Organ donation performance in critical care*
2009; Lippincott Williams & Wilkins; Volume: 10; Issue: 4 Linguagem: Inglês
10.1097/pcc.0b013e31819adedd
ISSN1947-3893
Autores Tópico(s)Palliative Care and End-of-Life Issues
ResumoMost articles on organ donation and transplantation start by presenting bleak statistics consisting of the number of patients on transplant waiting lists followed by the comparatively small number of organ donors and the number of patients who died (while waiting for a transplant) as a result of this substantial imbalance. This is usually followed by an urgent call to increase the number of organ donors. The organ donation community has made efforts to improve “supply,” with notable successes in the American context through the widely successful collaborative efforts. The mounting demand for organs is the result of increasing levels of disease leading to end-stage organ failure coupled with profound surgical and medical innovation in transplantation. This demand places pressure and accountability on critical care practice. However, the principle role of the critical care medicine community is not to “get more organs,” but rather, to provide and facilitate the opportunity whenever appropriate. This is good for families, consistent with their support of organ donation (1), and it has been shown to assist in their grieving process (2). Inherent in the many dimensions of organ donation and transplantation is a fundamental tension between the public good—increasing the supply of transplantable organs—and the rights of the individual to live and die with dignity. The push (seen by some as a moral obligation) to remove obstacles to donation has created controversy in areas such as: establishing acceptable limits of deceased donation; concepts and determinations of death; and real or perceived conflicts of interest in the care of the dying patient. Although these continue to be debated (3, 4), particularly with the gradual implementation of donation after cardiac death, there are principles upon which most critical care medicine practitioners would agree. Our specialty provides both life saving treatments and management of acute, palliative end-of-life care (5). The role of the pediatric critical care medicine practitioner is clear: provide life sustaining technologies to their fullest potential when the underlying condition is reversible with treatment, time, and/or transplantation; recognize when this goal is not achievable and counsel families with compassion and comfort; and finally when inevitable, anticipate and diagnose death, and where appropriate, offer the opportunity to donate organs and tissues. Our responsibilities do not end with the management of death, but encompass postmortem issues of interpreting and explaining autopsy results, supporting families through the grieving process and fulfilling intentions to donate organs. In this issue of Pediatric Critical Care Medicine, Webster and Markham’s survey (6) of U.S. organ procurement organizations is the first to capture detailed national information on pediatric organ donation in the United States. With a 100% response rate, standardized definitions, data comparable with that reported by the Organ Procurement and Transplantation Network, and what is likely the largest data set on pediatric organ donation in the world, this study helps inform pediatric critical care medicine practice and organ donation policy decisions. They surveyed all 58 U.S. organ procurement organizations with the objective of characterizing the eligible pediatric organ donor pool by age, consent rate, location, and cause of donor loss. For the year 2005, the authors recorded 1330 eligible, 920 consented (69%) and 849 procured (64%) pediatric organ donors. Pediatric organ donation is an infrequent event; <5% of the 435 hospitals in this study had ten or more eligible donors. The study found statistically significant associations between higher numbers of eligible donors/100 pediatric intensive care unit beds and the presence of either a level 1 trauma center or a pediatric critical care medicine fellowship program. The strength of the study include a broad description of pediatric OD practices, identification of pediatric intensive care unit, and age-related characteristics of pediatric donors and areas for potential improvement (i.e., consent rates, donor management, the role of the medical examiner, and pediatric donation after cardiac death). This study provides useful and informative data, but the study design did not allow for the collection of sufficiently detailed data for an insightful analysis. How do we accurately measure performance in the area of organ donation? To the transplant community, more organs equal better performance. This means increasing both the number of donors and the number of organs transplanted per donor (organ utilization). However, a more appropriate assessment of organ donation performance is to measure the efficiency of the process: the conversion of potential donors (those who are dead and eligible) into donors who provide organs that are actually transplanted. To measure efficiency and inform pediatric intensive care unit practice in the context of the Webster and Markham study, the following additional information is required: the number of brain dead eligible patients not approached for consent; the consent rates in relation to case mix, etiology of brain injury, and demography of the donors (ethnographics, religion, socioeconomic status); actual conversion rates (the percentage of eligible donors who actually provided a transplantable organ); organ utilization rates; and the reasons consent was not obtained and donors or their organs were not used. Capturing all this information requires the systematic tracking of all eligible donors through the donation process (identification, approach, consent, organ recovery, and transplantation) and recording the reasons why organs were not transplanted. Improvement in these procedural steps may not always lead to increases in donors, for example, if the incidence of brain death is decreasing as is suggested by a number of studies (7–9). Paradoxically, the true incidence of brain death remains unknown as there is no imperative to perform the clinical determination, nor a mechanism to record its occurrence. Yes, organ procurement organizations perform death record reviews in an attempt to identify missed opportunities and quantify the number of brain deaths. However, a simpler and more accurate way to do this would be to treat brain death as a vital statistic and include it on the medical certificate of death (10, 11). Once potential donors are identified and tracked, the responsibility of critical care medicine practitioners continues with aggressive organ resuscitation until surgical procurement occurs, unless consent for organ donation is refused. Both the United Network for Organ Sharing and the Canadian Council for Donation and Transplantation have published recommendations for organ donor management (12, 13). The United Network for Organ Sharing Critical Pathway for the Organ Donor has been shown to increase both the total number of organs recovered and transplanted (12). In addition, several studies have reported on the use of hormonal resuscitation therapy and increases in the number of organs transplanted per donor in adults (14, 15) with similar findings in children (16). It is then up to the organ procurement organization and the transplant team to ensure all recoverable organs are transplanted. Studies have shown that organ utilization varies not only by organ type and function, but as a result of deficits in logistic and procedural aspects of the procurement-to-transplantation process (17, 18). A few authors have even proposed performance measures based on organ utilization (19, 20). The critical care medicine community is inexorably linked to transplantation through the increasing use of mechanical bridges to transplant, such as extracorporeal life support, and the obligation to individuals, families and the public to provide organ donation as part of end-of-life care. The results of the Webster and Markham study will help inform practice in this area. However, fundamental data that include identification, approach, consent, and organ utilization are required to accurately evaluate and interpret organ donation performance. At a minimum, we need to know how many eligible donors actually have their organs transplanted and for every organ that was not, the reasons why. When we begin to systematically collect all this information we will know if organs are needlessly lost, why, and by whom. Karen Hornby, BScN, MSc Clin Epi Sam D. Shemie, MD Montreal Children’s Hospital McGill University Montreal, Quebec, Canada
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