Intensive Care Solely to Facilitate Organ Donation—New Challenges

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The shortfall of donor organs to meet the transplantation needs of people with organ failure drives initiatives to expand the donor pool. Effective public health measures have decreased the incidence of death from brain trauma and stroke, reducing the pool of “standard” brain-dead donors.1 This has led to the use of older expanded criteria donors and a greater emphasis on donation after circulatory death (DCD).2
A further, seldom discussed, and conceivably sizeable pool of potential donors are those in whom brain death may develop but where physiological supportive treatment is withdrawn or not instituted because of poor prognosis and lack of medical benefit to the patient.
In this issue of Transplantation, Domínguez-Gil et al describe the Spanish experience with this important group of potential donors and discuss their approach in providing intensive care for the sole purpose of facilitating organ donation.3 The article draws on patient data collected in 68 hospitals in Spain during the ACCORD initiative.4 It focuses on patients who died from devastating brain injury and whose families had been approached to consent for donation prior to brain death developing and at a point when ongoing treatment was deemed futile. Patients were in 1 of 3 scenarios at the time of family approach: 1) not intubated outside of the intensive care unit (ICU), that is, in the emergency department (ED) or general ward, 2) intubated outside of the ICU, and 3) intubated in the ICU.
Patients in whom consent was obtained received supportive treatments in ICU, including mechanical ventilation, for a period prenegotiated with the family to allow for brain death to occur (eg, 24 hours). Of these, 79% developed brain death and 72% went on to be organ donors, comprising 24% of all deceased donors during this period.
The report highlights several important issues and uncertainties. First, the patients described may signify a sizeable and underutilized pool of potential donors. Clinical practice will vary between regions, hospitals, and individual clinicians when it comes to prognostication, end-of-life care decision making, and ICU access, and these different approaches will influence the size of this donor pool and its subgroups. By way of example, depending on the hospital a patient is taken to, a 70-year-old with a massive intracerebral hemorrhage deemed nonsurvivable could be palliated without intubation in the ED, initially intubated and then palliated in the ED, intubated and admitted to the ICU as a matter of course, or only admitted to ICU for the purpose of donation if the family has provided consent. Clearly, the opportunity for donation is influenced by the clinical approach adopted in each institution.
Establishing hospital practices so that donation is routinely considered in such circumstances seems to be a reasonable goal. Many countries, including the United States, UK, and Australia, have clinical triggers to assist busy ED, ward, and ICU staff in identifying and referring such patients to donation personnel. This needs to be associated with a timely and appropriate assessment of the likelihood of brain death developing and medical suitability for donation. These judgments require considerable medical expertise and will be imperfect.
The family approach to seek consent for donation in these circumstances needs to include an explanation that donation is contingent upon brain death developing and an agreed duration negotiated with the family that they are prepared to wait for brain death to occur. Furthermore, the family needs to agree to continued or even additional supportive treatments, such as intubation and admission to ICU, and understand that they are for donation rather than to treat and aid possible survival of their relative.
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