Pediatric Deceased Donation-A Report of the Transplantation Society Meeting in Geneva

Organ Donation in Canadian PICUs: A Cross-Sectional Survey, 2021-2022

OBJECTIVES

To understand contemporary pediatric organ donation programs in Canadian PICUs, including: policies and practices, data collection and reporting, and system and process barriers.

DESIGN

A cross-sectional survey carried out 2021-2022.

SETTING

Canadian PICUs affiliated with a donor physician network.

SUBJECTS

Pediatric intensivists identified as the donation program lead, or most knowledgeable about donation for their institution.

MEASUREMENTS AND MAIN RESULTS

A 19-item survey was developed through collaboration with stakeholders from the organ donation and transplantation community within Canada. Domains and items were generated and reduced iteratively during an in-person workshop. Pretesting and pilot testing were completed to ensure readability, flow, clinical sensibility, and construct validity. Fifteen of 16 (94%) invited Canadian PICUs from seven provinces completed the survey representing 88% (15/18) of all noncardiac Canadian PICUs. Surveys were completed between June 2021 and September 2022. All units support donation after death by neurologic criteria (DNC); 14 of 15 indicated donation policies were in place and 1 of 15 indicated no policy but the ability to facilitate donation. Thirteen of 15 units (87%) support donation after death by circulatory criteria (DCC) with policies in place, with 11 of 13 of these indicating routine support of donation opportunities. The majority (13/15) of units identified a donation champion. Of the 16 identified champions across these centers, 13 were physicians and were registered nurses or nurse practitioners. Eight of 13 units (62%) with donation champions had positions supported financially, of which 5 units came from the Organ Donation Organization and the other 3 came from the provincial health authority. Finally, only 3 of 15 PICU donation programs have a pediatric donation committee with family involvement. Variability exists in identification (including determination of death practices), referral, and approach for donation between units.

CONCLUSIONS

Although all Canadian PICUs support donation after DNC donation, and most support donation after DCC, variability exists in the identification, referral, and approach of potential donors. There is a notable lack of family involvement in pediatric donation programs. There are many opportunities for standardization of PICU donation programs which may result in improved rates of pediatric organ donation in Canada.

Organ Dysfunction Among Children Meeting Brain Death Criteria: Implications for Organ Donation

OBJECTIVES

Over 70% of pediatric organ donors are declared deceased by brain death (BD) criteria. Patients with these devastating neurologic injuries often have accompanying multiple organ dysfunction. This study was performed to characterize organ dysfunction in children who met BD criteria and were able to donate their organs compared with those deemed medically ineligible.

DESIGN

Retrospective cohort study.

SETTING

PICU at a quaternary care children's hospital.

PATIENTS

Patients with International Classification of Diseases , 9th Edition codes corresponding to BD between 2012 and 2018 were included.

MEASUREMENTS AND MAIN RESULTS

Demographics, comorbidities, Pediatric Risk of Mortality (PRISM)-III, and injury mechanisms were derived from the medical record. Organ dysfunction was quantified by evaluating peak daily organ-specific variables. Fifty-eight patients, from newborn to 22 years old, were included with a median PRISM-III of 34 (interquartile range [IQR], 26-36), and all met criteria for multiple organ dysfunction syndrome (MODS). Thirty-four of 58 BD children (59%) donated at least one organ. Of the donors (not mutually exclusive proportions), 10 of 34 donated lungs, with a peak oxygenation index of 11 (IQR, 8-23); 24 of 34 donated their heart (with peak Vasoactive Inotrope Score 23 [IQR, 18-33]); 31 of 34 donated kidneys, of whom 16 of 31 (52%) had evidence of acute kidney injury; and 28 of 34 patients donated their liver, with peak alanine transferase (ALT) of 104 U/L (IQR, 44-268 U/L) and aspartate aminotransferase (AST) of 165 U/L (IQR, 94-434 U/L). Organ dysfunction was similar between heart and lung donors and respective medically ineligible nondonors. Those deemed medically ineligible to donate their liver had higher peak ALT 1,518 U/L (IQR, 986-1,748 U/L) ( p = 0.01) and AST 2,200 U/L (IQR, 1,453-2,405 U/L) ( p = 0.01) compared with liver donors.

CONCLUSIONS

In our single-center experience, all children with BD had MODS, yet more than one-half were still able to donate organs. Future research should further evaluate transplant outcomes of dysfunctional organs prior to standardizing donation eligibility criteria.

Potential of neonatal organ donation and outcome after transplantation

Organ transplantation is limited by access to suitable organs. Infant recipient waitlist mortality is increased due to the scarcity of size-matched organs. Neonatal organ donors have been proposed as an underutilized source of donor organs. However, the literature on the actual prevalence and outcome of neonatal organ donation and transplantation is fragmented and not well analyzed. This literature review aims to summarize the available literature on the potential of neonatal organ donation and to analyze published cases of neonatal organ transplantation. A systematic search of the Medline and Cochrane databases yielded 2964 articles, which were screened for eligibility. In total, 86 articles were considered eligible, of which 34 were included in the literature review: 8 articles describing the potential of neonatal organ donation programs, and 26 articles describing clinical transplantation. Current evidence suggests there is a large pool of potential neonatal organ donors. In contrast, the literature on neonatal organ donor utilization is sparse. However, case series of successful kidney, heart, liver, hepatocyte, and multivisceral transplantation using organs from neonatal donors are summarized. Although good posttransplant organ function was achieved, the use of neonatal organs is associated with increased risk of thrombosis in both kidney and liver transplantation. Neonatal organ donation is a promising alternative for expanding the current donor pool. Experience is limited, but reported patient and graft survival are acceptable and more research on the subject is warranted.

Implementation of a neonatal donation protocol in the neonatal intensive care unit: A single-center experience

BACKGROUND

Lack of specific protocols for neonatal donation contributes to the rarity of neonatal donors. In this study, we evaluate the impact of the implementation of a neonatal donation protocol in our NICU.

METHODS

In this single-center study, we conducted a retrospective chart review of neonatal deaths in our NICU from January 2013 to January 2022. The study was divided into two periods: before and after the implementation of a neonatal donation protocol. The referral rates of potential neonatal donors to the OPO in the two periods were compared using the chi-square test. A p value < .05 was considered statistically significant.

RESULTS

Sixty-four infants were reviewed. Seven (10.9%) met the inclusion criteria for potential neonatal donors after DCC. The referral rate of potential neonatal donors increased from 2.5% to 16.7% after the implementation of this protocol (p = .041), and one infant (4.1%) became an effective heart-valve donor.

CONCLUSION

The implementation of a local neonatal donation protocol could have contributed to increase the referral rate of potential neonatal donors in our NICU. Following the implementation of a local neonatal donation protocol, we were able to perform a heart-valve donation for the first time in our unit.

Exploring Ethical Dimensions of Physician Involvement in Requests for Organ Donation in Pediatric Brain Death

Pediatric organ transplantation remains a life-saving therapy, with donated organs being absolutely scarce resources. Efforts to both increase pediatric organ donation authorization by families of children declared dead by neurologic criteria and mitigate perception of conflicts of interest have resulted in frequent exclusion of physicians from this process. This article provides of focused review of pediatric organ donation in the setting of brain death, explores the breadth of consequences of physician exclusion in donation authorization requests, and provides an ethical framework defending physician involvement in the organ donation process for this patient population.

Pediatric transplantation: An international perspective

The international practice of transplant in the pediatric population is heterogenous. Global trends in pediatric transplant activity are increasing, with diffusion of transplant activities into developing and emerging economies. There have been impacts of the COVID-19 pandemic which have in the earlier part of the pandemic caused a decrease in the number of transplants. While deceased donor programs are well established in advanced economies, emerging and developing countries rely heavily on live donor programs. Prioritization of organs for children exists in different forms throughout the world. Pediatric transplantation as a sub-specialty is young but growing around the world with a need to train surgeons and physicians in this discipline. Outreach efforts with multi-national and multi-institutional partnerships have enabled resource poor countries to establish new transplant programs for children. Further international collaboration, good quality data collection and audit, prospective research and ongoing mentorship and education are needed to further improve outcomes of all children receiving solid organ transplants.

Eligible neonatal donors after circulatory determination of death (Maastricht type III): A national survey of level III NICUs

BACKGROUND

Organ donation continues to increase worldwide, but in general paediatric patients remain less likely to receive a transplant. The inclusion of neonates as donors after cDCD should be considered in an effort to increase donation rates.

METHODS

The survey for a cross-sectional national study of potential cDCD neonatal donors (Maastricht type III) was sent to all 90 level III Spanish neonatal units to explore: 1) protocols, education, and specific opinions on donation and 2) potential cDCD that could have been eligible over a 2-year period (2014-2015).

RESULTS

Forty-five centers (50%) completed the survey, and 38/45 gave information about potential eligible donors. In 16% of the centers specific protocols on neonatal donation exist. All hospitals demanded more specific training, and 65% noted that the donation process could be a problem in the family's dismissal of the child. During the study period 46 805 neonates were admitted in the 38 centers, and 625 neonates died. Ninety-five born at a gestational age ≥34 weeks and above 2000 gr died after an EoL decision, 38 (40%) and 13 (14%) of them due to neonatal encephalopathy and multiple congenital anomalies, respectively. There were 31 (33%) elegible infants who died in less than 120 min due to pathologies that did not contraindicate donation.

CONCLUSIONS

Neonatal cDCD could help to reduce the gap between the supply of and demand for organs according to the potentially eligible patients emerging from this study. Training in EoL and donation processes should be provided to healthcare professionals.

Is donation after circulatory determination of death feasible for pediatric patients in italy?

To determine the potential effect of a donation after cardiac death active program on the number of organ donors in a Italian Pediatric Intensive Care Unit (PICU). We conducted a retrospective study of all deaths in PICU of an academic Children Hospital between 2012 and 2020, tracing the organ donation activity. Patients were categorized as brain deaths, deaths despite maximal resuscitation, and deaths after withdrawal or limitation of life support. Patient demographics, premortem physiology, end-of-life circumstances, and functional warm ischemia time were recorded. Eligible donors after cardiac death were identified by the absence of medical contraindication and functional warm ischemia time <60 minutes. Of 124 deaths that occurred during the study period, 34 met criteria for brain death, 23 were potential donors, and 13 became actual donors. Of the remaining 90 patients that met criteria for cardiac death, 66 died despite maximal resuscitation, 24 died after withdrawal or limitation of care and between them 13 were identified as theoretically eligible DCD donors. Of these, 5 patients had a functional warm ischemia time of <1 hour and were potential candidates for DCD of 10 kidneys and 2 lungs. Even if few children could have been eligible for DCD in the study period, an active program could have been able to increase the number of potential organ donors by 20% in the last eight years at our institution. DCD deserves to be explored in Italy as a new option for children.

Comparison of pediatric brain-dead donors to donation after circulatory death donors in the United States

In pediatrics, an increasing need for transplantable organs exists. This study aimed to describe the epidemiology of pediatric deceased donors in the United States. This retrospective observational study utilized data from the Organ Procurement and Transplantation Network (OPTN) from 2000 to 2015. Patients were stratified based on method of organ donation. Demographic variables and mechanism of death were then compared. A total of 14,481 deceased pediatric organ donors, donation after brain death (DBD) and donation after circulatory death (DCD), were included in the study, of which 8% were DCD donors. A significant difference (p<0.001) existed between the two donor groups with respect to ethnicity and mechanism of death. The annual trend of DCD and DBD donors showed an inverse relationship. During the 15-year study period the number of DBD donors decreased from 985 to 785 per year while DCD donors increased from 15 to 146 per year. As well, overall organs transplanted per year decreased from 3,475 to 3,117 over the 15-year study period. Significant differences exist between pediatric DBD donors and DCD donors, specifically with respect to ethnicity and mechanism of death. The number of pediatric DBD donors is decreasing while the number of pediatric DCD is slowly rising, making it increasingly important to be able to characterize these donors to better identify eligible DCD donors to optimize organ utilization.

Neonatal donation: are newborns too young to be recognized?

Neonatal organ and tissue donation is not common practice in the Netherlands. At the same time, there is a transplant waiting list for small size-matched organs and tissues. Multiple factors may contribute to low neonatal donation rates, including a lack of awareness of this option. This study provides insight into potential neonatal organ and tissue donors and reports on how many donors were actually reported to the procurement organization. We performed a retrospective analysis of the mortality database and medical records of two largest neonatal intensive care units (NICUs) in the Netherlands. This study reviewed records of neonates with a gestational age >37 weeks and weight >3000g who died in the period from January 1, 2005 through December 31, 2016. During the study period, 259 term-born neonates died in the two NICUs. In total, 132 neonates with general contra-indications for donation were excluded. The medical records of 127 neonates were examined for donation suitability. We identified five neonates with documented brain death who were not recognized as potential organ and/or tissue donors. Of the remaining neonates, 27 were found suitable for tissue donation. One potential tissue donor had been reported to the procurement organization. In three cases, the possibility of donation was brought up by parents.Conclusion: A low proportion (2%) of neonates who died in the NICUs were found suitable for organ donation, and a higher proportion (12%) were found suitable for tissue donation. We suggest that increased awareness concerning the possibility of neonatal donation would likely increase the identification of potential neonatal donors. What is Known: • There is an urgent need for very small organs and tissues from neonatal donors What is New: • A number of neonates who died in the NICU were suitable organ or/and tissue donors but were not recognized as donors. • Knowledge on neonatal donation possibilities is also important for proper counseling of parents who sometimes inquire for the possibility of organ and tissue donation.

Lack of knowledge and experience highlights the need for a clear paediatric organ and tissue donation protocol in the Netherlands

Aim

This study explored the attitudes of medical professionals to organ and tissue donation in paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs) in the Netherlands. It also examined their compliance with the existing Dutch donation protocol and assessed whether a paediatric donation protocol was needed.

Methods

We invited 966 professionals working in all eight PICUs and the two largest NICUs to complete an online survey from December 2016 until April 2017.

Results

A quarter (25%) took part and they included PICU intensivists, neonatologists, nurses and other health and allied professionals. Most were female and nurses. More than half (54%) of the PICU respondents considered paediatric organ donation to be very important and 53% supported tissue donation. In contrast, only 22% of the NICU respondents believed that both neonatal organ and tissue donation were very important. Familiarity and compliance with the existing national donation protocol were low. PICU nurses had significantly less experience than PICU intensivists and felt less comfortable with the donation process. None of the NICU respondents had prior donation experience.

Conclusion

Paediatric intensive care units and NICU professionals lack specialised knowledge and experience on organ and tissue donation. A comprehensive and clear paediatric donation protocol is clearly needed.

For Victims of Fatal Child Abuse, Who Has the Right to Consent to Organ Donation?

In rare circumstances, children who have suffered traumatic brain injury from child abuse are declared dead by neurologic criteria and are eligible to donate organs. When the parents are the suspected abusers, there can be confusion about who has the legal right to authorize organ donation. Furthermore, organ donation may interfere with the collection of forensic evidence that is necessary to evaluate the abuse. Under those circumstances, particularly in the context of a child homicide investigation, the goals of organ donation and collection and preservation of critical forensic evidence may seem mutually exclusive. In this Ethics Rounds, we discuss such a case and suggest ways to resolve the apparent conflicts between the desire to procure organs for donation and the need to thoroughly evaluate the evidence of abuse.

Neonatal Organ and Tissue Donation for Research: Options Following Death by Natural Causes

The donation of organs and tissues from neonates (birth to 28 days) for transplantation has been a relatively infrequent occurrence. Less common has been the use of neonatal organs and tissues for research. Specific ethical and legal questions beg for rational and transparent guidelines with which to evaluate referrals of potential donors. Donation of organs and tissues from a neonate can play a key role in the care and support provided to families by health care professionals around the time of a neonate's death. We report on the recovery of neonatal organs and tissues for research. A working group made up of bioethicists, neonatologists, lawyers, obstetric practioners as well as organ procurement and tissue banking professionals evaluated legal, ethical and medical issues. Neonatal donor family members were also consulted. Our primary goals were (a) to ensure that referrals were made in compliance with all applicable federal and state laws, regulations and institutional protocols, and (b) to follow acceptable ethical standards. Algorithms and policies designed to assist in the evaluation of potential neonatal donors were developed. Neonatal donation is proving increasingly valuable for research into areas including diabetes, pulmonary, gastrointestinal, genitourinary and neurological development, rheumatoid arthritis, autism, childhood psychiatric and neurologic disorders, treatment of MRSA infection and pediatric emergency resuscitation. The development of policies and procedures will assist medical professionals who wish to offer the option of donation to family members anticipating the death of a neonate.

Non-standard criteria donors in pediatric kidney transplantation

KT remains the treatment of choice for ESRD in children. However, the demand for kidney transplants continues to outstrip supply, even in the pediatric scenario. We reviewed the applicability of nonSCDs for pediatric KT. There is a lack of studies analyzing this modality among pediatric donors and recipients, where most conclusions are based on predictions from adult data. Nevertheless, marginal donors might be a reasonable option in selected cases. For example, the use of older LDs is an acceptable option, with outcomes comparable to SCDs. Organs donated after cardiac death represent another possibility, albeit with logistic, ethical, and legal limitations in some countries. AKI donors also constitute an option in special situations, although there are no pediatric data on these transplants. Likewise, there are no data on the use of expanded criteria donors in pediatric patients, but this appears not to be a good option, considering the compromised long-term survival.

Development of a multinational registry of pediatric deceased organ donation activity

BACKGROUND

There are no currently agreed upon international standards for reporting of pediatric deceased organ donation activity. This leads to difficulty in comparisons between jurisdictions for both researchers and policy stakeholders. The goal of this project was to develop and test a standardized registry for pediatric deceased donation activity.

METHODS

Four countries (Canada, Spain, USA, and the UK) with geographical and practice diversity were approached to participate. Iterative exchanges were used to create data fields and definitions that were acceptable to all participants. Data from 2011 to 2015 (inclusive) were requested from national health databases and analyzed on a secure, web-based survey platform.

RESULTS

Data were obtained from three of the four countries (Canada unable to provide). Total pediatric donation rates were stable over the 5-year period, but with variation between countries. pDCD rates were the most variable, representing 32.2% of total pediatric donation in the UK, 14.4% in the United States, and 2.6% in Spain during the studied period. Most organs from pediatric donors were allocated to adult recipients, though the rates of allocation of pediatric kidneys to pediatric recipients ranged from 7% in the United States to 40% in Spain.

DISCUSSION

In this limited cohort of three countries, we demonstrated substantial variation in pediatric donation rates and practice. These data highlight opportunities for practice improvement such as the development of rigorous clinical practice guidelines. Future development of this registry will seek to engage more countries, and address barriers that prevented full participation of approached jurisdictions.

Organ Donation Following Neurologic and Circulatory Determination of Death

OBJECTIVES

To describe important considerations during the process of caring for critically ill children who may be potential organ donors and supporting the family during the death of their child.

DESIGN

Literature review and expert commentary.

MEASUREMENT AND MAIN RESULTS

Medical literature focusing on pediatric donation, best pediatric donation practices, donor management, and factors influencing donation were reviewed. Additional pediatric data were obtained and reviewed from the U.S. Organ Procurement and Transplantation Network. Achieving successful organ donation requires the coordinated efforts of the critical care team, organ donation organization, and transplant team to effectively manage a potential donor and recover suitable organs for transplantation. Collaboration between these teams is essential to ensure that all potential organs are recovered in optimal condition, to reduce death and morbidity in children on transplantation waiting lists as well as fulfilling the family's wishes for their dying child to become a donor.

CONCLUSIONS

Organ donation is an important component of end-of-life care and can help the healing process for families and medical staff following the death of a child. The process of pediatric organ donation requires healthcare providers to actively work to preserve the option of donation before the death of the child and ensure donation occurs after consent/authorization has been obtained from the family. Medical management of the pediatric organ donor requires the expertise of a multidisciplinary medical team skilled in the unique needs of caring for children after neurologic determination of death and those who become donors following circulatory death after withdrawal of life-sustaining medical therapies.

Literature overview highlights lack of paediatric donation protocols but identifies common themes that could guide their development

AIM

Paediatric donation is a unique and extremely sensitive process that requires specific knowledge and competencies. Most countries use protocols for organ and tissue donation to ensure optimal care for the donor and family, but these mainly focus on adults. However, the donation process for children differs from adults in many ways. An overview of the literature was performed to identify protocols for the paediatric population.

METHODS

PubMed, Web of Science, EMBASE and the Internet were searched up to March 2016 for papers or other sources in English related to specific organ and tissue donation protocols for children and neonates. This comprised title, abstract and then full-text screening of relevant data.

RESULTS

We included 12 papers and two electronic sources that were mainly from North America and Europe. Most discussed donations after cardiac death. The recurring themes included identifying potential donors, approaching parents, palliative care and collaboration with organ procurement organisations. Most papers called for paediatric donation policies to be standardised.

CONCLUSION

Scientific publications in English on paediatric donation protocols are very scarce. No comprehensive paediatric donation protocol was found. We identified several recurring themes in the literature that could be used to develop such protocols.

Measuring Critical Care Providers' Attitudes About Controlled Donation After Circulatory Death

INTRODUCTION

Unfavorable attitudes and insufficient knowledge about donation after cardiac death among critical care providers can have important consequences for the appropriate identification of potential donors, consistent implementation of donation after cardiac death policies, and relative strength of support for this type of donation. The lack of reliable and valid assessment measures has hampered research to capture providers' attitudes. Design and Research Aims: Using stakeholder engagement and an iterative process, we developed a questionnaire to measure attitudes of donation after cardiac death in critical care providers (n = 112) and examined its psychometric properties. Exploratory factor analysis, internal consistency, and validity analyses were conducted to examine the measure.

RESULTS

A 34-item questionnaire consisting of 4 factors (Personal Comfort, Process Satisfaction, Family Comfort, and System Trust) provided the most parsimonious fit. Internal consistency was acceptable for each of the subscales and the total questionnaire (Cronbach α > .70). A strong association between more favorable attitudes overall and knowledge ( r = .43, P < .001) provides evidence of convergent validity. Multivariable regression analyses showed that white race ( P = .002) and more experience with donation after cardiac death ( P < .001) were significant predictors of more favorable attitudes.

CONCLUSION

Study findings support the utility, reliability, and validity of a questionnaire for measuring attitudes in critical care providers and for isolating targets for additional education on donation after cardiac death.

Re A (A Child) and the United Kingdom Code of Practice for the Diagnosis and Confirmation of Death: Should a Secular Construct of Death Override Religious Values in a Pluralistic Society?

The determination of death by neurological criteria remains controversial scientifically, culturally, and legally, worldwide. In the United Kingdom, although the determination of death by neurological criteria is not legally codified, the Code of Practice of the Academy of Medical Royal Colleges is customarily used for neurological (brainstem) death determination and treatment withdrawal. Unlike some states in the US, however, there are no provisions under the law requiring accommodation of and respect for residents' religious rights and commitments when secular conceptions of death based on medical codes and practices conflict with a traditional concept well-grounded in religious and cultural values and practices. In this article, we analyse the medical, ethical, and legal issues that were generated by the recent judgement of the High Court of England and Wales in Re: A (A Child) [2015] EWHC 443 (Fam). Mechanical ventilation was withdrawn in this case despite parental religious objection to a determination of death based on the code of practice. We outline contemporary evidence that has refuted the reliability of tests of brainstem function to ascertain the two conjunctive clinical criteria for the determination of death that are stipulated in the code of practice: irreversible loss of capacity for consciousness and somatic integration of bodily biological functions. We argue that: (1) the tests of brainstem function were not properly undertaken in this case; (2) the two conjunctive clinical criteria set forth in the code of practice cannot be reliably confirmed by these tests in any event; and (3) absent authentication of the clinical criteria of death, the code of practice (in fact, although implicitly rather than explicitly) wrongly invokes a secular definition of death based on the loss of personhood. Consequently, the moral obligation of a pluralistic society to honor and respect diverse religious convictions to the greatest extent possible is being violated. Re A (A Child) is contrasted with the US case of Jahi McMath in which the court accommodated parental religious objection to the determination of neurological death codified in the Uniform Determination of Death Act. We conclude that the legal system in the United Kingdom should not favour a secular definition of death over a definition of death that is respectful of religious values about the inviolability and sanctity of life. We recommend the legal recognition of religious accommodation in death determination to facilitate cultural sensitivity and compassionate care to patients and families in a pluralistic society.

How modifiable factors influence parental decision-making about organ donation

A global shortage of organs from children and adults available for transplantation is compounded by the failure of next of kin to consent for organs to be donated after death. Non-modifiable and modifiable factors influence decision-making in this area. Modifiable factors are of interest when examining families' decision-making about the donation of organs from their deceased child. A scoping review was undertaken to determine how modifiable factors influence parental decision-making about organ donation. Thematic analysis identified two themes: interactions with healthcare professionals and pre-disposition to organ donation. Satisfaction with experiences of hospital care, the information provided and the way it was communicated, as well as interactions pertaining to emotional support were all found to be modifiable factors that influenced decision making. Likewise, a predisposition to organ donation and knowing the deceased's wishes were associated with the consent decision. Nurses working in critical care environments need to be able to support parents during this difficult time. This article aims to raise awareness of modifiable factors that influence parental decision-making, highlighting their relevance for children's nursing practice.

Canadian Guidelines for Controlled Pediatric Donation After Circulatory Determination of Death-Summary Report

OBJECTIVES

Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada.

METHODS

We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners.

RESULTS

We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report.

CONCLUSIONS

This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation.

Pediatric transplantation: An international perspective

Abdominal solid-organ transplantation has revolutionized the life of children with end-stage organ failure. The international practice of transplant in the pediatric population is heterogeneous. Global trends in pediatric transplant activity are increasing, with diffusion of transplant activities into developing and emerging economies. The organization of deceased donor programs varies internationally (with strong association to a country's gross domestic product (GDP) per capita and health spending). While deceased donor programs are well established in advanced economies, emerging and developing countries rely heavily on living donor programs. There are efforts underway to increase availability of pediatric and neonatal donor organs. Prioritization of organs for children exists in different forms throughout the world. Pediatric transplantation as a subspecialty is young but growing around the world with a need to train surgeons and physicians in this discipline. Outreach efforts with multinational and multi-institutional partnerships have enabled resource poor countries to establish new transplant programs for children. Further international collaboration, good quality data collection and audit, prospective research and ongoing mentorship, and education are needed to further improve outcomes of all children receiving solid-organ transplants.

Kidney donation after circulatory death: current evidence and opportunities for pediatric recipients

Organ donation after circulatory death (DCD) has experienced a revival worldwide over the past 20 years, and is now widely practiced for kidney transplantation. Some previous concerns about these organs such as the high incidence of delayed graft function have been alleviated through evidence from adult studies. There are now a number of large adult cohorts reporting favorable 5-year outcomes for DCD kidney transplants, comparable to kidneys donated after brain death (DBD). This has resulted in a marked increase in the use of DCD kidneys for adult recipients in some countries and an increase in the overall number of kidney transplants. In contrast, the uptake of DCD kidneys for pediatric recipients is still low and concerns still exist over the longer-term outcomes of DCD organs. In view of the data from adult practice and the poor outcomes for children who stay on dialysis, DCD kidney transplantation should be offered as an option for children on the kidney transplant waiting list.

Elective ventilation to facilitate organ donation in infants with anencephaly: perinatal professionals' views and an ethical analysis

AIM

Following the elective ventilation and referral for organ donation of an infant with anencephaly, we sought local perinatal professionals' views of this practice.

METHODS

Anonymous online survey: demographics, ethical viewpoints and potential public/maternal perceptions (standard 5-part Likert scale and free text).

RESULTS

DEMOGRAPHICS

49 replies (38 female): 4 obstetricians, 14 neonatologists, 6 foetal clinicians, 23 nurses, 1 anaesthetist and 1 reproductive specialist.

EXPERIENCE

0.5-33 years (average 12). Twenty-one had experience of anencephalic delivery, and 10 reported pregnancy continued for religious reasons.

ETHICS

(i) 73% thought anencephalic donation acceptable, of which 64% supported elective ventilation, 20% neutral and 16% disagreed. (ii) Provision of treatments not in infant's strict best interest to facilitate donation: 22% strongly agreed, 36% agreed, 33% neutral and 9% disagreed. (iii) Accept ventilation to permit donation if societal benefit: 53% agreed, 33% neutral and 13% disagreed. (iv) Public opinion: 59% disagreed anencephalic donation would harm public opinion about donation and 19% agreed.

CONCLUSION

We found a supportive local environment for donation in the setting of anencephaly, including support for elective ventilation. Given this, and our ethical analysis, we recommend provision of organ donation information as part of palliative care counselling for women carrying a foetus with a condition likely to be fatal in infancy.

Pediatric Donation After Circulatory Determination of Death: A Scoping Review

OBJECTIVE

Although pediatric donation after circulatory determination of death is increasing in frequency, there are no national or international donation after circulatory determination of death guidelines specific to pediatrics. This scoping review was performed to map the pediatric donation after circulatory determination of death literature, identify pediatric donation after circulatory determination of death knowledge gaps, and inform the development of national or regional pediatric donation after circulatory determination of death guidelines.

DATA SOURCES

Terms related to pediatric donation after circulatory determination of death were searched in Embase and MEDLINE, as well as the non-MEDLINE sources in PubMed from 1980 to May 2014.

STUDY SELECTION

Seven thousand five hundred ninety-seven references were discovered and 85 retained for analysis. All references addressing pediatric donation after circulatory determination of death were considered. Exclusion criteria were articles that did not address pediatric patients, animal or laboratory studies, surgical techniques, and local pediatric donation after circulatory determination of death protocols. Narrative reviews and opinion articles were the most frequently discovered reference (25/85) and the few discovered studies were observational or qualitative and almost exclusively retrospective.

DATA EXTRACTION

Retained references were divided into themes and analyzed using qualitative methodology.

DATA SYNTHESIS

The main discovered themes were 1) studies estimating the number of potential pediatric donation after circulatory determination of death donors and their impact on donation; 2) ethical issues in pediatric donation after circulatory determination of death; 3) physiology of the dying process after withdrawal of life-sustaining therapy; 4) cardiac pediatric donation after circulatory determination of death; and 5) neonatal pediatric donation after circulatory determination of death. Donor estimates suggest that pediatric donation after circulatory determination of death will remain an event less common than brain death, albeit with the potential to substantially expand the existing organ donation pool. Limited data suggest outcomes comparable with organs donated after neurologic determination of death. Although there is continued debate around ethical aspects of pediatric donation after circulatory determination of death, all pediatric donation after circulatory determination of death publications from professional societies contend that pediatric donation after circulatory determination of death can be practiced ethically.

CONCLUSIONS

This review provides a comprehensive overview of the published literature related to pediatric donation after circulatory determination of death. In addition to informing the development of pediatric-specific guidelines, this review serves to highlight several important knowledge gaps in this topic.