Palliative care consultation in the process of organ donation after cardiac death

Palliative care consultation has been demonstrated to be useful in many situations in which expert symptom management, communication around sensitive issues, and family support may serve to enhance or improve care. The process of organ donation is an example of this concept, specifically the process of donation after cardiac death (DCD). DCD allows patients with severe, irreversible brain injuries that do not meet standard criteria for brain death to donate organs when death is declared by cardiopulmonary criteria. The DCD method of donation has been deemed an ethically appropriate means of organ donation and is supported by the organ procurement and medical communities, as well as the public. The palliative care (PC) team can make a significant contribution to the care of the patient and family in the organ donation process. In this paper we describe the controlled DCD process at one institution that utilizes the PC team to provide expert end-of-life care, including comprehensive medical management and family support. PC skills and principles applicable to the DCD process include communication, coordination of care, and skillful ventilator withdrawal. If death occurs within 90 minutes of withdrawal of life support, organs may be successfully recovered for transplantation. If the patient survives longer than 90 minutes, his or her care continues to be provided by the PC team. Palliative care can contribute to standardizing quality end-of-life care practices in the DCD process and provide education for involved personnel. Further experience, research and national discussions will be helpful in refining these practices, to make this difficult and challenging experience as gentle and supportive as possible for the courageous families who participate in this process.     

Non-heart-beating organ donation: Issues and ethics for the critical care nurse.

Non-heart-beating organ donation is an important topic that continues to be misunderstood by many health care professionals. As organ transplantation has become an accepted mode of treatment for end-stage organ failure, the need for organs has increased. Non-heart-beating organ donation provides an option for families wishing to donate when their loved one does not meet brain death criteria. The author will review the history of organ donation, focusing on the process of non-heart-beating organ donation. A patient case study is presented to facilitate understanding of the critical care nursing role essential to the success of this process that can provide a positive outcome for families involved in very tragic situations.     

The physician's role in discussing organ donation with families

Federal Conditions of Participation from the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) introduced in 1998 require that all families be presented the option of organ and tissue donation when death is imminent. The perception that physicians were being excluded from participating in this process led to a resolution at the American Medical Association House of Delegates meeting in December 1999, calling on the American Medical Association Council on Scientific Affairs to review the Conditions of Participation "to ensure that there is no prohibition of physician involvement in the organ donation process..." The number of organs procured for transplantation in the United States is insufficient to meet needs. Families' hospital experiences significantly affect their decisions to donate organs. Discussing severe brain injury, brain death, and organ donation after brain death with families is a specialized form of end-of-life decision-making and care in the intensive care unit; however, the knowledge, skills, and attitudes necessary for physicians and nurses to promote good end-of-life decision-making are widely variable. The federal Conditions of Participation require that those making requests of families for organ donation receive specific training. They do not prohibit physician involvement in initiating organ donation requests, provided these individuals are properly trained. Physicians have an important role in caring for patients and families in these circumstances, and the care they provide is enhanced through training, attention to the special issues involved, and collaboration with organ procurement organization personnel.     

Organ donation and neuroscience nursing: your role in the process.

The death of a patient is seen by many nurses as the end of their interaction with the patient and family. However, the option of organ donation may extend that interaction and present another opportunity to serve as an advocate for the family, as well as for patients whom the nurse has never met. Patients who have been declared brain dead or from whom life support is going to be withdrawn following a neurological injury are potential organ donors. Although these patients and their families are frequently under the care of neuroscience nurses, all nurses need a thorough understanding of their responsibilities regarding identification and referral of potential organ donors to the designated Organ Procurement Organization (OPO). In addition, it is essential for nurses to understand the clinical presentation and determination of brain death in order to provide patient care and family education. Understanding how consent for organ donation should be obtained from families and how the organ recovery process works enables the nurse to collaborate with OPO staff and support the family in their decision regarding organ donation.     

Intimacy or utility? Organ donation and the choice between palliation and ventilation

Organ donation after brain death provides the most important source for deceased organs for transplantation, both because of the number of potential organ donors that it makes available and also because of the unparalleled viability of the organs retrieved. Analysis of worldwide deceased organ donation rates demonstrates that all countries with high deceased organ donation rates (>20 donors per million population per year) have high brain death rates (>40 brain deaths per million population per year). This analysis makes it clear that countries striving to increase their deceased organ donor rates to world leading levels must increase the rates of donation after brain death. For countries with end-of-life care strategies that stress palliation, advance care planning and treatment withdrawal for the terminally ill, the adoption of initiatives to meaningfully raise deceased donor rates will require increasing the rate at which brain death is diagnosed. This poses a difficult, and perhaps intractable, medical, ethical and sociocultural challenge as the changes that would be required to increase rates of brain death would mean conjugating an intimate clinical and cultural focus on the dying patient with the notion of how this person's death might be best managed to be of benefit to others.     

Some problems on the organ transplantation in Japan from the viewpoint of the neurocritical care units

The authors have referred to several issues encountered in the neuroemergency and critical care facilities in our country through the declaration of brain death to the successful removal of organs for donation. One of the most important is the fact that the legal validity of death in brain dead patients is only assured when the patient shows the advance directive for organ donation in Japan. So far as the selection of the recipient is not started until the brain death is declared legally, longer than 12 hours are to be spent in vain between the declaration of brain death and the beginning of the operation of removing the organs for donation. As there remain such several problems to be solved as mentioned above for organ donation in Japan, so it is suggested that the medical sciences and ethics should be respected and adopted in the rules for the organ donations by the national government.     

Organ and tissue donation: a survey of nurse's knowledge and educational needs in an adult ITU.

The aim of this paper is to present the results of a survey that was undertaken to assess nurses' knowledge and educational needs towards organ donation within one adult general intensive care unit. The survey consists of 31 registered nurses who completed a confidential questionnaire that aimed to assess their existing knowledge and deficits in organ and tissue donation. The survey highlights the sample lacked confidence in approaching relatives for donation consent, deficits in brain stem death testing and donor criteria. It was also apparent that a significant number of nurses could not identify which tissues can be donated and the contraindications for tissue donation. A majority of the sample stated their knowledge of donation issues would improve if an educational programme were developed on organ donation. This is further supported by previous work by [Bidigare S, Oermann M, 1991. Attitudes and knowledge of nurses regarding organ procurement. Heart & lung 1:20-3; Smith-Brew S, Yanai L, 1996. The organ donation process through a review of the literature. Part 1. Accident & emergency nursing 4:5-11; Roark D, 2000. Overhauling the organ donation system. Am J Nurs 6:44-9] who suggest that educational programmes covering donation issues should enhance nurses' knowledge and confidence in the organ donation process and ultimately increase the number of potential donors.     

Mort encéphalique traumatique et don d’organes en pédiatrie. Comment optimiser le prélèvement d’organes lorsqu’un obstacle médicolégal pourrait s’y opposer ?

Pediatric organ donors are rare and mainly due to unnatural brain death. These traumatic circumstances issued from accidental or nonaccidental events can lead to forensic reservations, which complicate the donation process. In the aim to recruit these young potential donors, health care professionals have to prove a close collaboration with the judiciary team, by not interfering in the research of the exact cause of death. They must make available any medical and radiological date before and during operative period. In response, prosecutors will be more attentive to these intensive care doctors and the Organ Donation Service Teams (ODST) who solicit them for an authorization of a Multiple Organ Procurement. If the judiciary investigation permits it, the prosecutors can initially give an agreement in principle. Later, if the donation process develops favorably with a parental agreement, an official judiciary authorization can be given to the ODST who claim it. This close collaboration and mutual respect between the health care workers and the judiciary team has contributed to facilitate recruitment of potential donors with an increased organ procurement in this cohort of 22 brain dead children under 3 years old, identified by the ODST.     

家属对亲属器官捐献决定的影响因素及对策研究

[目的]通过参与协调的潜在心脏死亡遗体器官捐献(DCD)案例,探讨影响家属决定亲属器官捐献的因素及解决对策.[方法]2010年3月至2011年3月,对51例潜在捐献者家属进行开放式访谈,探讨协调介入时间和环境、协调员的专业水平、家属对脑死亡及捐献流程信息的了解、家庭组成对家属捐献决定的影响.[结果]成功捐献的案例,协调...     

ICU nurses’ perceptions of responsibilities and organisation in relation to organ donation—A phenomenographic study

Objectives

According to the Istanbul declaration, health services should create better routines for identifying potential donors. A previous study involving 702 intensive and critical care (ICU) nurses revealed that only 48% trusted clinical diagnosis of brain death without a confirmatory cerebral angiography. The aim was to study ICU nurses’ perceptions of their experiences of professional responsibilities and organisational aspects in relation to organ donation and how they understand and perceive brain death.

Methods

A phenomenographic method was chosen. Data collection (interviews) took place in Sweden and included fifteen nurses; one man and fourteen women, from six hospitals serving different geographic areas.

Results

The findings pertain to three domains: ICU nurses’ perceptions of (1) their professional responsibility, (2) the role of the organisation regarding organ donation and (3) death and the diagnosis of brain death.

Conclusion

The ambiguity and various perceptions of brain death diagnosis seem to be a crucial aspect when caring for a brain dead patient. The lack of structured and sufficient organisation also appears to be a limiting factor. Both these aspects are essential for the ICU nurses’ opportunities to fulfil their professional responsibility during the organ donation process.     

A study of the perception and experiences of critical care nurses in caring for potential and actual organ donors: implications for nurse education

This paper describes a research study designed to explore the knowledge, perceptions and attitudes of practising critical care nurses towards caring for 'brain stem dead' cadaver organ donors and their families The influence of formal nurse education and experiential learning were investigated together with what nurses felt could better prepare them for this role Data were collected through self-completion questionnaires from 103 critical care nurses This was instrumental in forming a semi-structured interview schedule whereby seven respondents were interviewed The findings of the study suggest that nurses are very favourable towards organ donation and this correlated with their knowledge of brain stem death (P<0 024) Nurses with between 6 and 10 years critical care experience had a significantly higher knowledge base (P<0 05) than those of less or greater experience Nevertheless, when challenged some nurses were less comfortable with the concept of brain stem death and caring for these patients A degree of cognitive dissonance was identified Discussion revealed that all nurses need to have a better understanding of their role in organ donation, no matter what nursing discipline they practice This may help to expel some of the myths that have, undeservedly, become established and given the donor process a rather sinister image     

脑死亡患者家属器官捐献决策体验的Meta整合

目的 对脑死亡患者家属器官捐献决策的体验进行Meta整合。方法 检索PubMed、Cochrane Library、Web of Science、Embase、CINAHL、ProQuest、中国知网、万方数据库、维普数据库、中国生物医学文献数据库关于脑死亡患者家属器官捐献决策体验的质性研究，检索时限为建库至2022年6月。采用2016版澳大利亚乔安娜布里格斯研究所循证卫生保健中心质性研究质量评价标准进行质量评价，对结果进行Meta整合。结果 共纳入12项研究，提炼出63个研究结果，归纳出10个新类别，3个整合结果。整合结果1为尊重患者及益处获得；整合结果2为矛盾且复杂的决策过程；整合结果3为渴望正向互动与社会支持。结论 脑死亡患者家属器官捐献决策体验复杂，与医护人员的互动质量影响最终的决策结果，医护人员应提供脑死亡相关知识并确保家属正确理解，不断提高器官捐献沟通的专业性，给家属相应的支持及人文关怀，帮助其渡过丧亲之痛，解决决策困境，作出符合其家庭情况的捐献决定。     

Identifying the potential organ donor: an audit of hospital deaths

Objective To quantify the potential for organ donation in Victoria and identify missed opportunities for organ donation.Design and setting Prospective medical record audit of all deaths in 12 Victorian hospitals.Measurements Data on deaths, total potential donors, organ donors and outcome of requests for organ donation were collected. Patients in whom brain death was confirmed or likely to occur and in whom organ donation was not requested (unrealised potential donors) were classified by an independent panel. Rates of organ donation and unrealised donors were determined as a proportion of total potential donors and hospital deaths and the maximal potential organ donor rate was estimated.Results Of 5551 deaths, there were 112 potential donors, with 66 requests for organ donation resulting in 39 consents (consent rate of 59%) and 37 organ donors (33% of total potential donors; 0.7% of hospital deaths). Two consented potential donors did not donate due to failed physiological support (5%). There were 46 medically suitable unrealised potential donors; 3 with confirmed brain death. Approximately half of these patients had treatment withdrawn in the intensive care unit and half in the Emergency Department. The estimated maximal potential donor rate was 30 per million population.Conclusions The potential for organ donation in Victoria is relatively low compared with previous estimates in Australia and overseas. An increase in the organ donation rate may be possible through increasing consent and the identification and support of potential donors. This would require substantial changes in clinical practice that have resource and ethical implications.     

Empirically based recommendations to support parents facing the dilemma of paediatric cadaver organ donation.

The aim of the study was to describe the challenges donor and non-donor parents encounter before, during, and after the organ donation decision, and to identify parents' needs and expectations from health care professionals. A further aim was to propose evidence-based recommendations for effectively introducing the option of donation, and supporting families through the grieving process. This study was undertaken as part of a larger research project investigating the experiences of Greek parents who consented or declined organ and tissue donation, using a qualitative methodology for data collection and analysis. The experiences of 22 Greek bereaved parents of 14 underage brain dead children were studied through semi-structured interviews. Parents' decision-making process was described as challenging and fraught with difficulties both before and after the donation period. Identified challenges were clustered into: (a) personal challenges, (b) conditions of organ request, and (c) interpersonal challenges. Parents' main concern following donation was the lack of information about transplantation outcomes. Findings led to a list of recommendations for nurses and other health professionals for approaching and supporting parents in making choices about paediatric organ donation that are appropriate to them, and for facilitating their adjustment to the sudden death of their underage child.     

Organizing medical institutions for organ donation

In spite of the fact that organ donation requires a substantial commitment in terms of personnel and time, the place most likely to become the center for organ donation is emergency medical departments, which are already under extreme pressure. However, it is often in emergency medical departments, where the everyday load of work is already substantial, that organ donation options are presented by medical staff in response to requests from families. Therefore, it is necessary to improve understanding of terminal care medicine, including brain death, in order to participate justly and fairly in organ donation after revision of the law. More importantly, the system of organization within hospitals must be improved in order to ensure support for emergency departments.     

Current status and issues of organ transplantation in Japan

Since Organ Transplant Act was legislated and enforced in 1997, there reported to be 86 cases of organ donation from brain-dead donors, and 70 cases for heart transplantation, 67 for lung transplantation, 67 for liver transplantation, 64 for pancreas transplantation and 103 for kidney transplantation as of the end of May, 2010. The organ donation from brain-dead persons in Japan required the documented will of the deceased to accept brain death and to remove his/her organs for the purpose of transplantation, and the written consent of his/her family member to brain death diagnosis and organ donation. Furthermore enforcement regulations and related guideline too much restricted and limited the necessary conditions for the organ donation from brain-dead donors. In 2009, Organ Transplant Act was amended, and after related regulations and guideline were revised, amended Organ Transplant Act was enforced in 2010, which provide that organ removal from brain-dead persons for the purpose of transplantation requires the written consent of his/her family member to brain death diagnosis and organ donation in case that there is no reason to believe that the deceased indicated any objection, in life, to organ donation and brain death, or in case that the deceased expressed his/her will in writing during his/her lifetime. Although the increase in the number of organ donation would be expected, it is considered to be indispensable to enlighten the public upon organ donation/transplantation, encourage that in those understanding and to minimize any burdens on donor hospitals as far as possible.     

Why families deny consent to organ donation.

Advances in medical practice and technology and the success of organ transplantation over the past 2 decades have resulted in an increased demand for organ donors. However, the health care community and organ procurement organisations (OPO) are faced with a worldwide shortage of donor organs. The non-consent of families is the most common reason that organs of medically suitable potential donors are not recovered. A review of published research post 1990 was conducted to primarily determine the major factors that influence a family's decision to deny consent to donation. Other objectives included providing suggestions for health care personnel to facilitate the donation request experience and to suggest strategies that would increase donation consent rates to benefit the organ procurement process. Databases predominately used in the review included CINAHL and Medline. The world wide web (www) was also accessed. The literature review indicates that the significant factors associated with denial of consent include: the misunderstanding of brain death; cultural beliefs; the specific timing of the request; the setting in which the request is made; the approach of the individual making the request; and characteristics of the deceased. Organ donation and transplantation rates could be increased by the joint involvement of medical, nursing and OPO personnel to enhance the quality of hospital care and to ensure that requests for donation are handled in a way that meets the family's informational and emotional needs. Increased consent rates have the potential to save lives and improve the quality of life for organ recipients.     

Family bereavement: A case study of controlled organ donation after circulatory death

Deceased organ donation represents a major source of organs for human transplantation practice. In the United Kingdom, as well as other parts of the world, donation after circulatory death accounts for a proportion of all deceased organ donors. Organ and tissue donation emotively takes place in the context of dying, death and bereavement, yet little is known about the family experience of donation after circulatory death. This paper presents a case study of the phenomenon of controlled donation after circulatory death in intensive care. We present a critical analysis of care processes through the lens of a British donor family who participated in a national study of organ and tissue donation. Anonymized family quotes are applied to illustrate specific case issues, and with reference to relevant national guidance and international research. The case portrayed intimate details of the moment in time when the family experienced the potential for controlled donation after circulatory death, factors that appeared to influence family consent and the perceived expectations and outcomes arising from the donation decision. Case analysis demonstrated local compliance with best practice guidance and compassionate end‐of‐life care while supporting organ retrieval. Caring for the grieving family of potential organ donors requires sensitivity and skill. Of importance is a sound professional knowledge and understanding of the clinical care pathway, together with effective teamwork, optimal communication, family and staff support. Further research is required to determine the impact of controlled donation after circulatory death on family grief and bereavement.     

Organ donation in adults: a critical care perspective

Purpose

The shortage of organs for transplantation is an important medical and societal problem because transplantation is often the best therapeutic option for end-stage organ failure.

Methods

We review the potential deceased organ donation pathways in adult ICU practice, i.e. donation after brain death (DBD) and controlled donation after circulatory death (cDCD), which follows the planned withdrawal of life-sustaining treatments (WLST) and subsequent confirmation of death using cardiorespiratory criteria.

Results

Strategies in the ICU to increase the number of organs available for transplantation are discussed. These include timely identification of the potential organ donor, optimization of the brain-dead donor by aggressive management of the physiological consequence of brain death, implementation of cDCD protocols, and the potential for ex vivo perfusion techniques.

Conclusions

Organ donation should be offered as a routine component of the end-of-life care plan of every patient dying in the ICU where appropriate, and intensivists are the key professional in this process.

     

La donación de órganos en asistolia controlada tipo iii de Maastricht: implicaciones éticas y cuidados al final de la vida

The decrease in potential donation after brain death has resulted in a need to evaluate alternative sources. Donation after cardiac death is a good option. The objectives of this article are to describe the Maastricht type iii controlled organ donation characteristics and to determine end-of-life care and the role of nurses in the donation process. In this type of donation, cardiocirculatory arrest is predictable after the limitation of life sustaining treatments. These are patients for whom there are no effective therapy options and, in the context of an organised and planned practice involving all the professionals involved in the care of the patient, the decision is made, in consultation with the family, to withdraw life support measures. This limitation of life sustaining treatments is never carried out with the aim of making a Maastricht iii donation, but to avoid prolonging the dying process through useless and possibly degrading interventions. The obligation of the health team is to provide a dignified death and this not only includes the absence of pain, but the patient and their family must be guaranteed a feeling of calmness and serenity. Once the decision has been taken to withhold or withdraw measures, the nurse has an important role in the implementation of a palliative care plan in where physicians, nurses and patients/families should be involved and whose focus should be on patients’ dignity and comfort, considering their physical, psychological and spiritual needs.