Supplementary memorandum by Dr Paul Murphy
1. Provision of ICU facilities in the UK compared
with our European neighbours and correlation with organ donation
1.1 It is commonly held, particularly amongst
transplant surgeons, that the poor UK performance on organ donation
can be attributed to a relative lack of critical care capacity,
at least in part. This proposition would seem to imply that lack
of ICU beds results in patients who die in the wrong place and
in the wrong way, and in so doing lose their potential to donate
their organs after death.
1.2 I am not sure that the evidence for
this argument is particularly persuasive. Thus, whilst it is true
that the UK has fewer critical care beds than many of our European
neighbours, there appears to be no correlation between ICU beds
(as % of total acute hospital bed capacity) and donation rates,
as shown in the table below:
|
| Country | ICU Beds / 100
acute beds
| donors per million
population
|
|
| UK | 2.6 |
12.8 |
| Austria | 2.8
| 24.8 |
| France | 3.0
| 22.2 |
| Spain | 3.2
| 35.1 |
| Germany | 3.3
| 14.8 |
| Holland | 3.5
| 14.6 |
| Belgium | 3.7
| 23.8 |
| Denmark | 4.1
| 11.9 |
|
1.3 Thus whilst Austria, France and Spain all identify
many more donors with only a modest increase in ICU beds, Denmark
has many more beds but performs even worse than the UK in the
identification of deceased donors.
1.4 In addition, the Potential Donor Audit indicates
that there is a large cohort of patients who die on ICU—literally
hundreds each year—who could have been donors had brainstem
death tests been performed or donation systematically considered.
1.5 This is not to say that there will not be occasions
when patients lose their potential to donate because a decision
is made not to admit to ICU on the grounds that it would be futile
to so do, and therefore contrary to the best interests of the
patient. The clearest example I know of is the circumstance of
a patient with a catastrophic brain haemorrhage in an Emergency
Department—it can be clear even at this early stage that
admission to ICU would offer no prospect for recovery, and I suspect
that even though to admit to ICU would at the very least preserve
the potential to donate, increasingly this does not happen—rather,
patients die in the Emergency Department or in a ward side room,
and are thereby denied their opportunity to donate. I stress that
such management is driven more by beliefs around best interests
and futility that an absolute shortage of critical care facilities.
2. The Potential Donor Audit (PDA)
2.1 From the outset we need to understand the limitations
of the PDA—it is a retrospective and incomplete audit conducted
by donor transplant co-ordinators (agents who perhaps have an
interest in the outcome of the audit). Nevertheless, it offers
a powerful insight into deceased donation in the UK.
2.2 The committee is obviously aware of the headline
findings of the PDA, perhaps the most contentious of which is
the suggestion that there may be in excess of 500 patients each
year who were likely to have been brainstem dead, but who were
not tested and who were thereby effectively denied the potential
to donate. I have recently conducted a subanalysis of this group
of patients to try to understand why brainstem death tests were
not performed, finding the following:
|
| Reason for not testing | % incidence
|
|
| cardiovascular instability | 30
|
| unknown | 28
|
| residual neurological function (ie not brain dead)
| 15 |
| family refusal (for donation) | 11
|
| inability to perform brainstem death tests |
8 |
| medical contra-indications to donation |
6 |
| others | 2
|
|
2.3 Cardiovascular instability is common in brainstem
death, but is usually easily correctable, implying that some clinicians
are reluctant to take such measures (because they recognise that
this will not prevent the patient's death) even though the potential
to donate will be lost.
2.4 In my opinion this is a large cohort of patients
in whom, were management to be different, a substantial number
of additional heart beating donors could be identified.
2.5 There is another group of patients in whom donation
is not considered even though brainstem death has been confirmed.
There are approximately 200 such patients annually. My analysis
indicates that, when known, reasons for not pursuing the option
of donation include (apparent) medical contra-indication, prior
knowledge that the family will refuse to give consent, and obstruction
by the Coronial service or CID.
2.6 Non heart beating organ donation (NHBOD) should be
considered separately—it is a form of donation that is under
development and is currently only supported by a minority of intensive
care units—perhaps as few as 20% of the total nationwide
(as suggested by recent data from the Potential Donor Audit where
NHBOD was considered in only 632 deaths from a total of 1,835
suitable cases). The committee should recognise that many ICUs
are actively resistant to the introduction of NHBOD—certainly
in the absence of a binding and authoritative statement on the
ethico-legal probity of the process.
2.7 NHBOD refers to the retrieval of organs from patients
who suffer a cardiac death following the withdrawal of treatment
that has been judged to be futile, and necessarily requires the
potential to donate to be considered before death has occurred.
Current ethico-legal objections to NHBOD include:
2.7.1 The potential for conflict of interest between decision
making over futility and the potential to subsequently donate,
and the personal liability that clinicians might thereby be exposed
to.
2.7.2 The potential unlawfulness of delaying the withdrawal
of treatments that have been adjudged futile in order to allow
time for a surgical retrieval tema to assemble on the donor hospital
site, since such a delay is seen to be in the interests of a third
party (ie an organ recipient) rather than the dying patient.
2.7.3 The current lack of a robust definition of cardiac
death in the UK.
2.8 I would advise the Committee that NHBOD is work in
progress, and that although the numbers of non heart beating donors
in the UK is increasing, the big gains are to be found in systematically
applying best practice to the identification and management of
brainstem dead donors. It is perhaps of interest to note that
NHBOD from ICU is practically non existent in Spain, and elsewhere
in the world is a form of donation introduced because of poorly
performing heart beating programs.
3. What do ICU staff perceive as the main obstacles to
donation?
3.1 Many UK ICUs will have only one to two deceased donors
per year, whereas units such as mine might see as many as 20.
AS a result, I am not sure whether there is any single one answer
that captures the views of a profession whose exposure to and
focus on deceased donation varies some much—indeed, many
ICU will not register it as a problem at all, because it is not
viewed as core business of the unit at all. In contrast, others
feel profoundly irritated that they are perceived in failing to
identify sufficient donors (an necessary element of which is,
of course, the death of their patients), and there is a healthy
degree of suspicion of the transplantation agenda in general and
UK Transplant in particular.
3.2 For those who take a more balanced overview, I suspect
that the following views might appear:
3.2.1 High relative refusal rate.
3.2.2 On-going ethico-legal obstacles that focus on the
degree to which "best interests" justifies the alteration
of the way in which a patient dies in order to pursue donation
after death.
3.2.3 Lack of resource to treat the living, never mind
the dead—the management of a potential organ donor is labour
intensive, particularly of a consultant's time, and almost always
extends well beyond the end of the working day.
3.3 It is not at all clear who ICU staff will react to
a system of presumed consent for organ donation. Neither the Intensive
Care Society, nor the Royal College of Anaesthetists have a formulated
view, and although the BMA are heavily supportive of it, the Royal
College of Nursing (who represent thousands of ICU nurses) are
heavily critical, describing it as "no consent at all".
3.3.1 At an individual level there will be a spectrum
of opinion, underpinned I suspect by a belief that presumed consent
is a pragmatic attempt to increase donation rates rather than
a principled approach to more closely approximate the desires
of individual to donate (or not) with the eventual outcome. I
suspect that the majority of professional reactions to the introduction
of presumed consent will be negative.
3.3.2 The evidence that presumed consent in its proposed
form (ie a soft opt-out) will increase donation rates is at best
equivocal. In this system, families retain the right to veto (although
this will very much depend upon the approach of both the requestor
and potential donor family). In particular, I do not expect a
soft opt out to have any beneficial effect upon donation rates
from ethnic minority groups, not least because it is the tension
between the authority of caring clinicians versus that of the
patient's family that is so central to the difficulty that BMEs
face in interacting with the donation agenda.
3.3.3 Whilst I am aware of the support being given to
presumed consent from groups that are either neutral (such as
the BMA) or those that represent the interests of transplantation
(be them professional such as the British Transplantation Society,
or patient-focused such as the National Kidney Federation), I
would humbly suggest that presumed consent is a pragmatic construct
that offers at best a very limited and partial solution to a problem
that is rather more reaching. Thus:
— if consent rates in the UK rose
from their current level of 60% to those achieved in Spain (85%),
the donation rates in the UK would only rise to 18 donors per
million population (compared to 35 donors pmp in Spain).
— Spain had a system of presumed
consent for some years before any increase in donation rates.
The success of the Spanish model is down to systematic performance
management of donor identification.
— the USA has achieved an impressive
increase in donor numbers at the same time as rejecting any legislative
move towards presumed consent.
— Northern Italy has successfully
adopted the Spanish model of donor identification and organ procurement
in all respects but one—namely, presumed consent. Nevertheless,
the overnight increases in donor numbers have been truly breath-taking.
4. To what extent have you benefited from activity at the
EU level?
4.1 Whilst I recognise the broader responsibilities of
the EU towards issues such as the illegal trafficking of organs
and measures to ensure the safety of organs, my principal works
lies in the identification and procurement of organs. In this
regard, it seems to me that the role of the EU lies in the nurturing,
identifying and sharing of best practice. I think that it is also
the case that the different legislative frameworks that underpin
organ donation in various member states represent a significant
obstacle to any uniformity in donor identification, and in any
event, all my instincts tell me that donation in the UK is a very
personal, local thing, a matter of local pride.
4.2 I work on donor identification / organ procurement
side of things, and in any event as an island nation with low
rates of organ sharing between the UK and mainland Europe have
little experience of the operational benefits of organ sharing,
organ safety initiatives etc.
4.3 In terms donor identification and organ procurement
by far the greatest benefit to the UK has been the examples set
elsewhere in Europe, and the demonstrations that deceased donation
rates can be increased in a sustainable fashion. The lessons to
be learnt have come, of course, principally from Spain, and indeed
the Organ Donation Task Force was honoured to received evidence
and advice from Dr Rafael Matesanz, the architect of the Spanish
model. It is fair to say that the experiences from Spain have
heavily influenced the report of the Organ Donation Task Force
and the recommendations therein.
5. What are the reasons for the low donation rates amongst
ethnic minority groups?
5.1 As outlined in my written evidence, my perception
is that failure to engage minority ethnic groups in organ donation
is but a single aspect of how clinical staff struggle to interact
with the families of critical ill patients from these groups.
A specific point of tension is generated over disputes over authority
when a patient becomes mentally incompetent, this tension becoming
maximal when issues over futility, the withdrawal of care or the
significance of brain death become relevant. Very often then,
perhaps almost inevitably, organ donation is discussed against
a background of an unsatisfactory pre-existing relationship with
the family of the potential donor, and very often a lack of respect,
understanding and trust. It is clear to me that the national endorsements
by all the relevant faith groups of organ donation after death
have had little influence on how individual families respond to
such requests, and there is anecdotal evidence that local faith
leaders do not necessarily support or implement the policies of
their national councils.
5.2 There is some evidence that patients from BME groups
are not treated in the same way as other potential organ donors—my
analysis of the PDA suggests that ethnic minority patients are
slightly less likely to have brainstem death tests performed,
less likely to have donation considered if they are brainstem
dead, and less likely to have the option of donation discussed
with their next of kin. This I think reflects the unease that
many ICU staff have when working with families from BME groups,
and perhaps is also an indication that ICU staff do not have as
good an understanding of how different cultures and groups view
death and manage its immediate aftermath.
5.3 I have no magic solution for this problem—indeed,
I think that this is the most difficult problem facing organ procurement
in the UK. I do however believe that the solution to the problem
has to be generated, if only in part, from within those groups—until
this time it will remain as one of my colleagues puts it "white
man's medicine". It may be that in some areas of particularly
high density of BME populations we should consider how well the
ethnic distribution of our clinical staff reflects that of the
local population. On a broader setting, we should be doing everything
that we can to engage the support of high profile and influential
BME individuals (politicians, sports people, celebrities etc)
to champion the cause of donation. I also believe that there is
a role to play from transplant recipients from BME groups to champion
the cause locally.
6. How will the recommendations of the Organ donation Taskforce
ameliorate some of these issues?
6.1 At its very heart, the report of the ODTF seeks to
consolidate the principles of the Human Tissue Act and the Mental
Capacity Act, by recognizing the right of patients to donate their
organs after their death if that is their wish and by empowering
hospital staff to pursue that option on behalf of their incompetent
patient whenever it is clinically possible. In this way, we believe
that donation after death should become a routine consideration
in the event of any death.
6.2 I think that it is important to recognise that the
Task Force report is not recommending anything that is radically
new. Fundamentally, the recommendation of the ODTF is that "best
practice" regarding donor identification and organ procurement
should become "standard practice"—everywhere and
all the time. To achieve this goal we need to:
— engage Trusts through better data collection and
performance management—currently Trust senior managers have
no idea what is going on in terms of organ donation in their hospitals,
— engage clinicians through the appointment of "Donor
Champions" and the commissioning of better education and
training for them, and
— improve the interaction between ICUs and donor
transplant co-ordinators by increasing the number of DTCs and
emphasing their role as a member of the critical care team—specializing
in bereavement issues—rather than being seen as external
agents of organ procurement.
6.3 The Task Force has identified a number of potential
obstacles that threaten the success of these recommendations:
— it is absolutely vital that we resolve the outstanding
/ apparent ethico-legal obstacles to donation;
— we have defined very clearly for clinical staff
the circumstances in which we expect potential donors should be
referred to the local retrieval service, making it clear that
is they who should make the judgement over suitability for donation
rather than the ICU team;
— we are moving towards payment by results for critical
care medicine, and if this is the case then we should ensure that
Trusts are adequately reimbursed for the expenses related to the
identification of potential organ donors; and
— it will be apparent that by their very nature,
the deaths of some potential donors will be subject to some form
of Coronial enquiry, and sometimes even criminal investigation.
Although it does not happen that often, it is particularly distressing
for both ICU and the family of a potential donor for a Coroner
or a police officer to veto organ retrieval. In the United States
there is now a zero tolerance towards refusal for donation from
the medical examiner, and I think that there is a pressing need
for the Department of Justice to review the role of the Coroner
in Organ donation here.
6.4 Engagement with the general public is clearly vital,
and the Task Force has recommended that:
— we both personally and publicly recognise organ
donors in some form of national memorial; and
— we urgently explore the most effective means of
increasing public awareness of organ donation and the gift of
life, particularly in the BME population.
29 February 2008
COMPREHENSIVE POTENTIAL DONOR IDENTIFICATION
Confidence that all potential deceased donors are being identified
everywhere and all the times is central to all successful organ
procurement programs. It is equally important that the identification
of potential donors occurs early enough for this to furnish the
best opportunity for a good donation (ie a donation that is directed
by patient autonomy, that is accepted by the family, that is congruent
with a nationally endorsed ethicolegal framework and that offers
the maximum number of organs in the best possible condition) to
take place. Experience from the UK, but also particularly from
countries that have already made substantial improvements to their
deceased donation rates, suggests that earlier and closer liaison
with the teams that currently provide the interface between donation
and transplantation can considerably improve deceased donation
rates, particularly in circumstances where the attending clinicians
might have limited experience in and exposure to patients who
might wish to donate after their death.
The two models of deceased donation that are most widely
presented as examples of best practice are those that have been
developed in Spain and the United States. Both rely heavily upon
comprehensive identification of all potential donors, although
in somewhat different ways. Thus, whilst the American model is
based mandatory referral of patients with catastrophic neurological
injury based upon a set of agreed clinical parameters (eg GCS
<= 5) to a local Organ Procurement Agency, the Spanish approach
is to embed into hospitals with a high donation potential teams
of co-ordinators who are continually monitoring the donation potential
of patients on ICU. Despite these differences, the consequences
of identifying a patient who has a high likelihood of death from
a neurological condition are rather similar, in that it results
in the introduction another influence on the management of the
dying patient, viz. a team that is there to support the
patient and his/her family in the event that death occurs to achieve
the best possible death, that includes donation should this be
appropriate.
The current UK donation rate is 12.9 deceased donors per
million population per year compared with 22.6 in the United States
and 33.8 in Spain. Even were the UK conversion rate 100% (it is
currently approximately 45%), the apparent maximum achievable
rate of donation in the UK would still fall someway short of those
repeatedly reported in Spain. The inevitable conclusion is that
whilst there might be significant differences in how potential
donations are managed once they have been identified (particularly
family consent rates—barely 60% in the UK compared with
85% in Spain), there seems to be fewer identified potential donors
in the UK to start with. Whilst it seems likely that this can
be explained in part by differences in how patients with unsurvivable
brain injury are managed—for instance, withdrawal of ventilatory
support is very uncommon in Spain—it would be irresponsible
to fail to consider whether significant numbers of potential donors
are being missed in the UK.
The Potential Donor Audit (PDA) offers some insight into
the current effectiveness of donor identification in the UK, although
it is recognised that any conclusions that are reached are tempered
by the inevitably limited quality of the data that is sometimes
available for those completing this retrospective analysis of
patients who die in ICUs in the UK. There are three principle
stages within the database structure in which missed potential
donors might reside:
— Patients in whom brainstem death was a likely
diagnosis, but tests were not performed.
— Patients with confirmed brainstem death, donation
was not considered.
— Patients with confirmed brainstem death, donation
was considered but the family not approached.
Initial perusal of the data from these three groups suggests
that the reasons for not pursuing a clinical course that would
maintain the possibility of donation could be grouped under the
headings of:
— contra-indications to donation;
— family-related issues, including problems with
identifying next of kin;
— cardiovascular instability, be it related to the
primary cause of death or that frequently associated with brainstem
death;
— problems with the performance of brainstem death
tests, including residual neurology;
— actual or anticipated objections from law enforcement
agencies, the coroner or the procurator fiscal; and
— not known, ie despite a thorough examination of
the available material and follow up with the clinical staff involved,
no clear explanation for failure to follow a clinical path that
preserved the possibility of donation after death could be defined.
Brainstem death a likely diagnosis, but tests not performed
The PDA indicates that around 650 patients fall into this
category each year, the
commonest causes of death being neurological catastrophes,
trauma and primary cardiac problems (usually cardiac arrest).
The most frequent reason for not performing brainstem death tests
was cardiovascular instability, both for the
Brainstem death a likely diagnosis, patients not tested (all patients)
Brainstem death a likely diagnosis, patients not tested (all patients)
group as a whole and also for the subgroup of patients dying
from a primary neurological catastrophe (the most common of which
was spontaneous intracranial haemorrhage). However, inability
to identify why tests were not performed was almost equally as
common, while it was also clear that some clinicians would not
perform brainstem death tests if they thought that donation would
not take place, be it because of known family wishes, a perceived
medical contra-indication to donation or (less commonly) the possibility
of objection from the police or coronial services. Technical problems
in performing brainstem death tests were more common in patients
dying from trauma, this being largely attributable to issues surrounding
residual sedation. 15% of patients had documented evidence of
residual neurological activity that was incompatible with a diagnosis
of brainstem death.
Diagnosed brainstem death, donation not considered
On around 140 occasions each year brainstem death is confirmed
but donation
not considered, the commonest reason appearing to be a belief
that it was medically contra-indicated. (It is not clear from
the data how often these decisions were made without any discussion
with the donor transplant co-ordinators and the surgical retrieval
teams). It was frequently impossible to identify any plausible
reason why donation had not been considered, although once again,
pre-existing knowledge of a likely objection from the family seemed
to influence decision making, as did an anticipated objection
from the police or coronial service.
Diagnosed brainstem death, donation considered but family not
approached
This is a small group of patients, amounting to around 70
cases each year. Prominent reasons for not approaching the family
include medical contra-indications to donation and anticipated
problems with the police or coroner / procurator fiscal, and again
prior knowledge of a family's wish not to pursue donation also
featured strongly.
Potential for expansion of the deceased donor pool
This analysis has attempted to enquire as to why the apparent
donation potential of patients dying on ICU has been lost by examining
existing PDA at three key stages of the deceased donation pathway,
viz:
— when brainstem death was considered likely but
not diagnosed,
— when brainstem death was diagnosed but donation
not considered, or
— when brainstem death was diagnosed and donation
considered but the family not approached for their consent.
Common to all three groups, and particularly the first two,
was sufficient uncertainty in the data to require a return of
"unknown", indicating the current limitations of the
data and areas where the PDA (or the mode of data collection for
it) might be revised. Although the first group of patients (i.e
those with a likely
|
| Unknown reasons for of loss of donation potential;
|
| Group | n
| Refusal rate (%) |
|
| ? BSD, not tested | 650
| 28.1 |
| BSD, not considered | 140
| 37.2 |
| BSD, considered, family not approached |
75 | 9.5 |
| BSD, family approached, consent refused |
2,467 | n/a |
|
diagnosis of brainstem death who were never tested) is quantitatively
the largest (at approximately 650 patients per year), the other
two smaller groups have the advantage of brainstem death actually
having been diagnosed. An accurate figure for the true incidence
of diagnosable brainstem death in the first group remains elusive,
although it seems unlikely that it is much more than half. Nevertheless,
it is also true to say that within all of these three groups there
were brainstem dead patients who could have gone on to donate
had the actions and decisions of those involved in their care
(including clinical staff, family members and members of the police
and coronial services) been different. It is similarly beyond
doubt that a significant number of those who were not brainstem
dead could have been given the option of donation after cardiac
death. Furthermore, where a reason for a patient's donation potential
being lost could be identified, the key issues that do emerge
are family refusal, cardiovascular instability, medical contra-indications
to donation and the on-going conflicts between the interests of
the deceased donor and the necessary legal enquiries that need
in some circumstances.
Family refusal is a major obstacle to donation after death
in the UK. Although the published PDA data indicates a family
refusal rate of 40%, this figure relates
|
| Family refusal as a cause of loss of donation potential;
|
| Group | n
| Refusal rate (%) |
|
| ? BSD, not tested | 650
| 11.0 |
| BSD, not considered | 140
| 13.3 |
| BSD, considered, family not approached |
75 | 24.3 |
| BSD, family approached, consent refused |
2,467 | 40 |
|
only to the stage at which brainstem death has been diagnosed
and a formal request made. This analysis suggests the true impact
of family objection to donation is somewhat higher, with a figure
closer to 45% emerging if the "occult" refusals from
these three earlier stages are taken into account.
Both the Spanish and American donation initiatives have invested
heavily in approaching potential donor families in a timely, consistent
and professional fashion. There is clear evidence from both these
programs and elsewhere that an early approach that is made by
a trained interviewer, with a re-approach should the initial request
be turned down, is more likely to help a donor family to accept
donation than the approach currently used in the UK. A recommendation
that all patients in whom brainstem death tests are to be performed
should be referred to the donor transplant coordinators regardless
of whether the donor family have already expressed an objection
to donation is likely to be problematic for some intensivists,
although will be necessary if the intention is to only accept
a refusal once a formal approach has been made by a designated
and trained requestor.
Cardiovascular instability is a common reported reason for
failing to perform brainstem death tests, and even where brainstem
death has been diagnosed will jeopardise the viability of potentially
procurable organs. Whilst sometimes it is a reflection of primary
cardiac pathology or catastrophic trauma, there are also occasions
where it appears to be the cardiovascular collapse associated
with brainstem death and the autonomic storm that accompanies
it. Whilst
|
| Cardiovascular instability as a cause of loss of donation potential;
|
| Group | n
| Refusal rate (%) |
|
| ? BSD, not tested | 650
| 30.4 |
| BSD, not considered | 140
| 1.4 |
| BSD, considered, family not approached |
75 | 1.1 |
| BSD, family approached, consent refused |
2,467 | n/a |
|
occasionally this can be very difficult to treat, it is usually
easily reversed with a combination of invasive monitoring, inotropic
support, fluid therapy and PEEP. Nevertheless, it is seems possible
that some intensivists regard such interventions as ethically
or legally unacceptable in the setting of a patient with catastrophic
brain injury whose death seems inevitable.
Medical contra-indication to donation is identified as a
reason not to perform brainstem death tests, not to consider donation
and not to approach a family. It
|
| Medical contra-indication as a cause of loss of donation potential;
|
| Group | n
| Refusal rate (%) |
|
| ? BSD, not tested | 650
| 6.1 |
| BSD, not considered | 140
| 41.4 |
| BSD, considered, family not approached |
75 | 36.6 |
| BSD, family approached, consent refused |
2,467 | n/a |
|
is not clear how often these decisions are made independently
by the ICU team rather than after discussion with the donor transplant
co-ordinators—for instance, intravenous drug addiction was
frequently cited as a contra-indication. Since there are few absolute
contra-indications to donation after death, and more and more
marginal donors are being considered, it would seem prudent to
recommend that all potential donors should be discussed with the
donor co-ordinators, regardless of age, life-style and co-morbidities.
Although relatively minor in absolute terms, real or potential
objections to donation from the police, the coroner or the procurator
fiscal are frustrating in as much as they appear to be a completely
unnecessary obstacle to donation and frequently emerge in the
setting of a family who are completely committed to donation.
Understandably, these objections feature most prominently as a
reason why a family might not be approached, although very often
may only emerge after consent for donation has been obtained.
|
| Coronial / police objections as a cause of loss of donation potential;
|
| Group | n
| Refusal rate (%) |
|
| ? BSD, not tested | 650
| 0.7 |
| BSD, not considered | 140
| 5.5 |
| BSD, considered, family not approached |
75 | 24.3 |
| BSD, family approached, consent refused |
2,467 | n/a |
|
Conclusions
By its very nature, the potential donor audit can only give
an indirect insight into the identification and management of
potential deceased donors on UK ICUs. It is however reasonable
to conclude that there is a variation in the end of life management
of patients with severe brain injury, and that this limits the
number of potential donors who are thereby identified. To extend
what might be considered best practice into standard practice
will require a closer and earlier collaboration between ICU staff
and those who in some circumstances will have greater expertise
in the identification and management of potential donors and their
families, a collaboration that is driven on the one hand by performance
management and proper funding, and the other hand by significant
and sustained education and training for those involved in the
care of potential deceased donors. This collaboration will be
based primarily upon a closer operational working relationship
between donor co-ordinators and ICU staff, but underwritten by
a triggered referral system that is able to ensure that notification
is made early enough to allow real changes in practice to be achieved.
Specific areas that might benefit from a more timely and collaborative
approach would include:
— the management of the cardiovascular instability
of brainstem death,
— guidance with brainstem death testing in difficult
circumstances,
— the identification of marginal donors who might
otherwise be overlooked, and
— a more supportive yet rigorous approach to seeking
consent from a patient's family.
— Real time collection of PDA data to improve data
quality and eradicate "unknowns".
Whilst early discussions with the coronial service etc may
reduce the number of legal objections to donation, any significant
resolution of these continuing and frustrating problems with the
police and the coronial service will require a different approach.
July 2007
|
