Organ Donation in Canadian PICUs: A Cross-Sectional Survey, 2021–2022*

Abstract

Objectives: To understand contemporary pediatric organ donation programs in Canadian PICUs, including: policies and practices, data collection and reporting, and system and process barriers. Design: A cross-sectional survey carried out 2021–2022. Setting: Canadian PICUs affiliated with a donor physician network. Subjects: Pediatric intensivists identified as the donation program lead, or most knowledgeable about donation for their institution. Measurements and Main Results: A 19-item survey was developed through collaboration with stakeholders from the organ donation and transplantation community within Canada. Domains and items were generated and reduced iteratively during an in-person workshop. Pretesting and pilot testing were completed to ensure readability, flow, clinical sensibility, and construct validity. Fifteen of 16 (94%) invited Canadian PICUs from seven provinces completed the survey representing 88% (15/18) of all noncardiac Canadian PICUs. Surveys were completed between June 2021 and September 2022. All units support donation after death by neurologic criteria (DNC); 14 of 15 indicated donation policies were in place and 1 of 15 indicated no policy but the ability to facilitate donation. Thirteen of 15 units (87%) support donation after death by circulatory criteria (DCC) with policies in place, with 11 of 13 of these indicating routine support of donation opportunities. The majority (13/15) of units identified a donation champion. Of the 16 identified champions across these centers, 13 were physicians and were registered nurses or nurse practitioners. Eight of 13 units (62%) with donation champions had positions supported financially, of which 5 units came from the Organ Donation Organization and the other 3 came from the provincial health authority. Finally, only 3 of 15 PICU donation programs have a pediatric donation committee with family involvement. Variability exists in identification (including determination of death practices), referral, and approach for donation between units. Conclusions: Although all Canadian PICUs support donation after DNC donation, and most support donation after DCC, variability exists in the identification, referral, and approach of potential donors. There is a notable lack of family involvement in pediatric donation programs. There are many opportunities for standardization of PICU donation programs which may result in improved rates of pediatric organ donation in Canada.

Optimizing Organ Donation: Time to Accept Evidence and Let Go of Authority Consensus?*

“…Organ donation of vital organs can save lives and/or improve the quality of life for people with end-stage organ disease. With this in mind, in this issue of Pediatric Critical Care Medicine , Lee et al (1) aimed to “describe the state of organ donation programs in 2021/2022 in Canadian PICUs and identify potential barriers and facilitators to pediatric and neonatal organ donation”.…”

“…In a survey of one donation lead at each Canadian PICU, with a response from 15 of 16 PICUs, there were some interesting findings (1). Only 13 of 15 PICUs routinely offered donation after death by circulatory criteria (DCD) (and only six supported this at the termination of extracorporeal life support), only 11 of 15 PICUs had requirements for mandatory referral of potential donors, and only 8 of 13 PICUs with donation champions had this role supported financially.…”

“…Some PICUs reported facilitators ( n = 3) or barriers ( n = 5), and these included the facilitator of “a positive relationship with an organ donation organization (ODO) professional” ( n = 3), and the barriers of delayed referral to an ODO ( n = 2), concern that donation impedes optimal end of life care ( n = 1), and first approach to donation being done by a physician ( n = 1). These findings have implications for optimizing organ donation, which the authors considered “to mean an efficient system in which all donation opportunities are identified, and all families are given the opportunity to consent or decline donation in an informed and supported manner.” Optimization is meant to avoid families being “deprived of the opportunity to experience the comfort, the creation of legacy, or the positive meaning that has been described by some donor families.” Indeed, the authors point out that “higher consent rates may be achieved if donation is first introduced by a donor coordinator” (1).…”

“…First, I worry that the findings only reflect what organ donation leaders already wanted to hear. The survey was sent to an organ donation lead for each PICU, identified “through their participation in the national donation network” (1). Yet, “due to the limited number of experts in pediatric organ donation, and several of these included in the development of the survey, external review [of the survey] was restricted to a single expert” (1).…”

“…The survey was sent to an organ donation lead for each PICU, identified “through their participation in the national donation network” (1). Yet, “due to the limited number of experts in pediatric organ donation, and several of these included in the development of the survey, external review [of the survey] was restricted to a single expert” (1). In other words, the experts who developed the survey may have designed it to allow them to make their potentially biased points of view known when they later responded.…”