Intimacy or utility? Organ donation and the choice between palliation and ventilation

“A Comparative Analysis of the Number of Organ Retrievals in Relation to Potential Donation Qualifications in Populations of Patients From a Single Anesthesiology and Intensive Care Unit in 2017-2018”

The population of patients declared as brain dead and qualified for organ donation is relatively low in Poland. The main causes of brain death include cerebral vascular diseases and brain trauma (54 and 34%, respectively, according to Poltransplant registry data). The number of organ procurements in Poland is constantly recorded on average at 14 donations per 1 million citizens (14/mln) in 2017 and 12 donations per one million in 2018. It is difficult to precisely define the number of patients who meet the criteria for brain death certification. The authors have retrospectively analyzed the medical data of 229 patients from 2017 and 2018 records with the aim of identifying potential organ donors among patients of the Intensive Care Unit (ICU) in the University Hospital in Western Poland. Brain death was suspected in 53 patients (23.14%). Brain imaging to confirm no cerebral flow (which is consistent with brain death) was performed in 17 patients (7.45%) and this, as a result, led to organ donation in 9 cases (3.93%). The factors identified as having a positive influence on organ donation included: daily thorough physical examination, (Glasgow Coma Scale) GCS assessment, depth and duration of sedation, ICU length of stay and early performance of a CT-angiogram.

An Automated Electronic Screening Tool (DETECT) for the Detection of Potentially Irreversible Loss of Brain Function

BACKGROUND

A major reason for the low number of organ donors in Germany is a deficit in the recognition of patients who may have impending irreversible loss of brain function (ILBF) in hospitals capable of organ retrieval.

METHODS

We used anonymized data from the German Organ Procurement Organization (Deutsche Stiftung Organtransplantation, DSO) to compare two 12-month periods (a reference period and an evaluation period) before and after the implementation of an electronic screening tool (DETECT) at the University Hospital Dresden (UKD) with four other university hospitals without tool implementation (comparative cohort). DETECT is intended to aid in the recognition of potentially impending ILBF. The study endpoints encompassed patients with potentially unrecognized ILBF, patients with recognized ILBF, organ donations performed, and reports to the DSO. Changes in absolute risk were compared with Breslow-Day tests.

RESULTS

309 patients who died with primary or secondary brain lesions were identified in the UKD in the reference and evaluation periods (164 and 145 patients, respectively), and 1060 (529, 531) in the comparative cohort. In the UKD, the number of unrecognized cases of possibly impending ILBF was 14/164 (8.54%) in the reference period and 1/145 (0.69%) in the evaluation period, yielding an absolute reduction of 7.85% (95% confidence interval [--3.36; --12.33]); by contrast, in the comparative cohort, there was a 0.55% absolute increase between the two periods ([--2.21; 3.30]; p = 0.002 for the comparison between the two cohorts). Only minor differences in absolute risk change were seen with regard to the probability of recognized ILBF (7.09% [0.29; 13.88] vs. 2.42% [1.18; 6.01]; p = 0.234), organ donation (4.70% [--0.89; 10.28] vs. 0.55% [--2.17; 3.26]; p = 0.214), or reporting to the DSO (4.17% [--1.77; 10.11] vs. 2.22% [--1.44; 5.89; p = 0.447); these changes may have arisen by chance.

CONCLUSION

These findings suggest that the use of DETECT can help to reduce the deficit in the recognition of patients with impending or manifest ILBF.

The relationship between life-sustaining treatment limitation and organ donation in Swedish intensive care: A nationwide register study

BACKGROUND

Life-sustaining treatment limitation (LSTL) on the intensive care unit (ICU) may affect the rate of organ donation after brain death (DBD). The primary aim of this study was to examine whether there is a relationship between LSTL and DBD. Furthermore, we aimed to determine the rate of LSTL involved in ICU deaths and to describe technical and procedural characteristics of LSTL on Swedish ICUs.

METHODS

This was an observational cohort study on all ICU deaths (n = 13 156) in Sweden between 2014 and 2017. We analysed differences in DBD rates between deaths in ICU with and those without LSTL, using descriptive statistics and logistic regression.

RESULTS

After excluding 1084 deaths on specialised ICUs and units not registering goals of treatment, the study population comprised 12 072 deaths including 615 DBDs, of which 7865 had LSTL, 1706 had no LSTL and 2501 had no stated goals of treatment. The final cohort on which the relationship between DBD and LSTL was analysed comprised 9571 deaths including 419 DBDs. When no LSTL was documented, the rate of organ donation was 9.5% compared to 3.3% when LSTL was documented (P < .001). LSTL was associated with a lower DBD rate after adjusting for patient- and ICU-related factors (OR 0.41, 95% CI 0.31-0.53, P < .001).

CONCLUSION

There was an inverse relationship between LSTL and DBD amongst patients who died on the ICU. This relationship remained after adjusting for factors known to influence organ donation. The reason remains to be determined.

Organ Donation in Intensive Care Units of Hospitals in Warsaw

BACKGROUND

In recent years a systematic decrease in donation activity in Poland (15.4 vs 13.0) has been observed. A significant reduction has been noticed in Warsaw (36.2 vs 19.2) as well.

METHODS

Data on deaths of patients admitted to intensive care units (ICUs) of Warsaw hospitals in from 2014 to 2018 were analyzed. Analysis was conducted in compliance with the Helsinki Congress and the Istanbul Declaration. Population of the city during this period averaged 1,753,480, although specialized capital hospitals service substantially bigger area than Warsaw alone. There are 18,500 to 18,600 deaths affecting this population every year. A total of 333 patients diagnosed as having brain death were included in analysis.

RESULTS

In 42 cases (12.7%) data collection was given up because of lack of authorization. In all donors, death was diagnosed according to neurologic criteria. The most common causes were vascular brain diseases (64.1%) and craniocerebral trauma (21.4%). In 14.5% brain death occurred from other reasons. There are 20 hospitals with ICUs in Warsaw, which totals 318 intensive care beds. Program of identification of deceased organ donors was active in only 14 hospitals. A total of 243 potential donors (73%) were identified in the 3 most active hospitals.

CONCLUSION

Analysis of ICU deaths of Warsaw hospitals showed a gradual decrease in the number of reported donors (from 75 in 2014 to 46 in 2018), although the number of all deaths did not decrease (the number of deaths in ICUs was on average 2.571/y).

The potential for organ donation in Iceland: A nationwide study of deaths in intensive care units

BACKGROUND

The deceased organ donation rate in Iceland has been low compared with other Western countries. The aim of this study was to explore the potential for organ donation after brain death in Iceland.

METHODS

Observational cohort study of patients with catastrophic brain injury who died in intensive care units (ICUs) at hospitals in Iceland in 2003-2016. Medical records were retrospectively reviewed to identify potential donors (PDs), using the WHO Critical Pathway for Deceased Donation. Trends in annual incidence of PDs, conversion to actual donors, and family refusals were assessed.

RESULTS

Among 1537 patients who died in the ICU, 125 (8.1%) were identified as PDs. Of 103 PDs who were declared brain dead, consent for organ donation was pursued in 84 cases and granted in 63. Fifty-six became actual donors. The annual donation rate averaged 13 per million population (pmp), but rose abruptly in the final 2 years to 36 and 27 pmp, respectively. This was paralleled by an increase in annual incidence of PDs from an average of 28 pmp to 54 and 42 pmp, respectively. The donor conversion rate increased during the study period (P = .026). Twenty-three PDs (18%) were not pursued without an apparent reason.

CONCLUSIONS

The donation rate increased markedly in the last 2 years of the study period after remaining low for more than a decade. This change can largely be explained by a high incidence of PDs and a low family refusal rate. Missed donation opportunities suggest a potential to maintain a high donation rate in the future.

Summary of Spanish recommendations on intensive care to facilitate organ donation

With the aim of consolidating recommendations about the practice of initiating or continuing intensive care to facilitate organ donation (ICOD), an ad hoc working group was established, comprising 10 intensivists designated by the Spanish Society of Intensive Care and Coronary Units (SEMICYUC) and the Spanish National Transplant Organization (ONT). Consensus was reached in all recommendations through a deliberative process. After a public consultation, the final recommendations were institutionally adopted by SEMICYUC, ONT, and the Transplant Committee of the National Health-Care System. This article reports on the resulting recommendations on ICOD for patients with a devastating brain injury for whom the decision has been made not to apply any medical or surgical treatment with a curative purpose on the grounds of futility. Emphasis is made on the systematic referral of these patients to donor coordinators, the proper assessment of the likelihood of brain death and medical suitability, and on transparency in communication with the patient's family. The legal and ethical aspects of ICOD are addressed. ICOD is considered a legitimate practice that offers more patients the opportunity of donating their organs upon their death and helps to increase the availability of organs for transplantation.

Admission to Intensive Care for Palliative Care or Potential Organ Donation: Demographics, Circumstances, Outcomes, and Resource Use

Supplemental Digital Content is available in the text.

Objectives:

To describe the characteristics, circumstances, change over time, resource use, and outcomes of patients admitted to ICUs in Australia and New Zealand for the purposes of “palliative care of a dying patient” or “potential organ donation,” and compare with actively managed ICU patients.

Design:

A retrospective study of data from the Australian and New Zealand Intensive Care Society Adult Patient Database and a nested cohort analysis of a single center.

Setting:

One hundred seventy-seven ICUs in Australia and New Zealand and a nested analysis of one university-affiliated hospital ICU in Melbourne, VIC, Australia.

Patients:

Three thousand seven hundred “palliative care of a dying patient” and 1,115 “potential organ donation” patients from 2007 to 2016. The nested cohort included 192 patients.

Interventions:

No interventions. Data extracted included patient demographics, diagnoses, length of stay, circumstances, and outcome of admission.

Measurements and Main Results:

ICU admissions for “palliative care of a dying patient” and “potential organ donation” increased from 179 in 2007 to 551 in 2016 and from 44 in 2007 to 174 in 2016 in each respective group, though only the “potential organ donation” cohort showed an increase in proportion of total ICU admissions. Lengths of stay in ICU were a mean of 33.8 hours (median, 17.5; interquartile range, 6.4–38.8) and 44.7 hours (26.6; 16.0–44.6), respectively, compared with 74.2 hours (41.5; 21.7–77.0) in actively managed patients. Hospital mortality was 86.6% and 95.9%, respectively. In the nested cohort of 192 patients, facilitating family discussions about goals of treatment and organ donation represented the most common reason for ICU admission.

Conclusions:

Patients admitted to ICU to manage end-of-life care represent a small proportion of overall ICU admissions, with an increasing proportion of “potential organ donation” admissions. They have shorter ICU lengths of stay than actively managed patients, suggesting resource use for these patients is not disproportionate.

Ethical Challenges and the Donation Physician Specialist: A Scoping Review

Deceased donation medicine involves unique ethical challenges. Physicians who are focused on deceased donation medicine as part of their practice can expect to encounter these challenges. The goal of this review is to identify and describe these challenges, highlight existing guidelines and policy regarding the management of these challenges and to describe how the donation physician role might promote ethical practice in deceased donation medicine. Themes of discussion include: communication with families, interprofessional conflict, donation physician personal characteristics, donation clinical processes, health resource allocation, research and education, and remuneration. The information presented in this review can be used to inform development of recommendations and guidelines for the management of ethical challenges encountered by donation physicians.

Identifying opportunities to increase organ donation after brain death. An observational study in Sweden 2009-2014

BACKGROUND

There is a wide gap between the number of organ donors and patients on waiting lists for transplantation. The purpose of this Swedish nationwide study of the critical pathway for organ donation after brain death (DBD) was to identify missed opportunities for organ donation.

METHODS

We performed a prospective, observational study of all ICU deaths in Sweden from Jan 1, 2009 to Dec 31, 2014. The protocol structure followed the critical pathway for organ donation, which was developed and tested during 2008. We analysed differences in donation incidences between healthcare providers (counties) and patient characteristics using descriptive statistics and logistic regression.

RESULTS

The number of DBD per million population (pmp) was 14.9, varying almost 10-fold from 4.3 to 40.6 DBD pmp between counties. Regional variation in DBD decreased when we assigned the donor to the place of residence (from 6.9 to 27.7 DBD pmp). Women were more likely to become donors compared to men [crude odds ratio (OR) 1.60, 95% confidence interval (CI) 1.38-1.85, P < 0.001]. The increased likelihood remained after adjusting for age, comorbidity, and main diagnostic categories (OR 1.49, 95% CI 1.25-1.77, P < 0.001). An end-of-life decision was found in 50.9% of possible organ donors.

CONCLUSIONS

Regional differences in DBD were considerable, and women were more likely to become donors than men. There is a need for increased awareness of the potential for organ donation as an integral part of end-of-life clinical care. In-depth analysis of these differences may reveal opportunities for action that could lead to increased DBD.

Are potential organ donors missed on general wards? A 6-month audit of hospital deaths

OBJECTIVE

To determine whether potential organ donors are being missed on general wards by the DonateLife Audit, which concentrates on patients dying in emergency departments and intensive care units.

DESIGN, SETTING AND PATIENTS

Six-month (1 July to 31 December 2012) retrospective audit of patient deaths in a 700-bed metropolitan Australian tertiary referral and teaching hospital.

MAIN OUTCOME MEASURE

Potential organ donor suitability as assessed by a panel of organ donation specialists.

RESULTS

In total, 427 patients died, including nine neonates (2.1%) who were not further assessed and 175 patients (41.0%) who were excluded on the basis of age contraindicating organ donation (≥ 80 years). Seventy-eight (18.3%) were excluded on the basis of active cancer or palliative care for cancer and 143 (33.5%) were deemed otherwise not medically suitable. Twelve (2.8%) had been referred to the DonateLife team for consideration for organ donation. Ten (2.3%) were submitted for panel review, and of these only three were considered to have "potential to develop brain death within 24 hours". These patients would have required mechanical ventilation if potential organ donation were to be realised. One additional potential candidate for donation after circulatory death was identified in the intensive care unit.

CONCLUSION

We identified very few potential organ donors among patients who died outside the emergency department and intensive care unit. For these patients to have progressed to organ donation, medical interventions not in keeping with standard Australian practice would have been required. The DonateLife Audit appears to be a robust tool for identifying realistic potential organ donors.

Non-therapeutic intensive care for organ donation

Background and Purpose:

Providing non-therapeutic intensive care for some patients in hopeless condition after cerebrovascular stroke in order to protect their organs for possible post-mortem organ donation after brain death is an effective but ethically tricky strategy to increase organ grafting. Finding out the feelings and opinion of the involved healthcare professionals and assessing the training needs before implementing such a strategy is critical to avoid backlash even in a presumed consent system.

Participants and methods:

A single-centre opinion survey of healthcare professionals was conducted in 2013 in the potentially involved wards of a French University Hospital: the Neurosurgical, Surgical and Medical Intensive Care Units, the Stroke Unit and the Emergency Department. A questionnaire with multiple-choice questions and one open-ended question was made available in the different wards between February and May 2013.

Ethical considerations:

The project was approved by the board of the Lorraine University Diploma in Medical Ethics.

Results:

Of a total of 340 healthcare professionals, 51% filled the form. Only 21.8% received a specific education on brain death, and only 18% on potential donor’s family approach and support. Most healthcare professionals (93%) think that non-therapeutic intensive care is the continuity of patient’s care. But more than 75% of respondents think that the advance patient’s consent and the consent of the family must be obtained despite the presumed consent rule regarding post-mortem organ donation in France.

Conclusion:

The acceptance by healthcare professionals of non-therapeutic intensive care for brain death organ donation seems fairly good, despite a suboptimal education regarding brain death, non-therapeutic intensive care and families’ support. But they ask to require previously expressed patient’s consent and family’s approval. So, it seems that non-therapeutic intensive care should only remain an ethically sound mean of empowerment of organ donors and their families to make post-mortem donation happen as a full respect of individual autonomy.