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3. Organ and Tissue Donation After Death, for Trans- Some distrust about brain death is evident in numerous
plantation: Guidelines for Ethical Practice for Health countries. One Australian study showed that 20% of fam-
Professionals: outlines ethical principles for health ilies of brain-dead patients continued to harbour doubts
professionals involved in donation after death and about whether the patient was actually dead, and a further
provide guidance on how these principles can be 66% of relatives accepted the death, but felt emotionally
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put into practice. 69 that the patient was still alive. Researchers describe the
4. Making a Decision about Organ and Tissue Donation contradictions and ambiguities associated with caring for
after Death: this booklet is derived from Organ brain dead patients, particularly the ambiguity that
and Tissue Donation after Death, for Transplantation: accompanies caring for a brain dead body that exhibits
Guidelines for Ethical Practice for Health Professionals, traditionally accepted signs of life. 72,73
and aims to help people think through some
ethical issues and make informed decisions about In a recent Australian study of experienced intensive care
organ and tissue donation after death. 68 nurses, almost half the participants did not regard brain
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death as a state of complete death. Further, there were
no correlations between brain death perception and the
DONATION AFTER CARDIAC DEATH independent variables of religious affiliation, intensive
There is increasing recognition of the role of donation care experience, experience of nursing brain dead patients,
after cardiac death (DCD) activity in Australia, New knowledge of brain death diagnostic procedures, educa-
Zealand and globally. So-called ‘cardiac death’ includes tional background, and knowledge of Australian legal
death of the person as a whole, with death of the brain definitions of death. Participants who were non-accepting
being an inevitable consequence of permanent cessation or ambivalent may not have perceived that the medico-
of the circulation. The organ yield (i.e. number of organs legal construct of brain death was congruent with their
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usefully transplanted) may be less in a DCD donor than ‘personal foundational death notions’. Consequently,
that of a brain death donor due to the differences in the authors cautioned against equating lack of acceptance
timing and length of ‘warm ischaemic’ time. See also with a lack of knowledge of the clinical aspects of brain
Chapter 27. death, but rather suggested that for some nurses, the
concept of brain death may run counter to their
previously-formed concept of death. It is important that
NURSES’ ATTITUDES TO, AND KNOWLEDGE critical care nurses possess a thorough understanding of
OF, ORGAN DONATION brain death, and that they reflect on their personal con-
Some critical care nurses have dedicated roles in the ceptions about death.
organ donation team and may be integral in providing
knowledge and leadership in all aspects of donation and The ambiguity surrounding brain death is probably best
high-quality care in the end-of-life care process. They demonstrated by the common situation in an ICU, where
offer the option of donation as appropriate to families some staff may continue to talk to a patient (while pro-
and supporting their decisions at extremely sad and viding direct care) who has been diagnosed as brain dead.
stressful times. Communication and interpersonal skills This can cause confusion for relatives who have already
are essential. Trustworthy relationships maximise identi- been informed that the patient ‘is brain dead with no
fication and referral. 55 possibility of recovery or being able to comprehend/hear’.
An alternative view is that relatives may in fact be com-
Organ donation must be conducted in a manner that forted by staff ‘talking’ to their loved ones (albeit they are
is ethically and legally justifiable. Current legislation brain dead) until their final farewell. There is no defini-
and consistent hospital practices provide this framework tive right and wrong, but this dilemma reinforces the
in Australia and New Zealand. However, for some need for sensitivity by all staff in these cases.
staff working in an ICU the issue of organ donation is
vexed. It seems that for some individuals the notion of The issue of language used is also relevant to doctors and
brain death runs counter to personal beliefs formed nurses, with the use of the depersonalising terms ‘cadaver’
over many years (prior to intensive care unit exposure) and ‘harvesting’ perhaps serving to psychologically protect
about death. Personal beliefs or conceptions of death staff but perhaps acting as a barrier to effective commu-
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may be informed by particular religions or other belief nication and understanding. The use of such language
systems. may reinforce the conceptual gap described above
between a personal notion of death and brain death.
The issue of organ donation also poses personal ethical
challenges for some individuals, perhaps related to beliefs Intensive care nurses are in a good position to foster a
held about the integrity of the human body and the positive attitude towards organ donation through educa-
interests of the donor and recipient. Some literature sug- tional and supportive actions with the family of the
gests that the current understanding of brain death is patient. It is recognised as important to allow the family
flawed, in that the diagnosis may be confused with ‘pro- time to come to terms with the death of the patient before
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found coma associated with massive brain damage’, making their decision about donation. It may be useful
while acknowledging that it seems apparent that inade- to note that the majority of donor families say that they
quate brain death testing, or misapplication of brain would make the same choice again if given the opportu-
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death criteria, is likely to be related to a wrong nity. Further discussion of the organ consent, donation
diagnosis. and transplant processes is provided in Chapter 27.