding BD in these patients is limited. We retrospectively analyzed the TTM registry of one hospital where life-sustaining therapy was not withdrawn. In-hospital death patients were categorized into BD and non-BD groups. We explored the process of evolution toward BD and its predictors by comparing the serial measurements of clinical variables and the results of various prognostic tests between the two groups. Of the 121 patients who died before hospital discharge, 19 patients (15.7%) developed BD at a median of 6 (interquartile range, 5.0–7.0) days after cardiac arrest. Four patients with pupillary light reflexes at 48 h eventually developed BD. The area under the curves of the gray-to-white matter ratio (GWR) on early brain computed tomography images and the level of S100 calcium-binding protein B (S100B) at 72 h were 0.67 (95% CI, 0.55–0.77) and 0.70 (95% CI, 0.55–0.83), respectively. In conclusion, approximately one-sixth of all in-hospital deaths were diagnosed with BD at a median of 6 days after cardiac arrest. The use of GWR and serial S100B measurements may help to screen potential BD.

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.

Barriers and Enablers to Organ Donation After Circulatory Determination of Death: A Qualitative Study Exploring the Beliefs of Frontline Intensive Care Unit Professionals and Organ Donor Coordinators

Background

A shortage of transplantable organs is a global problem. The purpose of this study was to explore frontline intensive care unit professionals' and organ donor coordinators' perceptions and beliefs around the process of, and the barriers and enablers to, donation after circulatory determination death (DCDD).

Methods

This qualitative descriptive study used a semistructured interview guide informed by the Theoretical Domains Framework to interview 55 key informants (physicians, nurses, and organ donation coordinators) in intensive care units (hospitals) and organ donation organizations across Canada.

Results

Interviews were analyzed using a 6-step systematic approach: coding, generation of specific beliefs, identification of themes, aggregation of themes into categories, assignment of barrier or enabler and analysis for shared and unique discipline barriers and enablers. Seven broad categories encompassing 29 themes of barriers (n = 21) and enablers (n = 4) to DCDD use were identified; n = 4 (14%) themes were conflicting, acting as barriers and enablers. Most themes (n = 26) were shared across the 3 key informant groups while n = 3 themes were unique to physicians. The top 3 shared barriers were: (1) DCDD education is needed for healthcare professionals, (2) a standardized and systematic screening process to identify potential DCDD donors is needed, and (3) practice variation across regions with respect to communication about DCDD with families. A limited number of differences were found by region.

Conclusions

Multiple barriers and enablers to DCDD use were identified. These beliefs identify potential individual, team, organization, and system targets for behavior change interventions to increase DCDD rates which, in turn, should lead to more transplantation, reducing patient morbidity and mortality at a population level.