Connect
MJA
MJA

Potential for organ donation in Victoria: an audit of hospital deaths

Helen I Opdam and William Silvester
Med J Aust 2006; 185 (5): 250-254. || doi: 10.5694/j.1326-5377.2006.tb00554.x
Published online: 4 September 2006

Abstract

Objective: To determine the potential for organ donation in 12 Victorian hospitals.

Design and setting: Prospective audit of all deaths in 12 major public hospitals in the state of Victoria between January 2002 and October 2004.

Main outcome measures: Number of organ donors and potential organ donors (patients with brain death or likely to progress to brain death within 24 hours if supportive treatment continued), requests for organ donation and consents. Unrealised potential donors (organ donation not requested) were categorised by an independent panel of intensivists as category A (brain death formally diagnosed); B (brain death not formally diagnosed but criteria likely to be fulfilled); and C (potential to progress to brain death within 24 hours).

Results: There were 17 230 deaths, 280 potential organ donors and 220 requests for organ donation. The 60 unrealised potential organ donors were classified as category A (3), B (17) and C (40). Consent rate was 53% to 65%, depending on the definition of potential donor (categories A, B and C or category A only). Consent rate was lower when discussions about organ donation were held by trainees or registrars (21%) than when specialists were present (57%) (P = 0.004). A maximum practically achievable organ donation rate for Victoria was estimated to be 15 to 17 donors per million population (current rate, 9 per million population).

Conclusions: The potential for organ donation in Victoria is limited by a small organ donor pool. There is potential to increase the number of organ donors by increasing the consent rate (lower than expected from public surveys), the identification of potential organ donors (particularly those likely to progress to brain death if supportive treatment is continued), and requests for organ donation.

Methods
Definition of the potential organ donor

Apart from living donation of kidneys and, very rarely, liver, solid organ donation is possible only after death has occurred. In Australia, death may be legally declared when there is irreversible cessation of either circulation of blood or all function of the brain. The latter is termed “brain death”, and its certification is a legal requirement if removal of organs for transplantation is to occur while respiration is being maintained artificially. Brain death may be diagnosed by demonstrating absent brain function with clinical brainstem tests (including apnoea) or by demonstrating absent intracranial blood flow using perfusion imaging.4

For brain death to occur, the patient must have sustained an acute brain injury sufficiently severe to culminate in eventual loss of all blood flow to the brain. Typical injuries include trauma, intracranial haemorrhage, thrombotic stroke and severe hypoxia–ischaemia (eg, resuscitated cardiac arrest).

For the purpose of this audit, potential donors were defined as patients with confirmed brain death, or those who were likely to progress to brain death within 24 hours if supportive treatment continued, and who were medically suitable for organ donation. Medical suitability for organ donation was defined by the guidelines of the Transplantation Society of Australia and New Zealand.5

It was not the role of this audit to determine the potential number of non-heart-beating donors (donation after cardiac death), who currently comprise fewer than 2% of cadaveric donors.1

Results

There were 17 230 deaths in the 12 hospitals between January 2002 and October 2004 (Box 3). In Hospital D, data collection was discontinued in mid-2002 after review of 193 deaths, as the hospital denied ongoing access to medical records.

Organ donation not considered or not requested

Of the 128 patients reviewed at intensivists’ meetings, 60 were categorised as unrealised potential donors: three as category A (confirmed brain death); 17 as category B (brain death likely but not formally diagnosed); and 40 as category C (potential to progress to brain death within 24 hours if supportive treatment had continued) (Box 3). These unrealised potential donors occurred across all hospitals, and in both intensive care units (ICUs) and emergency departments (EDs) (Box 4).

The remaining 68 patients were classified as category D (58), not medically suitable (5), failed physiological support (2) and non-consent (3).

Unrealised category B donors

Of the 17 unrealised category B potential donors, six had supportive care withdrawn in the ED (Box 5). They comprised:

The 11 patients who had treatment withdrawn in the ICU comprised:

Discussion

This audit suggests that there is limited but real potential to increase the number of organ donors in Victoria. The practically achievable maximum rate of organ donation for Victoria of 15 to 17 donors per million population is similar to that previously reported in Australia,6,7 but substantially lower than actual organ donation rates achieved in some countries.1 This may be due to a smaller organ donor pool in Victoria, as a result of less road and firearm trauma, and differences in the treatment of hypertension and severe brain injury.8

Were this practically achievable maximal rate of organ donation to be reached, the current demand for organs for transplantation would largely be satisfied.

An increase in the rate of cadaveric organ donation might be achieved by increasing the consent rate, and increasing the rates of identification of potential donors and request for organ donation.

Increasing the consent rate: The consent rate in this study was 53% to 65%, depending on how broadly the potential organ donor was defined. This is higher than rates reported for the United States (54% for patients with confirmed or suspected brain death)9 and the United Kingdom (59% for patients with confirmed brain death),10 but lower than rates reported in Spain (85%).11

Surveys suggest that public support for organ donation in Australia is as high as 77%.12 However, the support expressed in surveys may be higher than that felt by newly bereaved individuals facing the reality of making the decision on behalf of a family member. Other factors, such as the way in which the option of organ donation is raised with families, may also influence the likelihood of consent. In our study, non-consent was more likely when junior doctors, rather than specialists, discussed organ donation with the family. It is known that family consent is more likely if the approach is made by individuals who are informed about and support organ donation.13,14 Intensive care trainees now receive training on how to identify and care for potential organ donors and how to communicate better with the potential donor’s family.15

Increasing identification of potential donors and requests for organ donation: There were only three patients with confirmed brain death for whom organ donation was not requested. This is fewer than 2% of all patients with confirmed brain death and less than 0.02% of hospital deaths. These rates are very low compared with other published audits.9,10,16,17 Avoiding this most obvious type of “missed donor” requires clinicians to ensure that they always discuss the possibility of organ donation with the family.

There were 17 patients with unconfirmed brain death for whom organ donation was not discussed with the next-of-kin. In some of these, circumstances appear to have impeded the process of diagnosing brain death, requesting organ donation and physiologically supporting the potential donor until the time of organ procurement. However, in many cases it appears that brain death was just not recognised and hence not assessed, or, if thought of, was not pursued.

The largest group of unrealised potential donors comprised those with imminent brain death who had supportive treatment withdrawn without organ donation being considered. A change in practice would be needed if the option of organ donation were to be routinely offered for such patients. This would involve discussing the option of organ donation with the next-of-kin before brain death, and providing ongoing supportive treatment to allow time for brain death to occur.

It is vital that the discussion of organ donation not precede the family’s understanding and acceptance of a prognosis of death. Recommended practice is that the issue not be raised with the family until after brain death has been diagnosed and explained to them.4 However, the audit data demonstrate that, in many instances, organ donation is discussed with the next-of-kin before brain death is diagnosed. Indeed, for category C patients for whom withdrawal of supportive treatment is being considered, there is no other time to raise the issue. If embarked upon, these discussions should be conducted by skilled staff who are knowledgeable about brain death and organ donation. This would require additional resources in the ICU to provide supportive care for potential donors.

In conclusion, Victoria appears to have a relatively small organ donor pool. There is some potential to raise the organ donation rate through increasing rates of consent, and through optimising the identification and provision of supportive treatment for potential donors, and requests for organ donation.

Received 22 November 2005, accepted 16 May 2006

  • Helen I Opdam1,2
  • William Silvester1,2

  • 1 Department of Intensive Care, Austin Health, Melbourne, VIC.
  • 2 LIFEGift, Victorian Organ Donation Service, Melbourne, VIC.


Correspondence: helen.opdam@austin.org.au

Acknowledgements: 

This study was funded by the Department of Human Services through LIFEGift, the Victorian Organ Donation Service.

Competing interests:

None identified.

  • 1. Excell L, Russ G, Wride P, editors. Australia and New Zealand Organ Donation Registry report. Adelaide: ANZOD, 2005.
  • 2. International Registry Organ Donation and Transplantation. Available at: http://www.tpm.org/registry/reg_mondo.asp (accessed Apr 2006).
  • 3. Australian Institute of Health and Welfare. Australian hospital statistics 2003-04. Canberra: AIHW, 2005. (AIHW Cat. No. HSE 37; Health Series No. 23.)
  • 4. Australian and New Zealand Intensive Care Society. Recommendations on brain death and organ donation. 2nd ed. Melbourne: ANZICS, 1998.
  • 5. Transplantation Society of Australia and New Zealand. Organ allocation protocols. Sydney: TSANZ, 2000. Last update, Aug 2004. Available at: http://www.racp.edu.au/tsanz/oapmain.htm (accessed Jan 2005).
  • 6. Hibberd AD, Pearson IY, McCosker CJ, et al. Potential for cadaveric organ retrieval in New South Wales. BMJ 1992; 304: 1339-1343.
  • 7. Opdam HI, Silvester W. Identifying the potential organ donor: an audit of hospital deaths. Intensive Care Med 2004; 30: 1390-1397.
  • 8. Australian Transport Safety Bureau. Transport accident fatalities: Australia compared with other OECD countries, 1980-1999. Available at: http://www.atsb.gov.au/publications/2004/Int_Comp_5.aspx (accessed May 2006).
  • 9. Sheehy E, Conrad SL, Brigham LE, et al. Estimating the number of potential organ donors in the United States. N Engl J Med 2003; 349: 667-674.
  • 10. Barber K, Falvey S, Hamilton C, et al. Potential for organ donation in the United Kingdom: audit of intensive care records. BMJ 2006; 332: 1124-1127.
  • 11. Miranda B, Vilardell J, Grinyo JM. Optimizing cadaveric organ procurement: the Catalan and Spanish experience. Am J Transplantation 2003; 3: 1189-1196.
  • 12. Pfizer Australia. Health report, 23 August 2004. Australians accept animal organ transplants but under-informed. Available at: http://www.pfizer.com.au/Media/Transplants.aspx (accessed Mar 2005).
  • 13. Siminoff LA, Gordon N, Hewlett J, et al. Factors influencing families’ consent for donation of solid organs for transplantation. JAMA 2001; 286: 71-77.
  • 14. Gortmaker SL, Beasley CL, Sheehy E, et al. Improving the request process to increase family consent for organ donation. J Transpl Coord 1998; 8: 210-217.
  • 15. Gillott J, Berriman M. ADAPT. Australasian Donor Awareness Programme: final report for the Australian Government Department of Health and Ageing. Financial year 2004–2005. Canberra: Department of Health and Ageing, 2005.
  • 16. Siminoff LA, Arnold RM, Caplan AL, et al. Public policy governing organ and tissue procurement in the United States. Results from the National Organ and Tissue Procurement Study. Ann Intern Med 1995; 123: 10-17.
  • 17. Gore SM, Cable DJ, Holland AJ. Organ donation from intensive care units in England and Wales: two year confidential audit of deaths in intensive care. BMJ 1992; 304: 349-355.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.