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Brain death diagnoses and evaluation of the number of potential organ donors in Québec hospitals

[Les diagnostics de mort encéphalique et l’évaluation du nombre de donneurs d’organes possibles dans les hôpitaux du Québec]

Réal Cloutier, MD^*,, Dana Baran, MD^,, Jean E. Morin, MD^*,¶, Raymond Dandavino, MD^||, Denis Marleau, MD^**, Alain Naud, MD, Robert Gagnon, MSc^* and Marc Billard, MD^*

^* From the Transplantation Committee, Québec College of Physicians Montréal;
Directeur conseil, Conseil en Immobilisation et management Inc., Montreal,
Internal Medicine and Nephrology, McGill University Health Centre, Montréal,
Québec-Transplant; Montréal;
^¶ Cardiothoracic Surgery, McGill University Health Centre, Montréal;
^|| Hôpital Maisonneuve-Rosemont, Montréal;
^** Centre hospitalier de l’Université de Montréal St-Luc, Montréal;
Centre hospitalier Universitaire de Québec, Québec City; Québec, Canada.

Address correspondence to: Dr. Réal Cloutier, Conseil en Immobilisation et Management Inc. 440, boul. René-Lévesque Ouest, bureau 1700, Montréal, Québec H2Z 1V7. Phone: 514-393-4563, ext. 326; Fax: 514-393-4598; E-mail: rcloutier{at}cim-conseil.qc.ca

	Abstract

TOP Abstract Introduction Methods Results Discussion References

 
Purpose: Faced with our inability to respond to the growing number of Quebec patients waiting for organ transplants, we sought to determine the number of potential organ donors (OD) in acute care hospitals.

Methods: A retrospective chart review of all acute care, in-hospital deaths in Quebec in the year 2000 was undertaken. Hospital record librarians provided statistics and completed questionnaires on each chart after applying exclusion and inclusion criteria.

Results: There were 24,702 acute care in-hospital deaths reported by 83 hospitals participating in the study on a voluntary basis. Analyzing 2,067 files meeting inclusion criteria, we identified 348 potential OD (1.4% of deaths). In hospitals not providing tertiary adult trauma care, the potential donor rate was 0.99% of all deaths. There were 4.5 times more potential donors in tertiary care adult trauma centers. Brain death was formally diagnosed in 268/348 patients, and organ donation discussed as an option with 230/268 families. Consent for donation was given in 70% of cases, although not all these patients proved to be suitable after evaluation. There were 125 actual donors in Quebec in the year 2000 (18 per million population).

Conclusions: The gap between used and potential donors can be explained by several factors including failure to approach families for organ donation, family refusal, incomplete neurological assessment of patients, and medical unsuitability of some consented donors. There is room for improvement in the identification of potential donors and in the presentation of organ donation as an end of life option to families.

	Introduction

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THE number of organ donors in Canada is too small to meet the existing demand. In Québec alone, 815 patients were waiting for solid organ transplants in 2000 and 860 were listed in 2003.¹ Spain is recognized as the country with the highest organ donor rate PMP (33.9)² because of its highly organized donor identification system. In Canada, the rate was 13.3 per million population (PMP) in 2003, whereas in Québec the rate was 19.2.¹

Although actual donor rates are known, there are few studies on the number of potential organ donors in Canada. The only report concerning potential organ donors in Québec hospitals was published in 1991.³ Conducted in 24 hospitals, the study included only those patients most likely to become organ donors (cerebrovascular accident, trauma). In that study, only one out of two eligible patients was identified as a potential donor. In their report published in the summer of 2000, the Advisory Board on organ and tissue donation of Ontario⁴ deplored the lack of data on potential donors in Ontario hospitals. In 2001, the Canadian Institute for Health Information^A published a document using the method of Holt⁵ to estimate the number of potential donors among hospitalized patients in Canada. In April 2001, Baxter (The Urban Futures Institute, 2001)⁶ cast doubt on Canada’s ability to attain the organ donor rates of certain countries such as Spain, considered the gold standard, and the United States, given the differences in the causes of death among these countries. He also examined the disparities among rates pointing out that it is difficult to compare them since donors PMP is not calculated in a uniform fashion across countries.

In the context of this debate and considering all these factors, the Transplantation Committee of the College of Physicians of Québec, a subcommittee of the Professional Inspection Committee undertook the present study. The mandate resulted from an agreement with Québec-Transplant who asked the College to assume responsibility for an independent hospital chart review. In return, Québec-Transplant provided the College with all statistics concerning organ donation and financial support for secretarial assistance. A summary appears at: http://www.cmq.org/DocumentLibrary/UploadedContents/CmsDocuments/transplantationEng.pdf.⁷

This study had two objectives: a) to establish and report the number of potential donors in all Québec acute care hospitals compared to the number of donors in the year 2000 and b) to sensitize physicians to the identification of potential organ donors by sending individual hospital results to each Council of Physicians, Dentists and Pharmacists. This study is important because it directly estimates the number of brain dead patients in Québec hospitals and provides a realistic goal for organ donor identification and utilization.

	Methods

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The study was a retrospective chart review of all deaths that occurred in Québec acute care hospitals between January 1st and December 31^st 2000. Patients dying in emergency wards were not included in this study because their charts did not contain diagnostic codes. The study started in September 2000 when documents were mailed to acute care hospitals requesting their voluntary participation. Hospital record librarians provided statistics and completed questionnaires⁷ on each chart after applying exclusion and inclusion criteria (Table I). These data were captured in a database using a software program that automatically checks the validity of entries to reduce the risk of transcription errors. Québec-Transplant provided a separate list for purposes of validation of all phone calls concerning potential donors received from referring hospitals. The secretary of the Transplantation Committee reviewed all the questionnaires supplied by the medical record departments in order to identify potential organ donors (Appendix). When the information supplied was incomplete, copies of progress notes written by doctors, nurses and respiratory therapists in the last 24 hr of the patient’s life were requested. With all these data, it was possible to establish the state of consciousness of each patient, and to determine whether or not brainstem reflexes were present including spontaneous respiration. This enabled us to either include or exclude patients as potential organ donors. In controversial cases, the entire Transplantation Committee was consulted and decisions were made unanimously.

Statistical analysis
The primary analysis tested the difference between rates of potential donors and the proportion of apnea tests according to three hospital characteristics: the presence of tertiary trauma, the presence of dialysis service, and a location in remote regions. Differences between rates were tested with the Chi-square test with the Yates correction. Results were considered statistically significant at a P 0.05.

	Results

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Eighty three of 93 hospitals (89%) participated in the study: 80 hospitals provided complete information; of these, 31 hospitals had an active local organ and tissue donation committee. The total number of deaths in participating hospitals was 24,702 amongst hospitalized patients, accounting for 93% of all deaths occurring in the year 2000 in acute care hospitals as reported by a special request at the Central bank of data, Ministry of Health and social services Québec (MED-ECHO).⁹ After applying exclusion criteria, 8,973 charts were retained. This number was reduced to 2,067 for final study (8.3% of deaths) after applying the inclusion criterion. A detailed analysis of these charts permitted the identification of 348 potential organ donors. A Glasgow coma scale score¹⁰ was reported in 831 of the 2,067 charts reviewed (40%). The mean age of the 348 identified potential donors was 53 yr. A spontaneous neurological event was responsible for death in 54.3% of the identified potential donors, whereas 72 patients (20.7%) died from head trauma. Several other causes of death were also documented (Table II).

A specific analysis of the 268 patients with a formal diagnosis of brain death revealed the following: 205 charts with a documented Glasgow Coma Score (76% of cases), 181 apnea tests (67% of the cases), 205 requests to families (76% of cases) and a consent rate of 73%. The consent rate was similar to the consent rate of 70% for all families approached for donation (P = 0.44).

Apnea tests were documented in 204 of the 2,067 charts analyzed. One hundred and ninety tests were done in the 348 cases of identified potential organ donors, and 181 tests were done in the cohort of patients formally diagnosed as brain dead. The potential organ donor rate among hospitalized patients who died in acute care institutions was 1.41% for all causes of death combined (Figure 1). The rate in the 78 hospitals not offering tertiary trauma care was 0.99%. It was 4.5 times higher in the four hospitals providing adult tertiary trauma services. The rate was also higher than average in the 28 hospitals offering adult dialysis services (1.58%; P < 0.01). The potential organ donor rate in the 27 hospitals in distant regions was not different when compared to other Québec hospitals (0.96% vs 1.47%, P = 0.03). The conversion rate among hospitalized potential donors was 46% (125 utilized donors/268 documented cases of brain death).

View larger version (28K): [in this window] [in a new window]   FIGURE 1 Rate of potential donors in Québec as a function of hospital type.

View larger version (36K): [in this window] [in a new window]   FIGURE 2 Percent of apnea tests done in referring hospital patients in case of diagnosed brain death.

	Discussion

TOP Abstract Introduction Methods Results Discussion References

 
Our chart review established that most physicians adequately documented neurological signs permitting the identification of brain death in most cases. However, there is room for improvement in certain centres where incomplete information was recorded on the level of consciousness and other pertinent neurological signs. Physicians in trauma intensive care units are most sensitized to the identification of potential organ donors. Other physicians, however, do not always have a clear notion of how to diagnose brain death, or when and how to perform an apnea test. This may be explained by the small number of cases of brain death in most Québec hospitals.

Our data also suggest that more families should be approached regarding organ donation when brain death is diagnosed (only 77% of cases). The consent rate of 70% is higher than the 54% observed in the study of Sheehy et al.,¹¹ but could still be improved. The estimated consent rate in our study closely parallels the intentions of Quebecers reported in a Léger & Léger survey published in 1999^B indicating that 66% of those polled would agree to donate their organs.

The mean age of the potential donors was 53 yr, whereas the mean age of donors actually utilized by Québec-Transplant was 43 yr. This age discrepancy might be explained by a tendency of physicians to exclude patients from consideration based upon age alone.

The potential donor rate of 0.99% in hospitals without tertiary trauma care services is a new and interesting observation since it reflects the situation in the majority of hospitals. The higher potential donor rate in tertiary trauma centres (4.5%) is consistent with the study of Christiansen et al.¹² who identified the provision of trauma care as one of five characteristics predictive of the number of potential donors. Using our information on donor distribution, we have recently trained a group of in-house organ donor resource nurses who are working in the 20 Québec hospitals with the greatest organ donor potential. This initiative will hopefully lead to better donor identification in the future. Almost 8% of potential donors were found in distant regions which is an important observation that should not be neglected. Only a few hospitals (31) had active organ and tissue donation committees of the 83 participating hospitals.

Based on our results, it is theoretically possible to achieve a rate of approximately 28 donors PMP (Table III), which would permit Québec to have 200 donors per year (135 in 2000). The conversion rate of 46% observed in Québec is comparable to the rate reported by Sheehy et al.¹¹ but is, of course, far from optimal.

The present study has certain limitations: it is a retrospective chart review relying on the collaboration of hospital record librarians; in addition, it depends on local research tools (local data bank MED-ECHO), the accuracy of coding the charts, and the quality and quantity of information in the hospital records. A total of 40/2,047 charts (1.9%) reviewed were considered to be incomplete, and were reviewed in detail by the Transplantation Committee in an effort to classify patients as accurately as possible.

Despite several limitations, we believe that this study is important because it addresses the issue of organ donor potential in a direct manner, helping us to establish a realistic target for organ donation in the province of Québec. With the publication of these data, the Québec College of Physicians hopes to play a leading role in the analysis of organ donor potential in Canada, and to suggest ways in which more organ donors can be identified and utilized.

	Acknowledgments

 
We were able to conduct this study with the invaluable collaboration of all Québec hospitals, especially hospital record librarians, and with the support of Québec-Transplant. The Transplantation Committee extends special thanks to Donald Langlais, Anthony d’Amicantonio and Micheline Lyras (Québec-Transplant), Lisa Goulet (McGill University Hospital Centre) and Isabelle Brunet (Québec College of Physicians). We are also grateful to Dr. Sam Shemie for his collaboration and to Dr. Dana Baran for the English translation of this article.

	Footnotes

 
Accepted for publication August 30, 2005. Revision accepted November 25, 2005. Final revision accepted January 20, 2006.

Competing interests: None declared.

^A Canadian Institute for Health Information. Estimating potential cadaveric organ donors for Canada and its provinces, 1992 to 1998, a discussion paper. Ottawa, 2001: 61.

^B Léger & Léger. Attitudes des Québécois face au don d’organes. Montréal, Léger & Léger, Survey realized with 1,005 persons at the Québec-Transplant demand. April, 1999: 16.

	References

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1 Québec Transplant, statistics. Available from URL; http://www.Quebec-transplant.qc.ca/public.htm.

2 Organización Nacional de Trasplantes. Evolution of the donation and transplantation activity in Spain (Spanish). Available from URL; http://donacion.organos.ua.es/ont/.

3 Balk RA. Étude sur les donneurs d’organes au Québec. Soumis au Conseil de la santé et des services sociaux de la région de Montréal et au ministère de la Santé et des services sociaux (French). May 9, 1991: 68.

4 Premier Harris’ Advisory Board on organ and tissue donation. Organ and tissue donation in Ontario: a plan for change and action: report. May, 2000: 91.

5 Holt AW, Hodgeman GK, Vedig AE, Heard PE. Organ donor index: a benchmark for comparing hospital organ donor rates. Med J Aust 1999; 170: 479–81.[Medline]

6 Baxter D, The Urban Futures Institute. Beyond comparison: Canada’s organ donation rates in an international context. Vancouver, The Urban Futures Institute Report 51, 2001: 40.

7 Collège des médecins du Québec. Rapport du Comité de transplantation sur les donneurs potentiels d’organes dans les hôpitaux du Québec en 2000 – Potential Organ Donors in Québec Hospitals – Year 2000. 2003, Available from URL; http://www.cmq.org/DocumentLibrary/UploadedContents/CmsDocuments/transplantationEng.pdf.

8 Canadian Neurocritical Care Group. Guidelines for the diagnosis of brain death. Can J Neurol Sci 1999; 26: 64–6.[Medline]

9 Ministry of Health and Social Services, Québec. Maintenance et exploitation des données pour l’étude de la clientèle hospitalière – MED-ECHO (French). Special request of data for year 2000.

10 Sternbach GL. The Glasgow Coma Scale. J Emerg Med 2000; 19: 67–71.[Medline]

11 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: 667–74.[Abstract/Free Full Text]

12 Christiansen CL, Gortmaker SL, Williams JM, et al. A method for estimating solid organ donor potential by organ procurement region. Am J Public Health 1998; 88: 1645–50.[Abstract/Free Full Text]

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