Table 2 shows the end-of-life conditions of potential organ donors that were admitted to the ICU. At the time of decision to withdraw treatment, 43 patients (78.2%) were already mechanically ventilated and 12 (21.8%) were not (Table 2). Of these 12 patients, 5 patients were not intubated because the families objected to organ donation. The other 7 patients were subsequently intubated solely for the purpose of organ donation. Two of these 7 patients were intubated in anticipation of arrival of family members and turned out to be medically unsuitable for donation. Four were intubated after the family consented to intubation to make organ donation possible. Three of these 4 patients donated their organs and one patient was found to be medically unsuitable after additional testing. One of the 7 patients was registered with consent in the DR, and was intubated in anticipation of arrival of family members, after which the family agreed to donation.
In total, 42 donation requests (76.4%) were performed in the ICU (Table 2). In 5 cases, the possibility of organ donation was already discussed in the ED without making a formal donation request. In total, 6 donation requests (10.9%) were performed in the ED. Three patients that were admitted to the ICU solely for organ donation purposes came from the neurology department where their clinical condition had deteriorated to a state which led to a futile prognosis (Table 2).
In total, 27 families consented to organ donation (Table 2). In these 27 patients, 23 initiated organ donation procedures were performed leading to 20 successful donors (17 donation after brain death and 3 donation after circulatory death [DCD]). Ninety organs were transplanted (8 hearts, 12 pancreas, 39 kidneys, 17 livers, and 14 lungs). Also, 12 deceased patients became tissue donors. Seven consents did not lead to successful donations because these potential organ donors were considered to be medically unsuitable in the end (n = 5) or did not become brain dead and could not donate according to the age criteria for DCD (n = 2).
Potential Organ Donors Not Admitted to ICU
Some potential organ donors were not admitted to the ICU (Figure 2). Reasons for this were: objection to donation in the ED by next of kin (n = 4), limited availability of ICU beds (n = 1), and refraining from asking the donation question by the physician due to ethical reasons (n = 2). Four potential organ donors were not identified as such and were admitted to the neurology department. These 5 cases were evaluated according to the PDSA method and were discussed during staff meetings to further improve implementation of the approach.
Contribution of ED Donors on Total Donor Pool
Out of 5103 hospital deaths in the study period, there were in total 254 potential organ donors (5.0%). From these 254 potential organ donors, 55 patients were admitted to the ICU solely for the purpose of organ donation (Table 2). Of these 55 patients, 20 donated their organs. During the study period, a total of 69 patients donated their organs in the 6 hospitals. This means that in 29% of the total pool of organ donors in the participating hospitals, futility of prognosis was already made before admission to the ICU. In our study, the 3 donation after brain death donors with a futile prognosis at admission, donated on average 4.5 organs per donor compared with approximately 3.8 organs per donor nationwide in 2016. DCD donors donated on average 2.7 organs per donor in our study compared with 2.8 nationwide.
Ethical Problems and Improvements of the Approach
We have used multiple PDSA cycles to implement the approach. In the upcoming paragraphs, we would like to describe the outcomes of these cycles and the improvements we made to the approach.
First, before start of the implementation, several physicians in all participating hospitals foresaw problems explaining a nontherapeutic ICU admission to the family. Our approach was initially presented in such a way that the organ donation request was preferably decoupled from the conversation about futility of treatment to give the family more time to grieve. In most situations, this meant that donation was requested in the ICU. However, many of the treating physicians had ethical issues with such a setup, because it would mean they had to discuss that the patient would be admitted to the ICU to give the family more time to grieve without discussing organ donation in the ED. Before starting in the first hospital, we jointly adjusted the approach and included 2 possible options: (1) organ donation discussion would be done in the ED or (2) organ donation discussion would be deferred until after ICU admission (Figure 1). It was up to the treating team to choose which option would suit the specific patient case. We also included examples of how to inform the family in situations where Intensive Care to facilitate Organ Donation (ICOD) was a possibility. Although before starting the implementation, most physicians thought they would discuss organ donation the ED, their natural response when guiding these families in the ED was to defer organ donation discussion until after ICU admission. In 84% of all organ donation requests, organ donation was discussed in the ICU (Table 2). This was an important point for additional hospitals that started later with the implementation, but also for us as a team. Once we communicated that both options are possible in all circumstances, it was no longer seen as a problem. During the implementation, this point was evaluated specifically, and was not mentioned as an issue in any of the patient cases.
Second, several patient cases showed dilemmas regarding intubation of a patient with the sole purpose of organ donation. In a few of these cases, family was not present while the patient deteriorated rapidly. The dilemma was whether to intubate the patient before any consent from the family. We used these cases to educate physicians about the (legal) possibilities to intubate a patient for organ donation and discuss ethical issues.
Third, beforehand, several ICU physicians thought admission of such patients could be a problem due to bed capacity and availability of staff. Of the 67 patients where the decision to withdraw treatment was made in the ED, only one was not admitted due to bed capacity (Figure 2).
The typical organ donor is a patient that is treated in the ICU until clinical deterioration and subsequently becomes an organ donor. In this study, we showed that 20 patients donated their organs out of a cohort of 69 patients with a DBI with futile prognosis in the ED. This highlights the importance of a close collaboration between the ED and medical teams involved in organ donation. We showed that collaboration between such teams and the ED is feasible and important in donor identification, as we have shown that only a few potential organ donors were not recognized during the implementation period compared with an earlier cohort in the same hospitals.1
Other international studies have also shown that potential organ donors are missed in the ED.4,11,16-18 The College of Emergency Medicine and the British Transplantation Society reported that the ED has a poorly recognized, but important role in the identification and referral of patients who may be potential organ donors.2 One of their recommendations was to develop policies and guidelines that describe the care of a potential organ donor and plan the transfer of care of the potential donor from the ED to the ICU.
Several intervention studies aimed to improve identification and the care for potential organ donors in the ED.6,7,19,20 These studies implemented some kind of multidisciplinary approach for organ donation in the ED describing the triggers for identification of potential organ donors and the steps to be taken to make organ donation possible. In 2 studies, the implementation of such an approach resulted in an increased referral of potential organ donors to organ donation services, although many of these referrals did not lead to organ donation procedures.6,20 Other studies showed that most of the referrals from the ED led to successful donation procedures.7,11,14,19 Most of these studies were from Spain, where ICOD is more routine practice.3,7,11,14 A recent study of Martínez-Soba et al14 described their experience with an ICOD protocol comparable to the one we used in our study. While they performed a retrospective study focusing on patients in the ICU, emergency or hospital ward, we performed a prospective study focusing on patients where the futile medical prognosis was made by a multidisciplinary team in the ED.
In our study, 55 patients were admitted to the ICU to incorporate organ donation into end-of-life care. In 27 of these cases, their families consented to organ donation. One could argue that in the 28 cases where families objected, ICU resources were unnecessarily used. However, organ donation was often not the only reason to admit patients to the ICU. Most patients were intubated. In some cases, family members were not present at all in the ED. In others, family members needed more time to accept the loss of their loved one and make a decision on donation. These circumstances necessitate admission to the ICU, as most EDs are not equipped to have critically ill or intubated patients for prolonged periods of time. On the other hand, ICU resources are limited. In order to have efficient use of both ED and ICU resources, a multidisciplinary approach is needed in our opinion. This minimizes admission of a high number of potential organ donors to the ICU which are likely not to donate as was shown earlier by others.6,20
Our approach has multiple beneficial effects, which could justify the use of ICU resources for potential organ donors. First, it has been shown in the literature that donation could have a beneficial effect on the bereavement process for donorfamilies.21,22 Second, our approach could increase the number of organ donors. Although for many organs there is discussion whether organ transplantation reduces healthcare costs, it has been reported that it could reduce the costs in the case of kidney transplantation. For instance, transplantation of a kidney involves one-off costs, while the costs for dialysis are lifelong. For the Dutch situation, dialysis costs approximately 55 000 euros per patient per year. A kidney transplant costs 80 000 euros in the first year. Every year thereafter costs 8000 euros per patient for nephrological aftercare with medicines. After 15 years, the saving is 633 000 euros.23
The NeuroCritical Care Society recommended in 2015 to delay decisions regarding end-of-life care within the 72 hours in patients with DBI, regardless of organ donation potential, in order not to miss the small potential for good medical outcome.24 Others have also written in favor of delaying prognostication in cases of DBI.25 Delaying prognostication necessitates physical stabilization and admission to the intensive care. However, data from different countries, for example, the United Kingdom, The Netherlands, and the United States, show that organ donors are missed within those patients that die on the ED.1,9,10 For example, the NHS Blood and Transplant in the United Kingdom reports that from 2012 to 2016, there were over 1500 patients who died in the ED who met the criteria for referral as a potential donor. In three-quarters of these cases, donation was a possibility. However, only 46% of the potential organ donors were referred to the organ donation team and just 3% actually donated organs after death.9 After implementing our protocol, we showed that only 6% (4 of 67) potential organ donors were missed in the ED.
Organ donation awareness in the ED is important, because 29% of the total pool of organ donors in the participating centers presented in the ED with a fatal brain injury. This is comparable to what others reported.3,7 In addition, in a retrospective cohort study, it was shown that ED referrals for organ donation lead to more organs per donor than intensive care referrals.26
A limitation of our study is that, although a substantial proportion of our donors came from the ED, we cannot exactly define which patients would have been missed if our implementation strategy would not have been used. However, in an earlier report, we showed that there could be a substantial number of missed potential organ donors outside the ICU.1 The hospitals that participated in the data we present here were also part of that earlier study. A comparison with other hospitals that did not participate is not easy to make as the number of donors depends on several factors (eg, number of medically suitable potential donors, hospital type and protocol being used, and consent by family) and fluctuates over the years.5 Also, the primary aim of our study was to evaluate the implementation process, and not the effect it had on the number of potential donor identifications and referrals. Such an approach would necessitate 2 patient groups including randomization. Apart from not being our primary aim, it would also be ethically difficult to justify randomization and withholding an ICU admission in patients with a DBI, even if their prognosis was deemed futile. Although our previous cohort study and the data of this implementation period are not fully comparable, we have shown that in the implementation period only 4 out of 67 potential organ donors were missed (6%). This was significantly lower than our previous cohort, in which the number of unrecognized potential donors in the ED was 37 out of 98 potential donors outside the ICU (38%).
In conclusion, organ donors from the ED with a fatal brain injury are an important portion (29%) of the total pool of organ donors. The implementation of a multidisciplinary approach is feasible and could improve donation awareness in the ED and lead to better identification of potential donors in the ED.
We would like to thank all physicians and donation coordinators who were involved in this project for their contributions.
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