Neonatal organ donation: Retrospective audit into potential donation in a single neonatal unit

BACKGROUND

Research has shown that many babies who die in neonatal units could have been potential tissue and/or organ donors. Despite the existence of guidelines supporting its implementation, the incidence of neonatal donation remains rare in the United Kingdom.

AIM

The aim of this audit was to retrospectively determine potential eligibility for neonatal tissue and/or organ donation referral in infants who died in a single UK tertiary-level neonatal unit between 2012 and 2021. Cause of death and documentation of any discussions held regarding referral for donation were also explored.

STUDY DESIGN

An audit was undertaken to identify all neonatal deaths at a single tertiary-level NICU in London from 2012-2021. Infants who retrospectively could have been referred as potential tissue and/or organ donors were identified using current NHS Blood and Transplant inclusion and exclusion criteria.

RESULTS AND CONCLUSION

A significant missed potential for neonatal tissue and/or organ donation referrals was identified, which is likely not just limited to the unit audited. Causes of death were as expected for a tertiary level neonatal unit and centre for therapeutic cooling of babies born with hypoxic perinatal brain injuries. Only one documented conversation was found regarding neonatal donation.

RELEVANCE TO CLINICAL PRACTICE

To enable conversations regarding neonatal donation to become a routine part of end-of-life care discussions with families as appropriate, good links between neonatal healthcare professionals and Specialist Nurses in Organ Donation need to be established. This will facilitate the referral of all suitable neonates as potential donors and ensure that neonatal staff feel supported to care for babies identified as potential donors.

Fifteen-minute consultation: Paediatric organ and tissue donation

This article explores ways in which paediatricians can help increase awareness and embed organ and tissue donation in the end-of-life care process. This can save patient lives on the organ transplant waiting list, many of whom currently die prematurely. The information benefits multidisciplinary staff including doctors, nurses and allied professionals to (1) recognise triggers for making referral to the specialist nurse for organ donation in order to make timely assessment for suitability for organ and/or tissue donation, (2) plan a multidisciplinary approach for families to make decisions for the gift of life and (3) help provide on-going support to families and staff.

Pediatric donor management to optimize donor heart utilization

Optimal management of pediatric cardiac donors is essential in order to maximize donor heart utilization and minimize the rate of discarded organs. This review was performed after a systematic literature review and gives a detailed overview on current practices and guidelines. The review focuses on optimal monitoring of pediatric donors, donor workup, hormonal replacement, and obliterating the adverse effects of brain death. The current evidence on catecholamine support and thyroid hormone replacement is also discussed. Recognizing and addressing this shall help in a standardized approach toward donor management and optimal utilization of pediatric heart donors organs.

ISHLT consensus statement on donor organ acceptability and management in pediatric heart transplantation

The number of potential pediatric heart transplant recipients continues to exceed the number of donors, and consequently the waitlist mortality remains significant. Despite this, around 40% of all donated organs are not used and are discarded. This document (62 authors from 53 institutions in 17 countries) evaluates factors responsible for discarding donor hearts and makes recommendations regarding donor heart acceptance. The aim of this statement is to ensure that no usable donor heart is discarded, waitlist mortality is reduced, and post-transplant survival is not adversely impacted.

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.

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.

The potential for neonatal organ donation in a children's hospital

OBJECTIVE

Neonatal organ donation does not occur in the UK. Unlike in other European countries, Australasia and the USA death verification/certification standards effectively prohibit use of neurological criteria for diagnosing death in infants between 37 weeks' gestation and 2 months of age and therefore donation after neurological determination of death. Neonatal donation after circulatory definition of death is also possible but is not currently undertaken. There is currently no specific information about the potential neonatal organ donation in the UK; this study provides this in one tertiary children's hospital.

DESIGN

Retrospective mortality database, clinical document database and patient notes review.

SETTING

Neonatal and Paediatric Intensive Care in a tertiary children's hospital.

PATIENTS

Infants dying between 37 weeks' gestation and 2 months of age between 1 January 2006 and 31 October 2012. Potential assessed using current UK guidelines for older children and neonatal criteria elsewhere.

RESULTS

84 infants died with 45 (54%) identified as potential donors. 34 (40%) were identified as potential donors after circulatory definition of death and 11 (13%) were identified as being theoretical potential donors after neurological determination of death. 10 (12%) were identified as unlikely donors due to relative contraindications and 39 (46%) were definitely not potential donors.

CONCLUSIONS

With around 60 paediatric organ donors in the UK annually, there does appear significant potential for donation within the neonatal population. Reconsideration of current infant brain stem death guidelines is required to allow parents the opportunity of donation after neurological determination of death, together with mandatory training in organ donation for neonatal teams, which will also facilitate donation after circulatory definition of death.

Prospective parental consent for autopsy research following sudden unexpected childhood deaths: a successful model

BACKGROUND

Organ retention issues, recent changes in the Coroners' (Amendment) Rules 2005 and the Human Tissue Act have resulted in pessimism regarding prospective consent for paediatric autopsy research in the UK.

OBJECTIVES

To examine the feasibility and acceptability of a prospective telephone consenting model for post-mortem magnetic resonance (MR) imaging research in HM Coroners' cases.

DESIGN

Following each autopsy referral from the HM Coroner, permission to contact the family for research was requested. A family liaison sister, with experience in dealing with bereaved families, then contacted the parents by telephone, explained the study and obtained oral, and then written consent for post-mortem imaging.

SETTING

London and an area south of London.

RESULTS

Of 76 eligible HM Coroners' cases referred during the study period, permission to contact parents (provided by the HM Coroners' Office) was obtained for only 32 cases (42%). The research sister contacted 32 parents during the study period of whom 31 (96.8%) gave oral research consent. "Helping other parents in the future" and "the importance of post-mortem research" were the main reasons for parents wanting to participate in research.

CONCLUSIONS

Prospective consenting for HM Coroners' cases for research is feasible in children, and can be done ethically by parental consenting via telephone contact before autopsy by appropriately trained staff. However, close co-ordination between mortuary staff, HM Coroners, research staff and medical staff is required. This model may be useful in performing post-mortem research in HM Coroners' cases and in developing paediatric tissue and brain banks in the UK.

Trust management creates suspicion

At a time when nothing seems to be sacred, the article 'The human factor' in the Right to Nurse campaign section was an eye-opener.