The authors reply

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We thank Dr. Kramer (1) for his commentary on our article (2), recently published in Critical Care Medicine, and appreciate the opportunity to respond. Dr. Kramer (1) comments that the characteristics of our cohort of missed potential donors were “not presented, making it difficult to confidently assess whether they truly could have been donors.” It is important to note that we excluded all medically unsuitable patients from our analysis, leaving only those patients who would have been eligible donors by current standard criteria in Ontario. As stated in our methods, medical unsuitability was based on the requirements of individual transplant programs. Patients with hemodynamic or respiratory instability were considered medically unsuitable and not included, and none of the potential missed donors survived beyond the allowable timeframe to be eligible for donation after circulatory death (DCD).
The retrospective design of our study (2) limited our ability to present reasons for nonreferral, and we acknowledge that the prospectively recorded examples cited by Dr. Kramer (1) are cases in which the local organ procurement organization (OPO) may determine that DCD is not possible (1). However, in Canada, organ donation and transplantation programs are the responsibility of individual provincial and territorial governments, and donor organ eligibility criteria vary by jurisdiction (3). Clinicians who assume patients are medically unsuitable for organ donation based on their knowledge of local contraindications may be incorrect. Interprovincial organ sharing accounts for nearly 20% of transplants (3), with very few transplant centers defining absolute contraindications (4). In addition, current strategies to increase the number of transplants include the consideration of organs from “expanded-criteria” donors, who would have previously been considered ineligible, and advancements in ex vivo organ repair, whereby previously unusable organs are being assessed and rehabilitated (3). Even experienced clinicians may not be aware of donor organ eligibility for individual cases, and they should focus on other aspects of end-of-life care while the OPO determines whether donation is an option.
Even if highly sensitive prediction tools regarding probability of death shortly after withdrawal of life-sustaining therapy (WLST) become available, these should be used to provide next-of-kin with additional information rather than impede referral. Furthermore, clinicians should exercise caution to ensure that families’ explicit requests not to speak to an OPO representative are not prompted by the healthcare team, who may inadvertently mention organ donation or referral at inopportune moments. Several studies support the recommendation that a trained professional should raise donation discussions (5).
We acknowledge that although some jurisdictions within Canada require all dying patients be referred to the OPO, some jurisdictions do not yet feel comfortable offering donation to all dying patients in the ICU, negating the practice of early referral. However, referral to the OPO when the clinician identifies clinical triggers, such as grave prognosis or planned discussion for WLST, is by no means an “in-depth consideration of DCD by the healthcare team.” On the contrary, early referral allows issues surrounding eligibility and consent for organ donation to be managed by trained representatives, such that the treating clinician can focus on providing other aspects of end-of-life care. The clinician who chooses to exercise professional judgment regarding whether or not a patient meets criteria for donor organ eligibility or is likely to die shortly after WLST may be introducing as much bias into their practice as the clinician who participates in early referral.
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