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* From the Departments of Medicine, University of Toronto, Toronto;
Critical Care Medicine, University of Calgary, Calgary;
Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec;
Neurology, Montreal Neurological Institute, McGill University, Montreal, Quebec; and
¶ Emergency Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada.
Address correspondence to: Dr. Dan Cass, Emergency Medicine, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada. E-mail: cassd{at}smh.toronto.on.ca This study was supported by a grant from the Clarica Corporation.
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Abstract |
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Methods: A one-year retrospective cohort study was undertaken using a convenience sample of patients transferred to eight ONCs for neurosurgical assessment, with evidence of either (a) brain death in the emergency department, or (b) severe brain injury who met criteria of a reasonable likelihood of progression to brain death. The outcome of these patients to disposition from the ONC was determined by chart review.
Results: Three thousand four hundred and forty-seven patients were identified of whom 141 met inclusion criteria. Eleven patients (7.8%) were pronounced dead in the emergency department, 96 (68.1%) patients were admitted, and 34 (24.1%) were transferred back to their referring hospital. Fourteen patients (9.9%) became organ donors: two died in the emergency department and 12 died following admission.
Conclusions: A significant number of patients transferred to ONCs have an injury with a likelihood of progressing to brain death, but only a small proportion of these patients become organ donors. Emergency department triage, assessment and admission decisions for patients with intracranial catastrophes should consider diagnostic criteria for brain death and recognition of donor potential as part of end-of-life care.
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Introduction |
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Cadaveric organ donors are patients pronounced dead by neurological criteria, most often due to head trauma or spontaneous catastrophic intracranial events such as intracranial hemorrhage. Most, if not all, of these potential organ donors receive their initial care in emergency departments (EDs), and from neurosurgeons and emergency physicians. In Ontario, 11 hospitals are designated as adult neurosurgical centres (ONCs). Patients are referred to ONC EDs from other facilities for neurosurgical management. Patients with a catastrophic illness/injury are evaluated for potential neurosurgical intervention and/or prognosis, and when not amenable to treatment, often die in the ED or are returned to their sending facility. Some of these patients may progress to meet neurological criteria for death (brain death), and be potential organ donors. However, if the health care professionals in the ED or sending hospital are not familiar with the criteria for neurological death, or in approaching families for organ donation, potential organs for transplant may not be realized. The purpose of this study was to estimate the number of patients referred to EDs with acute neurosurgical conditions where progression to brain death might reasonably be expected, and to determine the number of patients who actually became organ donors.
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Methods |
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). Patients were included if there was documented evidence of either (a) brain death in the ED, or (b) potential progression to brain death within 24 hr based upon a priori established criteria (Table I). These criteria were developed in consultation with neurosurgeons and intensive care physicians at one ONC based on expert opinion and clinical experience, and were meant to qualitatively identify those patients with severe brain injury and a high likelihood of progression to neurologic death. There was no attempt to formally validate these criteria in terms of their sensitivity and specificity.
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In order to maintain anonymity, results will be presented in table form without identifying the participating ONCs connected with specific statistics. Only the principal investigator and research assistants had access to non-anonymized data. A list of the participating institutions can be found in the Appendix
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Results |
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and Table II. Of 3,447 patients in Ontario transferred to the participating ONCs, 141 patients (4.1%) met the study inclusion criteria. The number of referrals to the neurosurgery service and potential donors assessed at the ONCs varied widely between institutions, reflecting the overall size of the institution and the population density of the catchment area served. Ninety-six patients (68.1%) were admitted to ONCs. They ranged between 17 and 97 yr of age. None sustained penetrating brain injuries. Eighty-six patients died during the hospitalization, and ten patients survived to be transferred to a rehabilitation facility. Each of these patients had an initial GCS of 4–5 in the ED and an intracranial lesion amenable to operative treatment. Of the 86 patients who died, in 22 cases organ donation was considered: consent was obtained in 14 cases, 12 of whom became organ donors. The donor rate was also variable between ONCs, from 0–25%, with an average donor rate of 9.9% (Table II).
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. Eleven of the 141 patients (7.8%) were pronounced dead in the ED. They were between 39 and 79 yr of age. Nine of these patients died of circulatory collapse. The other two patients met neurological criteria for death, and consent was obtained for organ donation following a request initiated by the family (Table IV).
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). They were between 35 and 85 yr of age. None sustained penetrating brain injuries. By our criteria, 11 likely had brain death in the ED, and 22 met the criteria for potential progression to brain death within 24 hr. In one of these cases, it was recommended that the patient return to their sending facility "for formal declaration of brain death, then possible consideration of organ donation." It is unknown if any of these patients subsequently became organ donors.
Fourteen patients (9.9% of all potential donors) became actual organ donors (Table II). Discussion of organ donation occurred for 37 (26.2%) of the 141 potential donors (Table IV). Eight of these patients became organ donors at their family’s request during discussion with either a staff neurosurgeon or staff intensivist. Both donors pronounced dead in the ED became donors after family-initiated discussion of the topic. Ten discussions (27% of discussions) were family-initiated. In contrast, of the potential 141 donors, 117 (83%) patient charts had no documented evidence of being identified as such by a health care professional or family member.
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Discussion |
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Our findings suggest that lack of identification of potential donors represents a major rate-limiting step in the organ donation process. Other work suggests that centres with expertise in the critical care management of neurosurgical emergencies have higher rates of organ donation than centres without this infrastructure. 3 It is likely that these centres have established processes in diagnosing brain death, organ donor identification, and familiarity with family support as part of end-of-life care. System problems affecting the ED such as increasing patient volumes, increasing ED lengths-of-stay, limited availability of intensive care unit beds that may affect admission criteria and, other causes of ED overcrowding may create a barrier to realizing potential organ donors by forcing the transfer of these patients back to their sending facility. Identifying as a priority the end-of-life care, which may include organ donation of these severely injured patients, may increase the number of potential and actual donors.
This study has limitations. First, chart reviews at three ONC centres were not undertaken due to inaccessibility of charts for the population sought in this study. Our results may inaccurately estimate the organ donor potential if there are systematic differences in how these three ONCs manage the decision to admit patients or return them to their sending facility, compared to the eight ONCs included in our study. It is possible that the rate of discussion of organ donation is also underestimated in our study. Some physicians could have considered and/or requested donation without documenting their request.5 Unfortunately, in a retrospective study, the only record is the documentation in the patient’s chart. Our study sample is not representative of the population of patients who usually progress to brain death. Our sample had a lower proportion of patients with traumatic brain injury compared to usual national statistics. Our sample probably under-represented the proportion of patients with traumatic brain injury because the ONC’s are also regional trauma centres, and patients are likely directly transferred to these facilities, not from other facilities. Finally, despite our criteria having been developed a priori and reviewed for face and content validity, our criteria did not always correctly identify patients who would progress to brain death. Of the patients admitted to ONCs who were expected to progress to brain death, ten of 96 (10.4%) ultimately survived, to be discharged to a rehabilitation facility. This finding highlights the uncertainty of early clinical findings in predicting outcome from brain injury. As discussed by Rocker et al.,6 survival predictions are characterized by significant practice variation, partly related to the patient and his/her disease, but also heavily influenced by physician and hospital characteristics. Given the evolving neuroprotective therapies,7–10 perhaps all patients with severe brain injury should be considered for a trial of treatment and accurate prognostication. Given these considerations, health care professionals must also ensure that they provide clear information to the patient’s family. Perceived miscommunication from the health care professionals involved can play a major role in family refusal.11 For example, a premature request or conflicting statements from a variety of physicians can undermine a family’s willingness to consider donation.11
The Canadian health care system does not yet have a reliable information collection procedure to assess the extent to which Canadian hospitals can identify potential donors, and take the steps to maximize organ use from each donor.1 Our study emphasizes the importance of ED health care professionals in identifying potential organ donors. Efforts including educational initiatives for ED staff on donor recognition, 12,13 and the use of in-hospital donation coordinators5,12,14,15 have been shown to have a positive impact in this area. System barriers within the hospital system may prevent patients from being admitted to facilities with expertise in end-of-life care, including organ donation. Our study implies that patients referred with catastrophic injury should be considered for admission for a trial of treatment and/or to facilitate end-of-life care. Data on organ donation practices should incorporate a mechanism to document and track the ‘at-risk’ population; i.e., patients with severe, catastrophic brain injuries assessed in EDs.
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Footnotes |
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Competing interests: None declared.
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2 Canadian Organ Replacement Registry Cumulative Report 2004, Canadian Institute for Health Information. Table 2B - "Patients Who Died While Waiting for a Transplant, January 1 to December 31, 2004". CIHI website (accessed February 1, 2006). Available from URL; http://secure.cihi.ca/cihiweb/en/downloads/CORRQ404_Table2B_C_e.pdf.
3 Cloutier R, Baran D, Morin JE, et al. Brain death diagnoses and evaluation of the number of potential organ donors in Québec hospitals. Can J Anesth 2006; 53: 716–22.
4 2005 Preliminary Statistics on Organ Donation, Transplantation and Waiting List. CIHI website (accessed February 1, 2006). Available from URL; http://secure.cihi.ca/cihiweb/en/downloads/CORR-CST2005_Gill-rev_July22_2005.ppt.
5 Riker RR, White BW. Organ and tissue donation from the emergency department. J Emerg Med 1991; 9: 405–10.[Medline]
6 Rocker G, Cook D, Sjokvist P, et al.; for the Level of Care Study Investigators; Canadian Critical Care Trials Group. Clinician predictions of intensive care unit mortality. Crit Care Med 2004; 32: 1149–54.[Medline]
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9 Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346: 557–63.
10 Schwab S, Steiner T, Aschoff A, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 1998; 29: 1888–93.
11 Kennedy AP Jr, West JC, Kelley SE, Brotman S. Utilization of trauma-related deaths for organ and tissue harvesting. J Trauma 1992; 33: 516–20.[Medline]
12 Henderson SO, Chao JL, Green D, Leinen R, Mallon WK. Organ procurement in an urban level I emergency department. Ann Emerg Med 1998; 31: 466–70.[Medline]
13 Riker RR, White BW. The effect of physician education on the rates of donation request and tissue donation. Transplantation 1995; 59: 880–4.[Medline]
14 Olsen JC, Buenefe ML, Falco WD. Death in the emergency department. Ann Emerg Med 1998; 31: 758–64.[Medline]
15 Howard RJ. How can we increase the number of organ and tissue donors? J Am Coll Surg 1999; 188: 317–27.[Medline]
This article has been cited by other articles:
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  S. D. Shemie Brain arrest to neurological determination of death to organ utilization: the evolution of hospital-based organ donation strategies in Canada/De l'arret cerebral a la determination neurologique de la mort et a l'utilisation d'organes : l'evolution du don d'organes en milieu hospitalier au Canada. Can J Anesth, August 1, 2006; 53(8): 747 - 752. [Full Text] [PDF]
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G. M. Rocker, D. J. Cook, and S. D Shemie Brief review: Practice variation in end of life care in the ICU: implications for patients with severe brain injury: [Revue sommaire de la variation des soins aux mourants dans les USI : implications pour les patients atteints de lesion cerebrale severe]. Can J Anesth, August 1, 2006; 53(8): 814 - 819. [Abstract] [Full Text] [PDF]
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