Organ Donation: Critical Questions

Sandralee Blosser, MD, FCCM*
Director of Adult Critical Care
Penn State Milton Hershey
Medical Center
Hershey, Pennsylvania, USA

Gerard Fulda, MD, FCCM**
Christiana Care Health System
Newark, Delaware, USA

Look for the publication of this consensus statement addressing both DBDD and DCDD patients in 2010. Visit LearnICU.org for more information on the management of organ donation.

Caring for the potential organ donor patient is an integral part of critical care practice, and the multiprofessional intensive care unit (ICU) team has a special role in ensuring humane end-of-life care during this delicate process. By design, the critical care team does not actually perform organ transplants, but its members play a major role in several aspects of organ donation. Most obviously, ICU professionals work together on the many aspects of care such as referral of patients to the Organ Procurement Organization (OPO), tending to the needs of the family, assisting with consent, and determination of brain death and the appropriate time to withdraw life support. The ICU team has great influence over the number of organs ultimately transplanted and in maximizing this gift of life in a respectful and responsible manner.

Many hospitals have their own policies, procedures, guidelines and standards of care that vary by institution, region, state and OPO. Despite hundreds of references on the topic, the majority of the literature is limited to retrospective reviews and small series. Few prospective studies specifically address the critically ill organ donor.

To help standardize the care delivered to potential organ donors, the American College of Critical Care Medicine (ACCM), in collaboration with several other professional societies, is developing an evidence-based consensus statement addressing this topic. This statement, supported by the most up-to-date literature, will serve as a practical tool for ICU caregivers.

Representatives from the Society of Critical Care Medicine (SCCM) and the American College of Chest Physicians (ACCP) are co-chairing a task force charged with developing a comprehensive document on the care of the critically ill potential organ donor. Other organizations participating on the task force include the American Thoracic Society (ATS), the United Network for Organ Sharing (UNOS), the Health Resources and Services Administration (HRSA), and the Association of Organ Procurement Organizations (AOPO). This multi-organization approach ensures that the final product will be a valuable resource for ICU caregivers, OPO staff and transplant surgeons.

The objectives of this effort are two-fold: 1) humane, respectful, appropriate treatment of the potential donor, and 2) provision of donor care that facilitates optimum organ functioning in the recipient. Topics covered in the consensus statement include:

• Donation after brain death determination (DBDD)
• Donation after circulatory death determination (DCDD)
• General contraindications to donation
• Consent process
• Hemodynamic management
• Endocrine dysfunction and hormone replacement therapy
• Organ-specific donation, such as lung, liver, kidney, small bowel and pancreas
• Miscellaneous management issues
• Pediatric considerations
• Areas for future research

Treating the Patient. Care of the potential organ donor begins at ICU admission. The goal is to provide optimum care throughout the patient’s stay, including at the time of death and throughout the actual organ procurement process. The consensus statement assesses methods of care beneficial to both the critically ill patient as well as the potential organ donor. In caring for the DCDD patient, most goals focus on providing the same level of 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. Thus, the goals of management are to maintain adequate blood pressure, intravascular volume and cardiac output to ensure preservation of organ function.

Obtaining Consent. At or near the time of death, the ICU team in conjunction with the OPO obtains consent from family members or the patient’s spokesperson. Designation of donor status on a driver’s license may be used as consent. Administration of medications or performance of procedures for the purpose of organ donation may not be performed without proper consent.

Determining Death. Death, which always precedes organ donation (Dead Donor Rule), may be determined using neurologic criteria or circulatory-respiratory criteria. The majority of transplanted organs derive from patients who have been declared dead based on the cessation of cerebral function – DBDD.

As demand for organs far exceeds the supply, two strategies have emerged to increase supply. One is to expand criteria for selecting suitable donors, particularly with kidney donation (referred to as Extended Donor Criteria). The second is to increase utilization of DCDD. Following recommendations from the Institute of Medicine, the last decade has seen an increase in organs obtained from patients declared dead following the cessation of circulatory function. This option is used when the patient does not meet the criteria for brain death, but the family wishes to withdraw medical therapy and still donate organs.

Disclosures:

* Author has no disclosures to report

** Author has no disclosures to report