Intensive Care Med DOI 10.1007/s00134-015-3833-y
Beatriz Domı´nguez-Gil Paul Murphy Francesco Procaccio
WHAT’S NEW IN INTENSIVE CA RE
Ten changes that could improve organ donation in the intensive care unit
Received: 20 January 2015 Accepted: 17 April 2015
physiology of the brain dead donor is optimized, and that family refusals are minimized [4]. We list below ten changes that could help improve these processes (Fig. 1):
Ó Springer-Verlag Berlin Heidelberg and ESICM 2015 Foreword: The necessary use of specific technical terms in this manuscript should not be understood as disrespectful to organ donors, their families, and their invaluable contribution to life. B. Domı´nguez-Gil ()) Organizacio´n Nacional de Trasplantes, C/Sinesio Delgado 6, pabello´n 3, 28029 Madrid, Spain e-mail: [email protected] Tel.: ?34 902 300224 P. Murphy NHS Blood and Transplant, Bridle Path, Leeds, UK F. Procaccio National Transplant Centre-Italian Health Institute, Rome, Italy
In March 2010, the Third WHO Global Consultation on Organ Donation and Transplantation (‘The Madrid Resolution’) called on countries to pursue self-sufficiency in transplantation in compliance with the WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation [1]. This included a call to maximize donation by incorporating it in all appropriate end-of-life care pathways. This recommendation is consistent with the progressively more accepted principle that end-of-life care decision making should be based upon an assessment of best interests that extends beyond a patient’s physical needs, to encompass broader ethical, social, moral and welfare issues, including wishes towards donation [2, 3]. Successful donation programmes have a fundamental reliance on the timely identification, referral and assessment of all possible donors. It is equally important that brain death is diagnosed whenever possible, that the
1. Routine referral Patients identified as possible organ donors should be routinely referred to the donor transplant coordinator (DTC) or corresponding organ procurement organization (OPO). In the recent ACCORD project, 35 % of patients dead as a result of a devastating brain injury in European hospitals were never referred, thus removing the option of organ donation [4]. If legally possible, early referral, e.g. when a patient’s death is considered inevitable and imminent and when treatments switch from active therapies to end-of-life care, has many advantages [5–7]. Assessment of the patient as a potential donor can begin earlier, reducing subsequent delays for both the intensive care unit (ICU) and the donor family. Specialist assistance with brain death testing and physiological optimization can be identified and the family approach for donation can be prepared more carefully. Checking compliance with routine referral should be standard practice. Retrospective chart reviews of patients who die from a devastating brain injury, particularly those conditions that are known to be common causes of brain death [8], allows evaluation of compliance with referral criteria. In case of noncompliance, efforts should be made to understand the underlying root causes—such as limited ICU resources—and educate ICU professionals in the routine referral policy. 2. Clinical triggers for donor identification Clinical triggers facilitate the routine identification of all possible organ donors, and take the form of specific medical criteria which when met should result in referral to the DTC/OPO [5–7, 9]. Clinical triggers
3.
4.
5.
6.
7.
should be developed by a panel of experts, and be simple, clearly defined, and easy to audit. Accurate donor assessment External audits have revealed 11 % of the decisions not to refer a potential donor on medical grounds to be incorrect [10]. All possible donors should be referred regardless of apparent medical contraindications, with decisions about medical suitability being made by the DTC/ OPO and the corresponding transplant teams, not treating physicians. Systematic brain death testing Brain death testing is not undertaken when this is a likely diagnosis in up to 21 % of cases in European hospitals, this representing an important unrealized opportunity for organ donation [4]. Testing for brain death should be performed whenever relevant criteria are met, regardless of whether organ donation seems likely [11]. In countries with a controlled donation after circulatory death (DCD) programme, shifting towards the DCD pathway at this time point should be avoided unless there is no option for donation after brain death (DBD). Goal-directed optimization of the DBD donor It is important to continue critical care management in order to correct the deranged physiology associated with brain death as soon and effectively as possible. This management should be directed towards sustaining or improving organ viability, and needs to be underpinned by training and protocols that are based upon evidence-based, goal-directed donor management strategies. The prospective implementation of nine donor management goals in eight OPOs in the US has resulted in an impressive number of C4 organs transplanted per donor [12]. Appropriate family approach to discuss the option of organ donation The family approach for donation should be planned and conducted by treating physicians and DTC/OPO staff working together [7, 13]. Every effort should be made to ensure that only professionals specifically trained in this area are in charge of the family approach, and that they are aware that organ donation should never be presented until the family has understood and accepted the inevitability of their loss. The approach should take donor-specific issues into account, and always be tailored to the cultural, religious and social needs of the family. Education and training Donation is an uncommon activity for most ICU professionals. If donation is to be systematically incorporated into end-of-life care,
it is vital that all staff who care for possible donors receive comprehensive training on the topic throughout their career. 8. Audit and performance management Accurate audit of practice is a pre-requisite of any attempt to improve donation processes. It allows opportunities for improvement to be identified and change interventions (e.g., those applied in selected European hospitals in ACCORD—http://www.accord-ja.eu) to be assessed. On-going data collection at local, regional and national levels is a prominent feature of all successful donation programmes [10]. 9. Clinical champions for organ donation The identification of an ICU clinician to ‘champion’ organ donation in their unit has many benefits. Champions can raise awareness amongst staff, provide education and training, and act as liaisons between ICU and DTC/ OPO staff. In Spain, a leading country in deceased donation, this takes the form of dedicated ICU physicians appointed as in-house DTC [14], while in the UK the introduction of clinical leads for donation has been associated with a 63 % increase in deceased donation rates over the last 6 years (http://www.odt.nhs.uk). Clinical leadership within the ICU should be supported by the hospital organization. 10. Donation as part of end-of-life care The primary duty of a physician caring for a patient with catastrophic brain injury is to preserve life. However, when brain death has developed or it has been recognised that further active treatments are no longer in the best interests of a patient, the duties of a doctor shift to palliation and end-of-life care. Philosophies which regard organ donation as a component of that care allow the physician to make this transition without fear of appearing conflicted. Whilst the emergence of such philosophies may be hampered by existing legal frameworks and will require considerable professional and public debate, very often they have their origins in an ICU rather than a court or government office [15]. End-of-life care and organ donation are heavily influenced by legal and ethical frameworks that reflect prevalent religious, cultural, and social values [16]. Whilst not all the changes listed here may be achievable by ICUs in isolation, it is nevertheless true that they can have a profound impact upon both the availability of donor organs and also the number of patients who have donation incorporated into their end-of-life care.
Organ donation as part of end-of-life care
Organ donation as part of end -of-life care • Education and training
• Audit and performance management
Possible organ donor • routine referral • clinical triggers for identification* • accurate donor assessment • systematic brain death testing • goal-directed donor optimization • best practice in family approach
Actual organ donor • Clinical leadership
Organ donation as part of end-of-life care
Fig. 1 Operational and strategic changes that promote organ donation within a philosophy of end-of-life care (a possible organ donor is a patient whose death is imminent and inevitable and who will die in such a way that organ donation can be considered. An actual organ donor is a patient from whom at least one organ has been retrieved for the purposes of transplantation after his/her death)
Organ donation as part of end-of-life care *Examples of clinical triggers are: (1) patients who have had a catastrophic brain injury and absence of one or more cranial nerve reflexes and a GCS score ≤4 not explained by sedation, unless there is a clear reason why the above clinical triggers are not met (e.g., sedation) and/or a decision has been made to perform brain death tests, whichever is the earlier; and (2) intention to withdraw life-sustaining treatment in patients with a life-threatening or life-limiting condition which will, or is expected to, result in circulatory death. (http://www.odt.nhs.uk/pdf/timelyidentification-and-referral-potential-donors.pdf). Imminent brain death defined as either a GCS of 3 and the progressive absence of at least three out of six brainstem reflexes, or a FOUR score of E0M0B0R0 [17]
Acknowledgments These recommendations represent key features Conflicts of interest On behalf of all authors, the corresponding of organ donation systems in a number of European and North author states that there is no conflict of interest. American countries. The authors wish to acknowledge the contributions of Dr Julien Charpentier (Service de Re´animation me´dicale. Groupe Hospitalier Cochin. APHP. Paris Cedex. France) and Dr Teresa Pont (Donor Transplant Coordination Unit. Hospital Universitari Vall d´Hebro´n. Barcelona. Spain) to their development.
References 1. The Madrid Resolution on organ donation and transplantation: national responsibility in meeting the needs of patients, guided by the WHO principles. Transplantation 91(Suppl 11):S29–31 2. Guide on the decision-making process regarding medical treatment in end-oflife situations. http://www.coe.int/t/dg3/healthbioethic/ Activities/09_End%20of%20Life/ default_en.asp. Accessed April 2015
3. UK Donation Ethics Committee. An ethical framework For controlled donation After circulatory death. http://www.aomrc.org.uk/doc_view/ 9425-an-ethical-framework-forcontrolled-donation-after-circulatorydeath. Accessed April 2015 4. ACCORD Consortium. Variations in end-of-life care pathways for patients with a devastating brain injury in Europe. Deliverable 7 (interim report). http://www.accord-ja.eu/sites/default/ files/download_documents/ InterimReportFinalMarch2014.pdf. Accessed April 2015
5. Domı´nguez-Gil B, Delmonico FL, Shaheen FA, Matesanz R, O’Connor K, Minina M et al (2011) The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation. Transpl Int 24(4):373–378 6. Shafer TJ, Wagner D, Chessare J, Schall MW, McBride V, Zampiello FA et al (2008) US organ donation breakthrough collaborative increases organ donation. Crit Care Nurs Q 31(3):190–210
7. Good practice guidelines in the process 11. Organs for transplants. A report from the 14. Matesanz R, Domı´nguez-Gil B, Coll E, de la Rosa G, Marazuela R (2011) organ donation taskforce. of organ donation. http://www.ont.es/ Spanish experience as a leading http://www.nhsbt.nhs.uk/to2020/ publicaciones/Documents/VERSI% country: what kind of measures were resources/Organsfortransplants C3%93N%20INGLESA%20MA taken? Transpl Int 24(4):333–343 TheOrganDonorTaskForce1streport.pdf. QUETADA_2.pdf. Accessed April 15. Thomas I, Caborn S, Manara AR (2008) Accessed April 2015 2015 Experiences in the development of non8. Matesanz R, Coll E, Domı´nguez-Gil B, 12. Malinoski DJ, Patel MS, Daly MC, heart beating organ donation scheme in Oley-Graybill MC, Salim A, UNOS de la Rosa G, Marazuela R, Arra´ez V a regional neurosciences intensive care Region 5 DMC workgroup (2012) The et al (2012) Benchmarking in the unit. Br J Anaesth 100(6):820–826 impact of meeting donor management process of donation after brain death: a 16. Sprung CL, Cohen SL, Sjokvist P, goals on the number of organs methodology to identify best performer Baras M, Bulow HH, Hovilehto S et al transplanted per donor: results from the hospitals. Am J Transpl (2003) End-of-life practices in United Network for Organ Sharing 12(9):2498–2506 European intensive care units: the region 5 prospective donor management 9. A short clinical guideline on organ ethicus study. JAMA 290(6):790–797 goals study. Crit Care Med donation. National Institute for Health 17. De Groot YJ, Jansen NE, Bakker J, 40:2773–2780 and Care Excellence. Kuiper MA, Aerdts S, Maas AI et al http://www.nice.org.uk/guidance/cg135. 13. Approaching the families of potential (2010) Imminent brain death: point of organ donors. Best practice guidance. Accessed April 2015 departure for potential heart-beating http://www.odt.nhs.uk/donation/ 10. de la Rosa G, Domı´nguez-Gil B, ´ lvarez organ donor recognition. Intensive Care deceased-donation/consentMatesanz R, Ramo´n S, Alonso-A Med 36:1488–1494 authorisation/nhsbt-best-practice.asp. J, Araiz J et al (2012) Continuously Accessed April 2015 evaluating performance in deceased donation: the Spanish quality assurance program. Am J Transpl 12(9):2507–2513
Beatriz Domı´nguez-Gil Paul Murphy Francesco Procaccio
WHAT’S NEW IN INTENSIVE CA RE
Ten changes that could improve organ donation in the intensive care unit
Received: 20 January 2015 Accepted: 17 April 2015
physiology of the brain dead donor is optimized, and that family refusals are minimized [4]. We list below ten changes that could help improve these processes (Fig. 1):
Ó Springer-Verlag Berlin Heidelberg and ESICM 2015 Foreword: The necessary use of specific technical terms in this manuscript should not be understood as disrespectful to organ donors, their families, and their invaluable contribution to life. B. Domı´nguez-Gil ()) Organizacio´n Nacional de Trasplantes, C/Sinesio Delgado 6, pabello´n 3, 28029 Madrid, Spain e-mail: [email protected] Tel.: ?34 902 300224 P. Murphy NHS Blood and Transplant, Bridle Path, Leeds, UK F. Procaccio National Transplant Centre-Italian Health Institute, Rome, Italy
In March 2010, the Third WHO Global Consultation on Organ Donation and Transplantation (‘The Madrid Resolution’) called on countries to pursue self-sufficiency in transplantation in compliance with the WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation [1]. This included a call to maximize donation by incorporating it in all appropriate end-of-life care pathways. This recommendation is consistent with the progressively more accepted principle that end-of-life care decision making should be based upon an assessment of best interests that extends beyond a patient’s physical needs, to encompass broader ethical, social, moral and welfare issues, including wishes towards donation [2, 3]. Successful donation programmes have a fundamental reliance on the timely identification, referral and assessment of all possible donors. It is equally important that brain death is diagnosed whenever possible, that the
1. Routine referral Patients identified as possible organ donors should be routinely referred to the donor transplant coordinator (DTC) or corresponding organ procurement organization (OPO). In the recent ACCORD project, 35 % of patients dead as a result of a devastating brain injury in European hospitals were never referred, thus removing the option of organ donation [4]. If legally possible, early referral, e.g. when a patient’s death is considered inevitable and imminent and when treatments switch from active therapies to end-of-life care, has many advantages [5–7]. Assessment of the patient as a potential donor can begin earlier, reducing subsequent delays for both the intensive care unit (ICU) and the donor family. Specialist assistance with brain death testing and physiological optimization can be identified and the family approach for donation can be prepared more carefully. Checking compliance with routine referral should be standard practice. Retrospective chart reviews of patients who die from a devastating brain injury, particularly those conditions that are known to be common causes of brain death [8], allows evaluation of compliance with referral criteria. In case of noncompliance, efforts should be made to understand the underlying root causes—such as limited ICU resources—and educate ICU professionals in the routine referral policy. 2. Clinical triggers for donor identification Clinical triggers facilitate the routine identification of all possible organ donors, and take the form of specific medical criteria which when met should result in referral to the DTC/OPO [5–7, 9]. Clinical triggers
3.
4.
5.
6.
7.
should be developed by a panel of experts, and be simple, clearly defined, and easy to audit. Accurate donor assessment External audits have revealed 11 % of the decisions not to refer a potential donor on medical grounds to be incorrect [10]. All possible donors should be referred regardless of apparent medical contraindications, with decisions about medical suitability being made by the DTC/ OPO and the corresponding transplant teams, not treating physicians. Systematic brain death testing Brain death testing is not undertaken when this is a likely diagnosis in up to 21 % of cases in European hospitals, this representing an important unrealized opportunity for organ donation [4]. Testing for brain death should be performed whenever relevant criteria are met, regardless of whether organ donation seems likely [11]. In countries with a controlled donation after circulatory death (DCD) programme, shifting towards the DCD pathway at this time point should be avoided unless there is no option for donation after brain death (DBD). Goal-directed optimization of the DBD donor It is important to continue critical care management in order to correct the deranged physiology associated with brain death as soon and effectively as possible. This management should be directed towards sustaining or improving organ viability, and needs to be underpinned by training and protocols that are based upon evidence-based, goal-directed donor management strategies. The prospective implementation of nine donor management goals in eight OPOs in the US has resulted in an impressive number of C4 organs transplanted per donor [12]. Appropriate family approach to discuss the option of organ donation The family approach for donation should be planned and conducted by treating physicians and DTC/OPO staff working together [7, 13]. Every effort should be made to ensure that only professionals specifically trained in this area are in charge of the family approach, and that they are aware that organ donation should never be presented until the family has understood and accepted the inevitability of their loss. The approach should take donor-specific issues into account, and always be tailored to the cultural, religious and social needs of the family. Education and training Donation is an uncommon activity for most ICU professionals. If donation is to be systematically incorporated into end-of-life care,
it is vital that all staff who care for possible donors receive comprehensive training on the topic throughout their career. 8. Audit and performance management Accurate audit of practice is a pre-requisite of any attempt to improve donation processes. It allows opportunities for improvement to be identified and change interventions (e.g., those applied in selected European hospitals in ACCORD—http://www.accord-ja.eu) to be assessed. On-going data collection at local, regional and national levels is a prominent feature of all successful donation programmes [10]. 9. Clinical champions for organ donation The identification of an ICU clinician to ‘champion’ organ donation in their unit has many benefits. Champions can raise awareness amongst staff, provide education and training, and act as liaisons between ICU and DTC/ OPO staff. In Spain, a leading country in deceased donation, this takes the form of dedicated ICU physicians appointed as in-house DTC [14], while in the UK the introduction of clinical leads for donation has been associated with a 63 % increase in deceased donation rates over the last 6 years (http://www.odt.nhs.uk). Clinical leadership within the ICU should be supported by the hospital organization. 10. Donation as part of end-of-life care The primary duty of a physician caring for a patient with catastrophic brain injury is to preserve life. However, when brain death has developed or it has been recognised that further active treatments are no longer in the best interests of a patient, the duties of a doctor shift to palliation and end-of-life care. Philosophies which regard organ donation as a component of that care allow the physician to make this transition without fear of appearing conflicted. Whilst the emergence of such philosophies may be hampered by existing legal frameworks and will require considerable professional and public debate, very often they have their origins in an ICU rather than a court or government office [15]. End-of-life care and organ donation are heavily influenced by legal and ethical frameworks that reflect prevalent religious, cultural, and social values [16]. Whilst not all the changes listed here may be achievable by ICUs in isolation, it is nevertheless true that they can have a profound impact upon both the availability of donor organs and also the number of patients who have donation incorporated into their end-of-life care.
Organ donation as part of end-of-life care
Organ donation as part of end -of-life care • Education and training
• Audit and performance management
Possible organ donor • routine referral • clinical triggers for identification* • accurate donor assessment • systematic brain death testing • goal-directed donor optimization • best practice in family approach
Actual organ donor • Clinical leadership
Organ donation as part of end-of-life care
Fig. 1 Operational and strategic changes that promote organ donation within a philosophy of end-of-life care (a possible organ donor is a patient whose death is imminent and inevitable and who will die in such a way that organ donation can be considered. An actual organ donor is a patient from whom at least one organ has been retrieved for the purposes of transplantation after his/her death)
Organ donation as part of end-of-life care *Examples of clinical triggers are: (1) patients who have had a catastrophic brain injury and absence of one or more cranial nerve reflexes and a GCS score ≤4 not explained by sedation, unless there is a clear reason why the above clinical triggers are not met (e.g., sedation) and/or a decision has been made to perform brain death tests, whichever is the earlier; and (2) intention to withdraw life-sustaining treatment in patients with a life-threatening or life-limiting condition which will, or is expected to, result in circulatory death. (http://www.odt.nhs.uk/pdf/timelyidentification-and-referral-potential-donors.pdf). Imminent brain death defined as either a GCS of 3 and the progressive absence of at least three out of six brainstem reflexes, or a FOUR score of E0M0B0R0 [17]
Acknowledgments These recommendations represent key features Conflicts of interest On behalf of all authors, the corresponding of organ donation systems in a number of European and North author states that there is no conflict of interest. American countries. The authors wish to acknowledge the contributions of Dr Julien Charpentier (Service de Re´animation me´dicale. Groupe Hospitalier Cochin. APHP. Paris Cedex. France) and Dr Teresa Pont (Donor Transplant Coordination Unit. Hospital Universitari Vall d´Hebro´n. Barcelona. Spain) to their development.
References 1. The Madrid Resolution on organ donation and transplantation: national responsibility in meeting the needs of patients, guided by the WHO principles. Transplantation 91(Suppl 11):S29–31 2. Guide on the decision-making process regarding medical treatment in end-oflife situations. http://www.coe.int/t/dg3/healthbioethic/ Activities/09_End%20of%20Life/ default_en.asp. Accessed April 2015
3. UK Donation Ethics Committee. An ethical framework For controlled donation After circulatory death. http://www.aomrc.org.uk/doc_view/ 9425-an-ethical-framework-forcontrolled-donation-after-circulatorydeath. Accessed April 2015 4. ACCORD Consortium. Variations in end-of-life care pathways for patients with a devastating brain injury in Europe. Deliverable 7 (interim report). http://www.accord-ja.eu/sites/default/ files/download_documents/ InterimReportFinalMarch2014.pdf. Accessed April 2015
5. Domı´nguez-Gil B, Delmonico FL, Shaheen FA, Matesanz R, O’Connor K, Minina M et al (2011) The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation. Transpl Int 24(4):373–378 6. Shafer TJ, Wagner D, Chessare J, Schall MW, McBride V, Zampiello FA et al (2008) US organ donation breakthrough collaborative increases organ donation. Crit Care Nurs Q 31(3):190–210
7. Good practice guidelines in the process 11. Organs for transplants. A report from the 14. Matesanz R, Domı´nguez-Gil B, Coll E, de la Rosa G, Marazuela R (2011) organ donation taskforce. of organ donation. http://www.ont.es/ Spanish experience as a leading http://www.nhsbt.nhs.uk/to2020/ publicaciones/Documents/VERSI% country: what kind of measures were resources/Organsfortransplants C3%93N%20INGLESA%20MA taken? Transpl Int 24(4):333–343 TheOrganDonorTaskForce1streport.pdf. QUETADA_2.pdf. Accessed April 15. Thomas I, Caborn S, Manara AR (2008) Accessed April 2015 2015 Experiences in the development of non8. Matesanz R, Coll E, Domı´nguez-Gil B, 12. Malinoski DJ, Patel MS, Daly MC, heart beating organ donation scheme in Oley-Graybill MC, Salim A, UNOS de la Rosa G, Marazuela R, Arra´ez V a regional neurosciences intensive care Region 5 DMC workgroup (2012) The et al (2012) Benchmarking in the unit. Br J Anaesth 100(6):820–826 impact of meeting donor management process of donation after brain death: a 16. Sprung CL, Cohen SL, Sjokvist P, goals on the number of organs methodology to identify best performer Baras M, Bulow HH, Hovilehto S et al transplanted per donor: results from the hospitals. Am J Transpl (2003) End-of-life practices in United Network for Organ Sharing 12(9):2498–2506 European intensive care units: the region 5 prospective donor management 9. A short clinical guideline on organ ethicus study. JAMA 290(6):790–797 goals study. Crit Care Med donation. National Institute for Health 17. De Groot YJ, Jansen NE, Bakker J, 40:2773–2780 and Care Excellence. Kuiper MA, Aerdts S, Maas AI et al http://www.nice.org.uk/guidance/cg135. 13. Approaching the families of potential (2010) Imminent brain death: point of organ donors. Best practice guidance. Accessed April 2015 departure for potential heart-beating http://www.odt.nhs.uk/donation/ 10. de la Rosa G, Domı´nguez-Gil B, ´ lvarez organ donor recognition. Intensive Care deceased-donation/consentMatesanz R, Ramo´n S, Alonso-A Med 36:1488–1494 authorisation/nhsbt-best-practice.asp. J, Araiz J et al (2012) Continuously Accessed April 2015 evaluating performance in deceased donation: the Spanish quality assurance program. Am J Transpl 12(9):2507–2513
