A 75 year old man with stage 3 chronic kidney disease and ischaemic heart disease was resuscitated from a witnessed out of hospital VF arrest. CT head on admission showed a large intracranial haemorrhage with midline shift and effacement of ventricles. Neurosurgical intervention was thought to be futile. There were some family members abroad, who wanted to be present when treatment was withdrawn so care was continued for 24 hours awaiting their arrival. On the day that treatment was planned to be withdrawn, the possibility of organ donation was raised by a team member. The specialist nurse for organ donation (SNOD) was contacted, but was delayed by several hours. The local ICU consultant made the initial approach to the family when they were all present which was promising. A subsequent conversation took place when the SNOD arrived. Consent for organ donation was eventually refused. The family felt that further delay to treatment withdrawal was inappropriate.
How can we improve rates of consent for organ donation on the ICU?
Prad Shanmugasundaram
As intensive care physicians we frequently deal with bereaved families and have a responsibility to maximise organ donation opportunities. However we rarely receive specific training on how to plan, approach and optimise our discussions with relatives. This lack of training has been identified as an area for improvement.
Early in 2013, the NHS Blood and Transplant (NHSBT) service announced that there had been a 50% increase in deceased organ donors over the previous five years, meeting a challenge set by the Organ Donation Taskforce in 2008. However, consent for organ donation rates in the UK still lag behind rates in other countries despite a positive public perception and a high level of public support for organ donation in the UK (1).
One of the recommendations of the Taskforce five years ago was in the introduction of a network of specialist nurses in organ donation (SN-ODs) who are specially trained to support families and coordinate and facilitate the complicated process of organ donation (2). Several national bodies, including NICE, NHSBT and the UK Donation Ethics Committee, have issued guidance over the last few years that advocate the involvement of SN-ODs at the earliest stage in the organ donation process, before the family approach takes place (2-4).
This model of collaborative requesting was assessed in the ACRE trial (5), a prospective multicentre trial comparing a collaborative approach with a donor transplant co-ordinator compared with routine requesting by the clinical team in 201 relatives of brain stem dead patients5. The trial found no difference in rates of consent for organ donation between routine and collaborative requesting. The findings in this trial were unexpected and directly contradicted observational data from other countries.
The subsequent published guidance from relevant organisations have largely acknowledged the ACRE trial findings, but have highlighted methodological issues with the trial. These issues were also discussed in a recent review of consent for organ donation (6). Their conclusion is that whoever approaches the family is more likely to receive consent if they have appropriate expertise and training. The role of the SN-ODs is to fill that gap in training that intensivists may have.
Perhaps most convincingly, the NHSBT publish yearly audit data since 2009/10 on the number of approaches made, and the number of successful donations resulting from the approaches. Their data shows a clear and consistent increase in successful consent when SN-ODs are involved at an early stage after deceased brain death (~70% vs ~50%) and deceased cardiac death (~70% vs ~35%) compared to approaches made without a SN-OD present (7).
Lessons learnt:
Organ donation is one of the most complicated processes undertaken in the NHS. A single donor has the potential to transform the lives of numerous others, whether it is a life-saving or sight restoring intervention. We have a mandate to maximise the identification of potential donors and the success of these approaches. Significant investment has been made over the last few years in establishing a network of specialist nurses to facilitate and co-ordinate this process. The audit data collected over the last 3-5 years unequivocally shows higher rates of successful consent when SN-ODs are involved in those discussions. The recommendations are that SN-ODs are involved at the earliest stages; indeed, involving a SN-OD may well be the first step in planning an approach. The onus is now on intensivists to engage with this network to maximise organ donation opportunities.
References:
1. http://www.organdonation.nhs.uk
2. Approaching the families of potential organ donors. NHS Blood and Transplant: Best Practice Guidance 2013
3. National Institute for Health and Clinical Excellence (December 2011). Organ donation for transplantation: improving donor identification and consent rates for deceased organ donation. http://guidance.nice.org.uk/CG135
4. An ethical framework for controlled donation after circulatory death. UK Donation Ethics Committee. Academy of Medical Royal Colleges, December 2011 Available at: http://aomrc.org.uk/publications/reports-a-guidance.html
5. The ACRE Trial Collaborators. Effect of ‘collaborative requesting’ on consent rate for organ donation: randomised controlled trial (ACRE trial). Br Med J 2009; 339: b3911
6. Vincent A, Logan L. Consent for organ donation. BJA (2012) 108 Suppl 1:i80-7
7. Potential Donor Audit, Summary for the 12 Month Period 1 April 2011 – 31 March 2012. NHS Blood and Transplant. Available from: http://www.organdonation.nhs.uk/ukt/statistics/potential_donor_audit/pdf/pda_report_1112.pdf
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