Eligibility for organ donation following end-of-life decisions: a study performed in 43 French intensive care units

Abstract

A significant number of patients who died during the study period in French ICUs under withholding/withdrawal conditions would have been eligible for organ donation. Brain-injured patients were more likely to die in circumstances which would have been compatible with such practice.

A few realistic questions raised by organ retrieval in the intensive care unit

“…This period may range from a few minutes to many hours or days, depending on the level of life support engaged at the time of the decision for WhWd, and how withdrawal is achieved. Because circulatory arrest must occur after a short period, only the withdrawal of life-sustaining cardiopulmonary support for highly-dependent patients [high inspired oxygen fraction (FiO 2 ), non-triggered modes of ventilation, inotrope/vasoactive drug use] is compatible with post-mortem organ donation (26,(28)(29)(30)(31)(32). Any patient in whom the elective WhWd measure is not withdrawal of life-sustaining treatment should therefore be definitively excluded from any intention to retrieve organs.…”

“…Removal of the endotracheal tube (extubation) is more often associated with progression to organ donation than terminal weaning without extubation (12). Death within one or two hour(s) of withdrawal usually correlates with severe brain injuries (low Glasgow Coma Scale, absence of brainstem reflexes) (30)(31)(32)(35)(36)(37)(38), high dependence on mechanical ventilation (non-triggered mode, high FiO 2 , high positive expiratory pressure) (28-32,36,38,39), use of inotrope drugs (29,30,35,39), young age (28,35,40), underlying diseases (37,39), and physiological anomalies (high severity index scores, low blood pressure, low pH on arterial blood gas analysis) (37,38,40,41). Under Maastricht III conditions, the removal of organs must be scheduled before withholding/ withdrawal implementation and starts as soon as death is certified.…”

Improving donor management and transplantation success: more research is needed

“…However, the number of organs that become available each year falls far short of providing for those in need, and thousands die each year waiting for transplantation. There are clearly many missed opportunities in the severely brain-injured population, many patients dying without the care teams pursuing the chance to give life to others through donation [3,4]. Donation after brain death (BD) still remains the main source for organs, and it carries the advantage of being performed in a relatively controlled setting with ongoing perfusion and oxygenation.…”

Reglaze your glasses!

“…In this issue of Intensive Care Medicine, Lesieur et al [10] describe the eligibility for organ donation following withdrawal of life-sustaining measures in 43 French ICUs. Although uncontrolled DCD is done in France on a small scale (in 2012, 53 donors, equivalent to 0.8 per million population), organ donation after controlled circulatory death is still not legally framed in France and, although it was debated in the French parliament in 2013, it is still not practised.…”

“…In other European countries the decline of brain-dead organ donors is progressive and inescapable, and the need for other sources of donor organs is striking. The initiative of Lesieur et al [10] should be followed by other scholars in European countries in which donation after controlled circulatory death is still not being done or where potential donors are missed [11], but where, as in many other countries, there is a widening gap between supply and demand of donor organs.…”