Organ and tissue donation

Essentials

1
Organ donation should be considered for all patients where death is expected. Suitability for donation should be discussed with an organ donation specialist.
2
A substantial numbers of missed potential organ and tissue donors can be identified in emergency departments (EDs) and intensive care units (ICUs).
3
Clinical triggers have been introduced in Australian EDs to assist with the early identification of potential donors.
4
Knowledge of pathways to donation and the skills required to commence donation discussions may decrease the numbers of missed potential donors and improve the numbers of organ and tissue donors.
5
Admission to an ICU should be considered for any intubated patient in the ED in whom end-of-life care is considered. This can facilitate early family discussions, timely prognostication and consideration of organ and tissue donation if appropriate.

Introduction

Transplantation has become the therapy of choice for patients with end-stage organ failure. However, worldwide, there are not enough organs available to meet the demand for those on transplantation waiting lists. In Australia at any one time, there are approximately 1400 people awaiting organ transplantation. In 2017, there were 519 deceased organ donors in Australia and 1675 transplant recipients. Between 2007 and 2016, over 1000 patients were admitted to Australian and New Zealand intensive care units (ICUs) primarily to assess their suitability for organ donation; of these, almost two-thirds came directly from the emergency department (ED).

In Australia there is a relatively small pool of potential donors, as less than 2% of patients who die in hospital are eligible to donate their organs. Despite this scarcity there is potential to increase the number of organ donors through higher consent rates, improved identification, increased resources for education, coordination, surgical retrieval and transplantation services. Despite high rates of community support for donation, consent rates for donation (approximately 60%) have changed little. Identification of missed opportunities for organ donation may have the greatest impact on donor numbers. Missed opportunities include situations where life-sustaining therapies are withdrawn in patients with imminent or potential brain death, particularly in the ED; patients who may be suitable but with whom donation is never raised owing to clinicians’ unwillingness to discuss donation; resource pressures; and an incorrect perception that a patient may not be medically suitable.

Although the donation of solid organs is a rare opportunity, eye and tissue (e.g. skin, bone, heart valves and connective tissues) donation can occur up to 24 hours after death and may be applicable to a larger population of patients, especially those in the ED. Few absolute contraindications to donation exist. Liver donation has occurred from patients over 80 years of age. HIV is no longer an absolute contraindication and organs are commonly donated from patients with a history of hepatitis C. Corneal donation may even be possible in patients with metastatic and hematological malignancies in whom the donation of other organs and tissue is not possible.

Emergency practitioners play an important role in the donation process. Within Australia, there is strong support for organ donation amongst ED staff, particularly amongst those who have had specific training and experience with organ donation. Lack of education, resources and time are commonly identified by ED staff as barriers to donation. However, donors identified in the ED have a greater rate of proceeding to successful donation than those referred from other inpatient critical care settings. Emergency clinicians are ideally placed to exhibit positive attitudes toward donation, support donation, identify and support potential donors and help families to make informed decisions about donation.

Donation pathways

The initial critical step in making organ donation a reality is to recognize the potential donor. These are usually ventilated patients in the ED or ICU who are expected to die often of neurological injuries but also potentially from non-neurological conditions.

Donation after brain death

The majority of deceased organ donations in Australia (70%) occur following brain death. Criteria to diagnose brain death vary slightly in different countries but essentially depend on the loss of capacity for consciousness and the ability to breathe. If preconditions are met (e.g. no effects of sedating drugs and a diagnosis consistent with producing severe brain injury), brain death may be diagnosed clinically by demonstrating loss of all brain-stem reflexes. A clinical diagnosis of brain death cannot be made until a period of observation has elapsed (minimum 4 hours in Australia). Thus brain death is rarely diagnosed in the ED, but patients who might become brain dead are commonly identified there. When clinical testing is not possible, imaging tests (e.g. cerebral angiogram, nuclear medicine scan and computed tomography [CT] angiography) may be performed. The donation of heart, lungs, liver, pancreas, bowel and kidneys from one brain-dead donor can lead to up to eight organ transplants.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here