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pool of potential donors are those in whom brain death may develop but where physiological supportive treatment is withdrawn or not instituted because of poor prognosis and lack of medical benefit to the patient.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. Families who are committed to donation often accept extending the duration of supportive ICU treatment despite the uncertainty of donation outcome, as regularly occurs in the context of controlled DCD. These types of complex communications need to be undertaken by highly skilled staff with donation knowledge and training and experience in these scenarios. Ensuring such expertise is available to families when possible donor situations arise, particularly those in ED that may be within hours of devastating brain injury onset, is a further challenge in pursuing donation in these situations.
The undertaking of intubation and nontherapeutic ventilation for donation is the most contentious subgroup described in this report. In some countries, such practices have been disallowed in law or by governing bodies, mostly because of being considered harmful and not in the best interests of the patient.5 Similar determinations have been made for certain antemortem interventions specific to DCD (eg, heparin administration).6 However, as the authors point out, a person’s best interests are increasingly recognized to extend beyond their physical well-being and to include consideration of their values and beliefs, including wishes with respect to donation.7 Nonetheless, the law in some countries may not enable substitute decision makers for incompetent patients to consent to overt practices such as initiating intubation and mechanical ventilation nor potentially any form of intensive care for the purpose of facilitating organ donation.8
Perhaps the biggest challenge in seeking to replicate the results of this approach in other countries will be transplant unit acceptance practices. The donor pool described in this report is relatively old (mean age, 69 years), and Spain is renowned for having high utilization of older donor organs.9 The very patient characteristics that contribute to a determination of poor prognosis and a decision for early limitation or withdrawal of treatment may be the same that preclude the person from being suitable to donate organs for transplantation.
This group of potential donors warrants greater understanding, given the complexity around the ethical, legal, community, and medical acceptability of this approach. Further accounts of this practice in other contexts are required using prospectively collected data that report the outcome of all patients in whom provision of intensive care is considered solely for organ donation. This will provide guidance with case selection and information about those patients who do not proceed to brain death and donation, including any adverse patient and family outcome. Organ utilization relative to the number of patients in whom intensive care to facilitate donation is attempted and the impost on ICU resources will be important as efficiency determinants. Ultimately, the applicability of this approach is likely to depend on existing clinical practice, ethical and legal frameworks, and family and community acceptance.
1. Bendorf A, Kerridge IH, Kelly PJ, et al. Explaining failure through success: a critical analysis of reduction in road and stroke deaths as an explanation for Australia's low deceased organ donation rates. Intern Med J
3. Domínguez-Gil B, Coll E, Elizalde J, et al. Expanding the donor pool through intensive care to facilitate organ donation: results of a Spanish multicenter study. Transplantation
4. Achieving Comprehensive Coordination in Organ Donation throughout the European Union—ACCORD. Available at: http://http://www.accord-ja.eu
/. Published 2017. Accessed February 2017.
5. UK Donation Ethics Committee. Nontherapeutic elective ventilation. A discussion paper. Available at: http://www.aomrc.org.uk
/category/publications/reports-guidance/ukdec-reports-and-guidance/. Published April 2016. Accessed February 2017.
6. UK Department of Health. Non-heartbeating organ donation: legal issues. Available at: http://www.dh.gov.uk
/publications. Published 20 November 2009. Accessed February 2017.
7. UK Donation Ethics Committee. An ethical framework for controlled organ donation after circulatory death. Available at: https://bts.org.uk/wp-content/uploads/2016/09/An-Ethical-framework-for-controlled-donation-after-circulatory-death-Full-Report.pdf. Published December 2011.
8. NSW Health. Discussion paper: the use of ante mortem (before death) interventions for organ donation in NSW 2016. Available at: http://www.health.nsw.gov.au
/legislation/Documents/discussion-paper-organ-donation.pdf. Accessed February 2017.
9. Halldorson J, Roberts JP. Decadal analysis of deceased organ donation in Spain and the United States linking an increased donation rate and the utilization of older donors. Liver Transpl