Page 1590 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 116: Care of the Multiorgan Donor 1109

and appropriate economic reimbursement for the hospitals are the mea- Mollaret and Gaulon in 1959, describing patients on ventilators who
sures advocated by the Spanish. This model has resulted in the highest have loss of neurologic function after persistent deep coma and loss of
continuous increase by far in deceased donor organ donation within a spontaneous ventilation; they first called this condition “coma depassé”
large country, reaching 35 organ donors per million population. 12 to denote neurologic damage beyond coma, but they did not equate this
Once a patient is identified as a potential organ donor, the critical entity with death itself. In 1968, the Ad Hoc Committee of the Harvard
17
pathway should be initiated by contacting the local organ procurement Medical School to Examine the Definition of Brain Death was created
organization to make the referral. Referral is critical; if this does not to standardize the definition of brain death and resolve some of the
occur the opportunity for donation may be lost entirely. Organ procure- growing controversies surrounding organ procurement for transplanta-
ment organization staff may wish to be notified as the condition of the tion from heart-beating donors. The resolutions from this committee
18
patient deteriorates even before brain death occurs. Most often, the organ are known as the Harvard Criteria of Brain Death. The reasons for this
procurement organization can quickly do a preliminary assessment to redefinition of death, according to the aforementioned Committee, were
determine whether the patient is a potential candidate for organ donation. the need to bring relief to the families of the sick, free up beds in the
If the patient is not a candidate, there is no need to discuss the option of intensive care units, and remove the grounds for objecting to the obtain-
donation with the patient’s family members, and the pathway is stopped. ing of organs for transplantation. 19
Furthermore, if family members broach the subject of organ donation, a Two criteria were considered for determining brain death: either the
clear answer can be provided as to why the patient is not a candidate for irreversible loss of all of the functions of the entire brain, including
donation, and any confusion can be avoided. Even if a patient is not a can- the brain stem, or the irreversible loss of the functions of the brain
didate for organ donation, the family may have other options to consider, stem only. 20
such as donations of eyes, skin, bone, and heart valves. 13 The concept of brain death continues to be a topic of international
Referral systems should be automatic and simple. Donors are lost debate among medical clinicians, anthropologists, philosophers, and
when hospital staff with limited knowledge of the acceptance criteria ethicists. 21,22 Much of this discussion is the result of the awareness of
for organ donors inappropriately rule out potential organ donors as continuing technological advances, neurodiagnostic developments, and
medically unsuitable. Retrospective reviews of the records of patients clinical insight. This ongoing dialogue can be viewed as a dynamically
who have died while in the hospital indicate that a surprising number of developing process of achieving a multidisciplinary consensus that is
potential donors were never evaluated by organ procurement organiza- responsive to a continually changing technological environment. 23
tion staff for this reason. The reasons given for the determination of Evidence-based guidelines for determining the brain-death criteria in
unsuitability, if any reason is noted in the chart, are many and include the United States are based on the Report of the Medical Consultants on
age, use of vasoactive drugs, disease (eg, diabetes), cardiopulmonary the Diagnosis of Death to the President’s Commission on the Study of
resuscitation, and positive cultures. Any patient with a significant and Ethical Problems in Medicine and Biomedical and Behavioral Research of
potentially life-threatening injury to the head, whether caused by trauma, 1981. The President’s Commission requires loss of brain stem function,
24
an intracerebral hemorrhage, or an anoxic event, should be referred to loss of cortical function, and that the condition is irreversible. Although
the organ procurement organization as early as possible for evaluation the guidelines reflect generic, scientifically based recommendations,
as a potential organ donor. This practice allows the organ procurement adaptation of certain details may vary across practice settings and states
organization to evaluate the situation and apprise staff members early on according to variations in institutional policy and local legislation. 25
about whether the patient is a potential donor or not. Currently, only a In 2010, the American Academy of Neurology (AAN) published an
few medical contraindications to donation are absolute, including: updated guideline for determining brain death in adults. It provided
26
practical, opinion-based brain death evaluation protocols for clinicians.
• Transmissible infectious disease that will adversely affect the recipi-
ent (eg, human immunodeficiency virus (HIV) infection, active viral According to the updated guideline, the 1995 AAN practice param-
eter for the determination of brain death has not been invalidated by
hepatitis B, encephalitis of unknown cause, prion disease, malaria,
and disseminated tuberculosis) published reports of neurologic recovery in patients who fulfill these
criteria. The AAN parameter emphasized the three clinical findings
• Active visceral or hematologic malignant neoplasm necessary to confirm irreversible cessation of all functions of the entire
• Characteristics that indicate the organ is unlikely to function brain, including the brain stem: coma (with a known cause), absence of
brainstem reflexes, and apnea. 27
Indeed, the only typical feature of a potential donor today is brain
death, and with the increased use of non–heart-beating donors in the
United States, even brain death is not necessarily typical anymore. REQUEST FOR CONSENT
Early referral is also key to success in recovering transplantable organs
for potential recipients. If an organ procurement organization receives Refusal by the family to provide consent for donation is the most
a referral from the critical care staff well after brain death has occurred, common reason that organs of medically suitable potential donors
decreases in end-organ function will already have taken place if donors are not recovered. According to estimates, 35% of the medically suit-
are not appropriately managed. If the organ procurement organization able organ donors do not donate because the family of the potential
is called in only well after the signs of brain death are present, the donor donor refuses to consent to donation. Hospitals with low donation
who might have had 5 to 7 organs suitable for donation and transplan- rates were more likely to have staff members who perceived dealing
tation, may by that time have only 1 or 2 suitable organs. On the other with a potential donor as time-consuming and burdensome, and who
hand, delay of organ procurement to allow optimization of organ condi- were uncomfortable with how their hospital handled donation. The role
tion is also necessary sometimes. 14,15 It has been questioned whether it that personal attitudes play in the ability of staff members to handle
is reasonable to expect nurses and physicians to keep pace with all of donation is unclear. Staff members in hospitals with high donation
the changes taking place in organ donation, and thus systems have been rates have a more positive personal attitude toward donation than do
developed and implemented—sometimes required by law, that do not staff members in hospitals with low donation rates; however, a positive
rely on hospital staff to screen potential donors. 16 personal attitude does not correlate with the ability to approach families
about donation. 16
DECLARATION OF BRAIN DEATH Another situational variable that has a marked influence on donation
rates is the timing of the request (ie, when the request is made relative
The introduction of successful kidney transplantation in the 1950s led to to when the family is informed of the death). Research clearly shows
the concept of the use of organs from “heart-beating cadavers.” The clin- that inappropriate timing of the request (ie, informing the family of the
ical findings of “brain death” were first described by French investigators death and requesting donation at the same time) is a formula for family

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