Management of the Potential Organ Donor in the ICU

2015 - 6 December - Quality Improvement
Sandralee Blosser, MD, FCCM; Gerard Fulda, MD, FCCM
This article centers on a document released jointly by SCCM and two of its medical society partners addressing the management of potential intensive care unit organ donors.

The Society of Critical Care Medicine (SCCM), the American College of Chest Physicians and the Association of Organ Procurement Organizations joined together to create a document that clarifies best practice for management  of the critically ill potential organ donor (Kotloff R, et al. Crit Care Med. 2015; 43(6):1291-1325). The multiorganization approach allows for a comprehensive document that can be a resource for intensive care unit (ICU) caregivers, organ procurement organizations (OPOs) and transplant surgeons.

Providing care for the patient who is a potential organ donor is an integral part of both critical care and humane end-of-life care. This document discusses the process of donation, from the ICU team identifying the patient to the OPO, to caring for the patient, to interacting with and caring for the family, to securing authorization for donation, to determining brain death or withdrawal of life support, to pronouncing the patient.  Although the critical care team does not perform organ transplants, the care provided by the team can have a great impact on the number of organs transplanted and the functioning of those organs.

Care of the critically ill potential organ donor is an essential component of intensive care medicine. Due to significant variation in patient care, SCCM determined a clinical practice guideline or consensus statement for care of the critically ill organ donor would help to standardize the care for potential organ donors. The goal was that the document be practical, interpreted in general practice and supported by the current literature.  Despite hundreds of references, the majority of the literature is limited to retrospective reviews and small series with few prospective studies addressing the critically ill organ donor. Therefore, it was determined that a consensus statement was the most appropriate document to produce. 

The document focuses on two main areas: 1) humane, respectful, appropriate treatment of the potential donor, and 2) provision of donor care that will facilitate the optimum functioning of the donated organs in the recipients. Topics covered include: death determination using neurologic criteria, donation after circulatory determination of death, general contraindications to donation, the  authorization process, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management issues, and organ system-specific considerations.

Management of the potential organ donor begins from the time that the patient is admitted to the ICU. The goal is to provide optimum care throughout the hospital course, including at the time of death and up until organ donation occurs.  One goal of the document is to demonstrate care that may be beneficial to both the critically ill patient as well as the potential organ donor. The ideal care of these patients should provide a smooth transition from a potential organ donor to a realized organ donor and maximize the number of organs able to be transplanted. This approach of providing optimal care treats the patient with dignity and increases the number of available organs following the patient death.

Death, which always precedes organ donation (dead-donor rule), may be determined by using neurologic criteria (donation after brain death determination [DBDD]) or circulatory-respiratory criteria (donation after circulatory death determination [DCDD]). The majority of organs transplanted are derived from donors who have been declared dead based on the cessation of neurologic function (DBDD). The current demand for organs exceeds the supply, which has led to exploring other means of increasing the donor pool. Two strategies have evolved to increase the supply. One is to expand criteria for selecting suitable organs, particularly the kidney, referred to as “extended donor criteria”; the second is to utilize donation after circulatory death. Following recommendations from the Institute of Medicine has increased the number of organs obtained from patients declared dead following the cessation of circulatory function. This option for declaring death has been used when the patient does not meet the criteria for the determination of brain death and the family desires to withdraw medical therapy and still donate organs. 

The consensus statement addresses care of both the DBDD and DCDD patient. For the DCDD patient, this involves giving the same comfort care that a patient would receive if he or she were not an organ donor, including administration of analgesia, suctioning of the airway, and other measures of comfort until death. Care of the DBDD patient may be more complex, as the patient often becomes unstable after brain death.  The goals of management are to maintain adequate blood pressure, intravascular volume, and cardiac output, and the preservation of organ function.

The document includes tools that can be used by the practitioner, such as the Checklist for Determination of Brain Death, criteria for prediction of brain death after withdrawal of care, and Pediatric Donor Management Goals. This document serves as a complete reference for ICU practitioners caring for the potential organ donor.