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Organ Donation and Transplantation 749

and complementary medicines, although an agreement
to establish a Joint Scheme for the Regulation of Therapeutic TABLE 27.2 Conditions associated with brain death 65
Products between the Governments of Australia and New
Zealand is in place. 15 Condition Incidence
The process of potential donor identification and manage- Hypotension 81%
ment in critical care is directed by the Australian and New Diabetes insipidus 53%
13
Zealand Intensive Care Society (ANZICS). Education
of health professionals is facilitated by the Australasian Disseminated intravascular coagulation 28%
Donor Awareness Program (ADAPT), in association with Arrhythmias 27%
the Australian College of Critical Care Nurses (ACCCN)
and the College of Intensive Care Medicine (CICM). Cardiac arrest 25%
Pulmonary oedema 19%
Donor criteria and organ allocation is regulated by the
Transplantation Society of Australia and New Zealand Hypoxia 11%
(TSANZ). Donor and recipient data are collated by the Acidosis 11%
Australia and New Zealand Organ Donation Registry
(ANZOD Registry). Professional groups related to this
specialty area also cover both countries. The Australasian Table 27.2 lists the conditions commonly associated with
Transplant Coordinators Association (ATCA) is com- brain death. Irrespective of the degree of external support,
posed of clinicians working as donor and/or transplant cardiac standstill will occur in a matter of hours to days
coordinators, and the Transplant Nurses Association once brain death has occurred. 13,18
(TNA) is a specialty group for nurses working with trans-
plant recipients (see Online resources). Role of Designated Specialists
According to Australian law, senior medical staff eligible
IDENTIFICATION OF ORGAN AND to certify brain death using brain death criteria must be
TISSUE DONORS appointed by the governing body of their health insti-
tution, have relevant and recent experience, and not be
The four main factors that directly influence the number involved with transplant recipient selection. The most
of multi-organ donations are: common medical specialties appointed to the role are
intensivists, neurologists and neurosurgeons in metro-
1. incidence of brain death politan centres, and general surgeons or physicians in
2. identification of potential donors rural settings. 17
3. brain death confirmation and informed consent
for donation In New Zealand the role is not appointed although
4. donor management after brain death. medical staff confirming brain death must also act inde-
pendently; neither can be members of the transplant
BRAIN DEATH team, and both must be appropriately qualified and suit-
13
The incidence of brain death determines the size of the ably experienced in the care of such patients. The New
19
Zealand Code of Practice for Transplantation also rec-
potential organ donor pool. Diagnosis of brain death is ommends that the medical staff not be involved in treat-
now widely accepted, and most developed countries have ing the recipient of the organ to be removed, and one of
legislation governing the definition of death and the the doctors should be a specialist in charge of the clinical
retrieval of organs for transplant. In Australia and New care of the patient.
16
Zealand the most common cause of brain death has
changed from traumatic head injury to cerebrovascular Testing Methods
accident, which has implications for the organs and
tissues retrieved as donors are older and often have car- The aim of testing for brain death is to determine irrever-
17
diovascular and other co-morbidities. There is no legal sible cessation of brain function. Testing does not dem-
requirement to confirm brain death if organs and tissues onstrate that every brain cell has died but that a point of
are not going to be retrieved for transplant. 13 irreversible ischaemic damage involving cessation of the
vital functions of the brainstem has been reached. There
Two medical practitioners participate in determining are a number of steps in the process, the first being the
brain death; in Australia one must be a designated speci- observation period. An observation period of at least 4
alist. Brain death is observed clinically only when the hours from onset of observed no response is recom-
patient is supported with artificial ventilation, as the mended before the first set of testing commences, in the
respiratory reflex lost due to cerebral ischaemia will result context of a patient being mechanically ventilated with a
in respiratory and cardiac arrest. Artificial (mechanical) Glasgow Coma Scale score of three, non-reacting pupils,
ventilation maintains oxygen supply to the natural pace- absent cough and gag reflexes and no spontaneous res-
13
maker of the heart that functions independently of the piratory effort. The second step is to consider the pre-
central nervous system. Brain death results in hypoten- conditions (see Box 27.1). Once the observation period
sion due to loss of vasomotor control of the autonomic has passed (during which the patient receives ongoing
nervous system, loss of temperature regulation, reduction treatment) and the preconditions have been met, formal
in hormone activity and loss of all cranial nerve reflexes. testing can occur.