Organ and tissue procurement in the acute care setting: principles and practice--Part 1

The Physician's Perspective: A Survey of Attitudes toward Organ Donor Management

The demand for suitable organs in the United States greatly outweighs the supply of transplantable organs. It has been estimated that approximately half of all potential donors do not donate. Preexisting barriers seem to impede donation, and the physician is a vital link in this process. To better understand the physician's perspective and to identify barriers that may produce difficulties in the process, a survey of physicians in northern Ohio was conducted. Respondents identified the following barriers: consensus in tests performed in the diagnosis of death is lacking, ambivalence exists with respect to informing families of the patient's death and offering families the donation option, and physicians do not seem to recognize the importance of decoupling the discussion of brain death from the request for organs. Although physicians surveyed were in favor of donation and transplantation, an effort should be made to increase awareness in personal attitudes that may affect the donation process.

The importance of emergency medicine in organ donation: successful donation is more likely when potential donors are referred from the emergency department

OBJECTIVES

This study sought to identify factors that are associated with successful organ retrieval among patients referred to organ procurement services for potential organ donation. Particular attention was paid to the frequency, patient characteristics, and outcomes of patients referred for donation from the emergency department (ED).

METHODS

For this retrospective cohort study, data were collected on all solid-organ donor referrals made to a single organ procurement organization serving 78 hospitals over a 45-month period. Data retrieved included patient age, sex, race, referral site (ED vs. inpatient), and mechanism of injury. Outcome of referral (organs retrieved or not) was the primary outcome variable. Pearson chi-square and Student's t-tests were used for bivariate statistical analysis. Multiple logistic regression analysis was used to determine which variables remained associated with organ retrieval after controlling for potential confounders.

RESULTS

A total of 6,886 donor referrals were made in the study population. Of these, 155 were excluded due to incomplete data, leaving 6,731 subjects for analysis. Using bivariate statistical analysis, we found that successful organ retrieval was associated with younger age (donor mean age 40.8 years, 95% confidence interval [CI] = 39.1 to 42.5 vs. nondonor mean age 59.4, 95% CI = 58.9 to 59.9), mechanism of injury (p < 0.001), and referral from the ED (ED 15.5% retrieved, inpatient 5.9%, odds ratio [OR] = 2.92, 95% CI = 2.32 to 3.67). After controlling for potential confounders with multiple logistic regression, referral from the ED remained significantly associated with successful organ retrieval (OR = 1.52, 95% CI = 1.18 to 1.97), as did age (OR = 0.96, 95% CI = 0.96 to 0.97) and mechanism of injury (p < 0.001). On regression analysis, race emerged as a significant predictor of organ retrieval (p < 0.001). Medically suitable patients referred from the ED were significantly more likely on bivariate analysis to have consent for donation granted compared to patients referred from inpatient settings (OR = 1.48, 95% CI = 1.03 to 2.12), but this association was not found to be significant on regression analysis (OR = 1.37, 95% CI = 0.93 to 2.02).

CONCLUSIONS

Referral of potential organ donors from the ED is associated with an increased likelihood of successful organ retrieval. The authors conclude that further attention and resources should be directed toward the role of emergency medicine (EM) in the organ procurement process, owing to the relatively high likelihood of successful organ retrieval among patients referred from the ED.

Patient and family attitudes regarding the practice of procedures on the newly deceased

Performance of emergency lifesaving procedures is an integral part of emergency medicine resident training.

OBJECTIVE

To assess attitudes of ED patients regarding the practice of procedures on the newly deceased.

METHODS

A descriptive survey was administered to a convenience sample of ED patients and their families at two urban military Level-1 trauma centers. Subjects were asked about their overall opinions regarding the practice of nontherapeutic procedural skills on themselves or relatives immediately after death in the ED. Subgroup analysis included the issue of advanced permission and opinions regarding procedures defined by the investigators as noninvasive (e.g., laryngeal mask airway) or invasive (e.g., cricothyrotomy). Data were analyzed descriptively and with chi-square as appropriate. For comparison of proportions, a sample size of at least 140 was chosen for an alpha of 0.05 and a beta of 0.10 to detect an effect size of 0.3. Alpha was corrected for multiple comparisons prior to the study.

RESULTS

Three hundred seventeen surveys were collected and 88% (n = 280) were complete. Seventy-five percent (n = 290) and 70% (n = 273) of the respondents agreed to after-death procedures on themselves or their relatives, respectively. However, only 40% (n = 106) and 50% (n = 131) would allow such procedures without prior permission. Seventy-one percent (n = 189) were willing to give permission in a living will, while 85% (n = 238) indicated support of a wallet card format. There was no significant difference in permission rates when contrasting individual noninvasive and invasive procedures.

CONCLUSION

Most patients are willing to have procedures performed on themselves or relatives shortly after death, yet the majority request that permission be obtained in advance. A living will or carried card would be acceptable for such permission.

Death in the emergency department

Issues regarding the deaths of patients in the ED arise on a regular basis for emergency physicians. These issues include physician discomfort with death notification, the approach to families after ED deaths, autopsies, donation of organs and tissues, and procedures on the newly dead. If physicians were more comfortable with death notification, not only would families be better served but benefits to society could be realized through the increased use of autopsy and organ/tissue donation. The controversial topic of physician education through practice of medical procedures on the newly dead weighs the benefits to society against the rights of the individual. Improved physician education, including the need for a death notification plan and enlistment of the support of nursing personnel, social workers, and clergy, may improve the experience of events surrounding ED deaths for physicians, families, and society. We review the literature and give recommendations on approaches to deal with these issues.

The physician's perspective: a survey of attitudes toward organ donor management

The demand for suitable organs in the United States greatly outweighs the supply of transplantable organs. It has been estimated that approximately half of all potential donors do not donate. Preexisting barriers seem to impede donation, and the physician is a vital link in this process. To better understand the physician's perspective and to identify barriers that may produce difficulties in the process, a survey of physicians in northern Ohio was conducted. Respondents identified the following barriers: consensus in tests performed in the diagnosis of death is lacking, ambivalence exists with respect to informing families of the patient's death and offering families the donation option, and physicians do not seem to recognize the importance of decoupling the discussion of brain death from the request for organs. Although physicians surveyed were in favor of donation and transplantation, an effort should be made to increase awareness in personal attitudes that may affect the donation process.

Feasibility of obtaining family consent for teaching cricothyrotomy on the newly dead in the emergency department

STUDY OBJECTIVE

To determine whether family members of recently deceased emergency department patients would consent to the performance of a cricothyrotomy on the deceased for educational purposes.

DESIGN

Prospective study.

SETTING

Suburban tertiary care teaching hospital.

PARTICIPANTS

Family members of 51 patients older than 18 years who were pronounced dead in the ED from atraumatic causes.

INTERVENTIONS

Family members were approached by an attending physician for consent to perform a cricothyrotomy as a learning opportunity for physicians on their recently deceased family members. If consent was given, the procedure was performed by an emergency medicine resident physician under the attending physician's supervision.

RESULTS

Of 51 deaths, 20 families (39%) consented to postmortem cricothyrotomy, 23 families (45%) refused consent, and 8 families (16%) were too distraught to be approached for consent. All 20 families that consented to the procedure were white, with little representation from other ethnic groups.

CONCLUSION

Although there are difficulties in obtaining consent to perform invasive procedures on the recently deceased in the ED for educational purposes, our study demonstrates that many families will consent to such procedures if adequate information and explanation are provided. The results of this study may not be applicable to institutions serving patients with different cultural and ethnic backgrounds.

Organ and tissue donation from the emergency department

Despite mandatory request legislation, the lack of available donor organs and tissues continues to limit transplant efforts. The potential contribution from emergency department (ED) patients remains undefined. We reviewed the charts of patients dying in our ED for organs and tissues potentially suitable for transplantation, age, cause of death, and physician documentation of donation inquiry. Of 155 charts reviewed, potential donors were identified for corneas (99), bones (61), heart valves (42), and kidneys (3). Of the 155 charts, 130 (84%) made no mention of donation, and of 37 charts containing a donor request form, 34 (92%) were incorrectly filled out or left blank. Four charts (2.6%) mentioned donation in the narrative section, two (1.3%) documented discussion with family, and one patient was referred to our Organ Procurement Organization, with recovery of one kidney and heart valves. We conclude that physicians rarely document consideration of donation for patients dying in the ED; the number of potential donors far exceeds the number referred or recovered. Future efforts should focus on methods to increase recognition and referral of organ and tissue donors from the ED.