Protocol for increasing organ donation after cerebrovascular deaths in a district general hospital

The Implementation of a Multidisciplinary Approach for Potential Organ Donors in the Emergency Department

BACKGROUND

The aim of this study was to evaluate the implementation process of a multidisciplinary approach for potential organ donors in the emergency department (ED) in order to incorporate organ donation into their end-of-life care plans.

METHODS

A new multidisciplinary approach was implemented in 6 hospitals in The Netherlands between January 2016 and January 2018. The approach was introduced during staff meetings in the ED, intensive care unit (ICU), and neurology department. When patients with a devastating brain injury had a futile prognosis in the ED, without contraindications for organ donation, an ICU admission was considered. Every ICU admission to incorporate organ donation into end-of-life care was systematically evaluated with the involved physicians using a standardized questionnaire.

RESULTS

In total, 55 potential organ donors were admitted to the ICU to incorporate organ donation into end-of-life care. Twenty-seven families consented to donation and 20 successful organ donations were performed. Twenty-nine percent of the total pool of organ donors in these hospitals were admitted to the ICU for organ donation.

CONCLUSIONS

Patients with a devastating brain injury and futile medical prognosis in the ED are an important proportion of the total number of donors. The implementation of a multidisciplinary approach is feasible and could lead to better identification of potential donors in the ED.

[Intensive care to facilitate organ donation. ONT-SEMICYUC recommendations]

Intensive care to facilitate organ donation (ICOD) is defined as the initiation or continuation of life-sustaining measures, such as mechanical ventilation, in patients with a devastating brain injury with high probability of evolving to brain death and in whom curative treatment has been completely dismissed and considered futile. ICOD incorporates the option to organ donation allowing a holistic approach to end-of-life care, consistent with the patients wills and values. Should the patient not evolve to brain death, life-supportive treatment must be withdrawal and controlled asystolia donation could be evaluated. ICOD is a legitimate practice, within the ethical and legal regulations that contributes increasing the accessibility of patients to transplantation, promoting health by increasing deceased donation by 24%, and with a mean of 2.3 organs transplanted per donor, and collaborating with the sustainability of health-care system. This ONT-SEMICYUC recommendations provide a guide to facilitate an ICOD harmonized practice in spanish ICUs.

Interventions aimed at healthcare professionals to increase the number of organ donors: a systematic review

Background

The last decade, there have been many initiatives worldwide to increase the number of organ donors. However, it is not clear which initiatives are most effective. The aim of this study is to provide an overview of interventions aimed at healthcare professionals in order to increase the number of organ donors.

Methods

We systematically searched PubMed, EMBASE, CINAHL, PsycINFO, and the Cochrane Library for English language studies published until April 24, 2019. We included studies describing interventions in hospitals aimed at healthcare professionals who are involved in the identification, referral, and care of a family of potential organ donors. After the title abstract and full-text selection, two reviewers independently assessed each study’s quality and extracted data.

Results

From the 18,854 records initially extracted from five databases, we included 22 studies in our review. Of these 22 studies, 14 showed statistically significant effects on identification rate, family consent rate, and/or donation rate. Interventions that positively influenced one or more of these outcomes were training of emergency personnel in organ donation, an electronic support system to identify and/or refer potential donors, a collaborative care pathway, donation request by a trained professional, and additional family support in the ICU by a trained nurse. The methodological quality of the studies was relatively low, mainly because of the study designs.

Conclusions

Although there is paucity of data, collaborative care pathways, training of healthcare professionals and additional support for relatives of potential donors seem to be promising interventions to increase the number of organ donors.

Trial registration

PROSPERO, CRD42018068185

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2509-3) contains supplementary material, which is available to authorized users.

Intensive care for organ preservation: A four-stage pathway

Objective

Intensive care for organ preservation (ICOP) is defined as the initiation or pursuit of intensive care not to save the patient's life, but to protect and optimize organs for transplantation.

Analysis

When a patient has devastating brain injury that might progress to organ donation this can be conceptualized as evolving through four consecutive stages: (1) instability, (2) stability, (3) futility and (4) finality. ICOP might be applied at any of these stages, raising different ethical issues. Only in the stage of finality is the switch from neurointensive care to ICOP ethically justified.

Conclusion

The difference between the stages is that during instability, stability and futility the focus must be neurointensive care which seeks the patient's recovery or an accurate neurological prognostication, while finality focuses on withdrawal of life-sustaining therapy and commencement of comfort care, which may include ICOP for deceased donation.

Organ Donation and Elective Ventilation: A Necessary Strategy

Organ transplantation is the sole treatment to improve or save the life of patients with final-stage organ failure. The shortage of available organs for transplantation constitutes a universal problem, estimating that 10% of patients on waiting lists die. Brain death is an undesirable result; nevertheless, it has beneficial side-effects since it is the most frequent source of organs for transplantation. However, this phenomenon is relatively uncommon and has a limited potential. One of the options that focuses on increasing organ donation is to admit patients with catastrophic brain injuries (with a high probability of brain death and nontreatable) to the Intensive Care Unit, with the only purpose of donation. To perform elective nontherapeutic ventilation (ENTV), a patient's anticipated willingness to donate organs and/or explicit acceptance by his/her relatives is required. This process should focus exclusively on those patients with catastrophic brain injuries and imminent risk of death which, due to its acute damage, are not considered treatable. This article defends ENTV as an effective strategy to improve donation rate, analyzing its ethical and legal basis.

Brain death

Since the Harvard report of 1968, the concept of brain death has become widely recognized throughout the world. Most developed countries have accepted brain death as constituting death of the individual, and allow such patients to be used as ‘heart-beating’ organ donors. Although the US and most other countries accept a ‘whole-brain’ definition of brain death, the concept of brainstem death has been adopted in the UK. This article describes the UK diagnostic criteria in detail, and compares these with the criteria used in other countries. Management of the brain dead organ donor is described, and controversies relating to the concept of brain death are also discussed.

Intensive care medicine and organ donation: exploring the last frontiers?

The main, universal problem for transplantation is organ scarcity. The gap between offer and demand grows wider every year and causes many patients in waiting list to die. In Spain, 90% of transplants are done with organs taken from patients deceased in brain death but this has a limited potential. In order to diminish organ shortage, alternative strategies such as donations from living donors, expanded criteria donors or donation after circulatory death, have been developed. Nevertheless, these types of donors also have their limitations and so are not able to satisfy current organ demand. It is necessary to reduce family denial and to raise donation in brain death thus generalizing, among other strategies, non-therapeutic elective ventilation. As intensive care doctors, cornerstone to the national donation programme, we must consolidate our commitment with society and organ transplantation. We must contribute with the values proper to our specialization and try to reach self-sufficiency by rising organ obtainment.

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.

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

Organ donation after brain death provides the most important source for deceased organs for transplantation, both because of the number of potential organ donors that it makes available and also because of the unparalleled viability of the organs retrieved. Analysis of worldwide deceased organ donation rates demonstrates that all countries with high deceased organ donation rates (>20 donors per million population per year) have high brain death rates (>40 brain deaths per million population per year). This analysis makes it clear that countries striving to increase their deceased organ donor rates to world leading levels must increase the rates of donation after brain death. For countries with end-of-life care strategies that stress palliation, advance care planning and treatment withdrawal for the terminally ill, the adoption of initiatives to meaningfully raise deceased donor rates will require increasing the rate at which brain death is diagnosed. This poses a difficult, and perhaps intractable, medical, ethical and sociocultural challenge as the changes that would be required to increase rates of brain death would mean conjugating an intimate clinical and cultural focus on the dying patient with the notion of how this person's death might be best managed to be of benefit to others.

Allow elective ventilation to recruit more organ donors

Transplantation surgery started >50 years ago and has developed into an established medical practice in many countries. We consider it positive if our dead body could be used as an organ or tissue donor. If transplanted, our organs confer other human beings with a longer and better life. There is, however, a relative lack of organs compared with the needs, and many potential recipients die while on the waiting list for transplantation.

Towards the creation of decellularized organ constructs using irreversible electroporation and active mechanical perfusion

BACKGROUND

Despite advances in transplant surgery and general medicine, the number of patients awaiting transplant organs continues to grow, while the supply of organs does not. This work outlines a method of organ decellularization using non-thermal irreversible electroporation (N-TIRE) which, in combination with reseeding, may help supplement the supply of organs for transplant.

METHODS

In our study, brief but intense electric pulses were applied to porcine livers while under active low temperature cardio-emulation perfusion. Histological analysis and lesion measurements were used to determine the effects of the pulses in decellularizing the livers as a first step towards the development of extracellular scaffolds that may be used with stem cell reseeding. A dynamic conductivity numerical model was developed to simulate the treatment parameters used and determine an irreversible electroporation threshold.

RESULTS

Ninety-nine individual 1000 V/cm 100-μs square pulses with repetition rates between 0.25 and 4 Hz were found to produce a lesion within 24 hours post-treatment. The livers maintained intact bile ducts and vascular structures while demonstrating hepatocytic cord disruption and cell delamination from cord basal laminae after 24 hours of perfusion. A numerical model found an electric field threshold of 423 V/cm under specific experimental conditions, which may be used in the future to plan treatments for the decellularization of entire organs. Analysis of the pulse repetition rate shows that the largest treated area and the lowest interstitial density score was achieved for a pulse frequency of 1 Hz. After 24 hours of perfusion, a maximum density score reduction of 58.5 percent had been achieved.

CONCLUSIONS

This method is the first effort towards creating decellularized tissue scaffolds that could be used for organ transplantation using N-TIRE. In addition, it provides a versatile platform to study the effects of pulse parameters such as pulse length, repetition rate, and field strength on whole organ structures.

Liver transplantation: Issues for the next 20 years

The growing numbers of potential transplant recipients on waiting lists is increasingly disproportionate to the supply of cadaveric donor organs. The hope for the next 20 years is that supply will satisfy demand. This requires both a reduction in indications for the procedure and an increase in the transplants performed. A multi-pronged approach is needed to increase cadaveric organ donation, generating enthusiasm for donation among both the general public and hospital staff. Accurate assessment of marginal grafts with stringent criteria known to predict graft function will diminish wastage of organs. Methods of rehabilitating marginal grafts during extracorporeal perfusion will increase organ availability. Supply of non-heart beating donors can be greatly expanded and protocols developed with ethical consent to optimize their initial function despite warm ischemia. Splitting livers that fulfill selection criteria, thus providing for two recipients, should be universally applied with acceptable incentives to those units who do not directly benefit. A proportion of recipients, though not those transplanted for autoimmune disease, will be spared the side-effects of immunosuppression thanks to immune tolerance. Protocols for close monitoring of those patients for rejection during treatment withdrawal must be carefully observed. In addition to gene therapy, it is highly likely that hepatocyte transplantation will replace orthotopic grafting in patients without cirrhosis, especially for inherited metabolic diseases. It is much more difficult to envisage that heterologous stem cell transplantation or xenotransplantation will have clinical impact in the next 20 years, although research in those areas has obvious long-term potential.

Emergency medicine, organ donation and the Human Tissue Act

The Human Tissue Act 2004, which governs all activity relating to the human body, organs or tissues, is grounded in the principle of fully informed consent in line with societal expectations. The associated intention to deal with the current deficit of transplantable organs has paradoxically been translated into the legitimisation of non-consensual organ preservation manoeuvres after death. The procurement strategy targeted under this new statute is "uncontrolled" non-heart-beating donation, and the clinical arenas would be accident and emergency departments and acute medical wards. Practitioners in these fields need to have an understanding of the process and the associated ethical, logistical and legal hurdles to defensible implementation. In the light of these hurdles, there is an obvious need for more widespread professional and public consultation before adoption of this programme.

Commentary on de Cock Buning: a United kingdom perspective

de Cock Buning (1998) highlighted the existence of alternative and more favorable options available to xenotransplantation. Clearly, there is a need to emphasize a review of existing organ procurement programs worldwide. A tree interest in the welfare of animals encourages increased liaison between transplant communities throughout the world to discuss the experiences of various procurement programs.

Non-heartbeating organ donation: clinical process and fundamental issues

This case report outlines the clinical process whereby a patient with severe traumatic brain injury became a non-heartbeating organ donor after a withdrawal-of-care decision. This process raises a series of ethical questions regarding decision-making on grounds of futility, the role of the next of kin, informed consent, the accommodation of manoeuvres directed towards organ retrieval at maximal viability, and the timing and determination of death. Although many aspects of the process can be accommodated within fundamental ethical principles and a broad interpretation of the concept of the 'best interests', the variance with established law requires authoritative clarification if a need for transplantable organs is to be responded to without compromising the reputation of practitioners involved in this area of care. Therefore, this recruitment strategy warrants wide public and professional debate to achieve longer-term sustainability and ensure the protection of all parties.

Variation in cadaveric organ donor rates in the UK

BACKGROUND

Considerable variation exists in the organ donation rate between kidney retrieval areas (KRAs) within the UK. The causes for this are unknown. This study examines whether or not observed variations are correlated with various possible explanatory factors.

METHODS

A geographical study involving Poisson regression analysis was carried out of all 21 KRAs in the UK in 1999 and 2000, with donor rate as dependent variable, and the following independent variables: road traffic accident, intracerebral haemorrhage and other trauma death rates; intensive care unit (ICU) bed numbers; co-location of transplant and neurosurgical units; population ethnicity; proportion of the population on the organ donor register; transplant coordinator numbers; and transplant unit numbers. Main outcome measures were: donor rate in each KRA; strength of association between independent and dependent variables; and magnitude of changes in the donor rate associated with changes in independent variables.

RESULTS

The donor rate varied between eight and 27.4 donors per million population per year. There was an association between donor rate and general ICU bed numbers (more beds associated with a higher donor rate), but this was of borderline statistical significance (P = 0.065). However, the donor rate was negatively associated (P = 0.02) with neurosurgical ICU bed numbers (more beds, fewer donors) and the proportion of the population from minority ethnic communities. There was no statistically significant association with the other independent variables.

CONCLUSIONS

There is significant variation in the organ donor rate between different parts of the UK. More research is needed to explore the counter-intuitive association between neurosurgical ICU beds and donations, and to determine the remaining causes of the observed variation.

Shortage of donation despite an adequate number of donors: a professional attitude?

BACKGROUND

A major problem in the field of transplantation is the persistent shortage of donor organs and tissues for transplantation. This study was initiated to (1) chart the donor potential for organs and tissue in The Netherlands and (2) to identify factors influencing whether donation is discussed with next of kin.

METHODS

A registration form was constructed to obtain information at time of death of patients about the demographic characteristics, diagnosis, and medical suitability for donation. A prospective study was conducted among 11 hospitals in The Netherlands that gathered 4,877 filled-in forms equaling 8% to 10% of the people dying in a hospital in The Netherlands per year.

RESULTS

In the year of the study, organs were retrieved from 22 donors and tissues from 264 donors in the 11 hospitals. The organ potential is estimated at a maximum of 38.7 per million population per year. A mere 5% of the physicians got a 100% score on criteria and contraindications for donation. Factors of influence on receiving consent for donation were the will of the donor, using a protocol, giving verbal information to the relatives, and presence of the partner of the deceased patient. For 26% of the potential tissue donors and 69% of the potential organ donors, donation was discussed with the relatives. Consent for tissue donation was obtained in 27%, and consent for organ donation was obtained in 60%.

CONCLUSIONS

In The Netherlands, when taking into account current refusal percentages, 320 to 360 organ donations and 5,800 tissue donations could be effectuated if organ donation is posed to all possible donors. For this, knowledge of medical criteria and contraindications for donation by the physicians and their willingness to discuss donation with next of kin must be improved.

Is there a future for transplantation as we know it today?

If I have to answer the question in the title, the answer will be yes and no. No, there is no future for transplantation, as we know it today. The practices and policies are constantly changing. I hope that in the near future the number of cadaveric donors will increase in most countries owing to improvements in procurement organizations and better medical management of donors. I doubt, however, that it is possible to attain the number of cadaveric donors realized in Spain. Some of us may live to see that the cadaveric donor pool has decreased. Maximized donation without financial incentives for donors or their surviving families will go a long way to meet the demand, but I fear that in the future there will be some financial incentives involved in donation. Yes, there is a future for transplantation and there always will be, but not for transplantation as we know it today The question is whether xenotransplantation or stem cell therapy will be there to take over as the number of allotransplants fail to meet the increasing demand for organ allografts, a demand that cannot be met by a judicious combination of organs from living and deceased donors.

Legal aspects of consent 12: organ donation after death

Tony has been severely injured in a road accident. He is 23 years old. His parents are told that he has serious brain damage and is unlikely to survive. They are asked if they would agree to the donation of his organs. What is the law?

Report of the Xenotransplantation Advisory Committee of the International Society for Heart and Lung Transplantation: the present status of xenotransplantation and its potential role in the treatment of end-stage cardiac and pulmonary diseases

An urgent and steadily increasing need exists world-wide for a greater supply of donor thoracic organs. Xenotransplantation offers the possibility of an unlimited supply of hearts and lungs that could be available electively when required. However, anti-body- mediated mechanisms cause the rejection of pig organs transplanted into non-human primates, and these mechanisms provide major immunologic barriers that have not yet been overcome. Having reviewed the literature on xenotransplantation, we present a number of conclusions on its present status with regard to thoracic organs, and we make a number of recommendations relating to eventual clinical trials. Although pig hearts have functioned in heterotopic sites in non-human primates for periods of several weeks, median survival of orthotopically transplanted hearts is currently ,1 month. No transplanted pig lung has functioned for even 24 hours. Current experimental results indicate that a clinical trial would be premature. A potential risk exists, hitherto undetermined, of transferring infectious organisms along with the donor pig organ to the recipient, and possibly to other members of the community. A clinical trial of xeno-transplantation should not be undertaken until experts in microbiology and the relevant regulatory authorities consider this risk to be minimal. A clinical trial should be considered when approximately 60% survival of life-supporting pig organs in non-human primates has been achieved for a minimum of 3 months, with at least 10 animals surviving for this minimum period. Furthermore, evidence should suggest that longer survival (.6 months) can be achieved. These results should be achieved in the absence of life-threatening complications caused by the immunosuppressive regimen used. The relationship between the presence of anti-HLA antibody and anti-pig antibody and their cross-reactivity, and the outcome of pig-organ xenotransplantation in recipients previously sensitized to HLA antigens require further investigation. We recommend that the patients who initially enter into a clinical trial of cardiac xenotransplantation be unacceptable for allotransplantation, or acceptable for allotransplantation but unlikely to survive until a human cadaveric organ becomes available, and in whom mechanical assist-device bridging is not possible. National bodies that have wide-reaching government-backed control over all aspects of the trials should regulate the initial clinical trial and all subsequent clinical xenotransplantation procedures for the foreseeable future. We recommend coordination and monitoring of these trials through an international body, such as the International Society for Heart and Lung Transplantation, and setting up a registry to record and widely disperse the results of these trials. Xenotransplantation has the potential to solve the problem of donor-organ supply, and therefore research in this field should be actively encouraged and supported.

Increasing the donor pool in Chile

The purpose of this study was to evaluate organ donation in Chile following the creation of the "Corporación Nacional de Fomento de Trasplantes." The corporation was created in 1991 as a private, nonprofit organization whose main purpose was to increase the number of actual donors and multiorgan procurement. The organization is independent of the national government and acts as a link between the needs of patients and society and those of the National Ministry of Health. Following the creation of the corporation, the number of actual donors increased from 32 to 98. The number of potential donors increased 3-fold. Family refusal for organ donation was between 28% and 53.4%. Pediatric and marginal donors increased from 2% to 15%. Ninety-five percent of the donors came from Santiago, where 33% of the population lives and most of the efforts were concentrated. The corporation is working to increase organ donation throughout the rest of the country by organizing public campaigns; promoting knowledge about transplantation among medical and nursing personnel at hospitals, schools, universities, and social gatherings; evaluating technical and financial results; and helping with the processes of organ procurement.

[Interviews with families of organ donors: analysis of motivation for acceptance or refusal of donation]

OBJECTIVE

The reasons for organ donation acceptance or refusal are still unclear. This study analysed the influence of the circumstances of the conversations with the relatives of brain dead patients on their consent for organ donation.

STUDY DESIGN

Prospective study.

MATERIAL

The analysis included 41 questionnaires collected over nine months in one organ harvesting centre and focusing on the circumstances of death, the conditions of the conversations and the reasons for acceptance or refusal.

METHODS

Questionnaire filled in by the physicians after the interviews of the relatives of brain dead patients.

RESULTS

The refusal rate was higher (54 vs 21%) when only one physician participated in the conversation, when more than two relatives had to decide (42 vs 24%), when conversations took place during night or when the request for organ donation followed immediately the announcement of death (43 vs 20%). Most often the relatives gave their decision within minutes following the request.

CONCLUSION

The circumstances of conversation with families play an essential role in their decision-making. A written guideline implementation for these conversations would probably be beneficial for the decisions of families in favour of organ donation.

[Admission modalities of brain dead patients at Ile de France hospitals which do not harvest organs. Cooperative Group for Transplantation of Ile de France (GCIF)]

In order to identify possible causes for the shortage in organ procurement today in France, a regional survey including 74 hospitals in the Paris area which are likely to receive brain dead patients (BDP) and in which there were neither harvesting nor transplantation activities was conducted. Of the 66 hospitals (89%) answering this survey, half of them were district general hospitals. In the 2 years before the survey, they received on average three BDP. Such a figure represents at least 10% of BDP seen in this area. For one half of the centres, care of these patients was difficult or impossible due to the available facilities. Organisational concerns were among the major problems raised by the transfer of these patients to harvesting centres. A preestablished geographical network would be of help for simplifying the transfer of these patients. Interestingly, about 50% of centres already had such links with a transplantation centre. This study provides information concerning logistics and possible points which could be improved in order to increase the number of BDP liable to be transferred to transplantation centres.

Organ transplant initiatives: the twilight zone

Assessments of the acceptability of new transplantation practices require a pinpointing of not only the meaning of death, but also the timing of death. They typically perceive elective ventilation as occurring just prior to death and non-heart-beating donor protocols as operative just after death. However, such practices in fact highlight the general vagueness and ambiguity surrounding these issues in both law and ethics. Supply-side dilemmas in transplantation lend real urgency to this "life or death" debate.

Non-therapeutic (elective) ventilation of potential organ donors: the ethical basis for changing the law

Non-therapeutic ventilation of potential organ donors would increase the supply of kidneys for transplantation. There are no major ethical objections to it. The means of permitting it are forbidden by laws with an ethical basis. A law permitting it would need an ethical basis. Introducing a third legal method of diagnosing death would be unethical. Expanding the power of the advance directive to permit procedures involving minimal harm would be ethical but not helpful. Extending the power of proxies to permit specific non-therapeutic procedures which caused or risked minimal harm to incompetent patients is the best way forward.

Ethical issues in organ procurement: a review for intensivists

The current state of organ procurement and the ethical issues raised by the procurement process are reviewed in this article. After an examination of the legislative framework governing organ procurement, the intensivist's role in donation is discussed, including (1) donor identification, (2) asking the family to donate, and (3) obtaining consent. Recent proposals for changing the organ procurement system are analyzed, including increasing family donation or increasing the donor pool.

Contemporary transplantation initiatives: where's the harm in them?

Two contemporary strategies in cadaver organ transplantation, both with the potential to affect significantly expanding organ transplant waiting list sizes, have evolved: elective ventilation (EV) and use of nonheart-beating donors (NHBDs). Both are undergoing a period of critical review. It is not clear how widely EV is practiced around the world. In Great Britain, the Royal Devon and Exeter Hospital was the first hospital to develop an EV protocol (the Exeter Protocol), in 1988, after which other British hospitals followed suit. In the 1980s, new NHBD protocols of two distinct types were implemented worldwide, although both rely on death confirmed by traditional cardiopulmonary criteria. The first type involves the removal of organs immediately after death, the preeminent example being the University of Pittsburgh Medical Center Protocol (the Pittsburgh Protocol). The second involves the perfusion and cooling of kidneys immediately following death and subsequent organ removal. Protocols of this type have sprung up in Holland, Great Britain (for example, at Leicester General Hospital), Italy, France, Spain, Japan, and the United States (for example, the Regional Organ Bank of Illinois).

Elective ventilation of potential organ donors

Elective ventilation describes the procedure of transferring selected patients dying from rapidly progressive intracranial haemorrhage from general medical wards to intensive care units for a brief period of ventilation before confirmation of brain stem death and harvesting of organs. This approach in Exeter has led to a rate of kidney retrieval and transplant higher than has been achieved elsewhere in the United Kingdom, with a stabilisation of numbers on patients on dialysis. Recently doubt has been cast on the legality of our practice of elective ventilation on the grounds that relatives are not permitted to consent to treatment of an incompetent person when that treatment is not in the patient's best interests. We are thus faced with the dilemma of a protocol that is ethical, practical, and operates for the greater good but which may be illegal. This article explores various objections to the protocol and calls for public, medical, and legal debate on the issues.

A survey of personal and professional attitudes of intensivists to organ donation and transplantation

A questionnaire survey was carried out to examine the attitudes and practices of Australian and New Zealand intensivists with regard to brain death and organ donation. A return rate of 82.5% was achieved. Fifty-eight per cent had written evidence of their own wishes to donate organs and 94% would agree to donation from a dependent. At least one intensivist is involved in certifying brain death on 95% of occasions. Intensivists are involved in the request for organ donation over 90% of the time although one-third do not believe that it is their role to request organ donation. Although two-thirds believe that the family should always be approached for organ donation, another 52 out of 254 indicated that it was their (the intensivist's) role to decide if families should be asked for organ donation. Possible reasons for not requesting are language or other communication problems, perceptions of cultural differences and degrees of family distress. Twenty per cent of respondents do not provide haemodynamic support before brain death confirmation. Australian and New Zealand intensivists overwhelmingly support the concept of brain death, current methods of confirmation of brain death, organ donation and transplantation. Possible reasons behind loss of potential donors include decisions not to resuscitate both before and after brain death is confirmed. Perceptions of family grief and cultural differences clearly inhibit requests for organ donation. A very few units have an effective policy on approaching families about organ donation. Intensivists have almost exclusive control over requests for organ donation and thus bear a full professional responsibility for this element of hospital practice.

Obtaining consent for organ donation in nine NSW metropolitan hospitals

Organ donation rates vary markedly around the world. In an attempt to analyse why some patients' families are not asked about organ donation, the case notes of 6080 patients who died over a twelve-month period from April 1991 to March 1992 in nine hospitals in Sydney, NSW, were studied. Irreversible coma occurred in 515 patients. Of these, 177 were considered to be potentially brain dead donors, 126 of whom had a formal diagnosis of brain death. The clinicians caring for the patients at the time of death were asked at follow-up about the reasons for not considering donation, or the reasons for family refusal. Consent to proceed to organ donation was requested in 112 cases (49 donated and 63 refused) and not requested in 65. Analysis of the proportions asked and consenting in each hospital revealed no correlation. Half of the families refusing gave no reason (24/50) while eleven gave religious or cultural reasons, and six expressed a desire to prevent mutilation of the body as their primary reason for not consenting. There was universal failure to gain consent from families when the patient was not in an Intensive Care Unit. Analysis of those patients of whom consent was not sought showed that they died more quickly after admission, were older and died from causes other than trauma or intracranial haemorrhage. The odds of the family being asked dropped by about half as the age increased from one group to the next.(ABSTRACT TRUNCATED AT 250 WORDS)

Can cadaveric organ donation rates be improved?

There are many reasons why potential cadaveric organ donors may fail to become actual donors. These include permission refusal by the next of kin, incorrect assumptions about medical suitability and, occasionally, an excessive workload in the intensive care unit. Some potential donors currently regarded in Australia as "unrealistic" might become actual donors if attitudes were to change towards ventilation of patients with a clearly hopeless prognosis who have expressed a wish to be organ donors. "Required request" legislation ignores the wishes of the potential donor and "presumed consent" laws also present some ethical difficulties, but a suggested "required response" process could ensure that an individual's wishes concerning organ donation would be known and able to be carried out after death. For the present, however, it is clear that operating within existing Australian legislation and abiding by currently accepted codes of practice, we can still find considerable scope for improving cadaveric organ donation rates.

Ethical issues in transplantation

The transplantation of gastrointestinal organs has relied on cadaver donors for its successful development. The fact that success has been achieved is largely due to the certainty with which brain death can be diagnosed, and the acceptance of these criteria as signifying actual death by doctors, in particular, intensivists. If continuing goodwill leads to further co-operative effort, cadaveric liver, pancreas and eventually, small bowel transplants, should become more frequent. At present the numbers of recipients requiring these operations are considerably less than those in need of kidneys. There are grounds for believing therefore that the pressure to subvert good ethical standards in acquiring these organs (that pressure imposed by long waiting lists and a high death rate on those waiting lists) should be avoidable. The solution to the problem of deficits in cadaveric liver and pancreatic grafts will be achieved only by better education of nurses and doctors, professionalization and expansion of co-ordinator organizations, legal reform, and cultural change. Only by such progress, achieved at medical, governmental, and societal levels can we avoid the insidious tendency to commercialism which we have witnessed with disquiet in renal transplantation.