Potential organ donor identification and system accountability: expert guidance from a Canadian consensus conference

Abstract

Purpose Deceased donation rates in Canada remain below the predicted potential and lag behind leading countries. Missing a potential donor leads to preventable death and disability of transplant candidates and increased healthcare costs. Methods Stakeholders were invited to a national consensus conference on improving deceased organ donor identification and referral (ID&R) and healthcare system accountability. In advance, participants received evidence-based, background documents addressing death audits, clinical triggers, required referral legislation, ethics, clinical pathways, and donation standards. At the conference, expert presentations and summaries of background information prepared by the Steering Committee informed group discussions of the preset questions. The conference’s themes were: 1) expectations of potential donors, recipients and their families; 2) donor ID&R: clinical and legal perspectives; 3) enhancing accountability: gaps and solutions; and 4) enhancing accountability: quality/safety organizations. Results Thirty-seven consensus statements were generated. At the healthcare professional (HCP) level, key statements include: 1) donation be consistently addressed as part of end-of-life care but only after a decision to withdraw life-sustaining treatment; 2) HCP know how and when to identify and refer potential donors; and 3) transplant candidates be informed of local allocation guidelines and performance. At the healthcare system level, key statements include: 1) national adoption of clinical criteria to trigger ID&R; 2) dedicated resources to match donation activities, including transfer of a potential donor; 3) performance measurement through death audits; 4) reporting and investigation of missed donation opportunities ( MDO ) ; 5) recognition of top performers; and 6) missed donor ID&R be considered a preventable and critical safety incident. Conclusion Our consensus statements establish HCP and healthcare system responsibilities regarding potential organ donor ID&R and include the tracking, reviewing and elimination of MDO through system-wide death audits. Once implemented, these consensus statements will help honour patients’ wishes to donate, improve service to potential transplant recipients, and support HCPs in fulfilling their ethical and legal responsibilitites. Next steps include implementation, assessment of their impact on donation rates, and investigation of new evidence-based targets for system improvement.

Survey of Canadian intensivists on physician non-referral and family override of deceased organ donation

“…Mandatory referral of patients is currently required by law in six provinces. 12 Nevertheless, few hospitals or healthcare systems have processes to actively ensure compliance with this legislation, 12 and our results affirm that many clinicians do not refer these patients in a systematic manner. Questions related specifically to mandatory referral were included in the broader survey and will be reported in future manuscripts.…”

“…ODOs generally encourage clinicians to refer a broad spectrum of patients for evaluation. 12 Knowledge translation initiatives designed to disseminate these practices may improve referral and ultimately donation rates. 13 Similar to family override, legislation exists in several provinces that would seem to limit the practice of physician non-referral.…”

Donation after circulatory death today: an updated overview of the European landscape

“…Donation after circulatory death can help increase the availability of organs for transplantation and offer more patients the opportunity of donating their organs after their death. The concept that decision‐making at the end of life should be based not only on medical aspects, but also on moral, societal, and welfare considerations , has set the basis for many professional societies to consider that donation should be offered as an option in end‐of‐life care . However, although a large number of persons die following an unsuccessfully resuscitated cardiac arrest or the decision to WLST, DCD is only developed in a limited number of countries .…”

CAEP, CCCS, and CNSF Position Statement – Management of devastating brain injuries in the emergency department: Enhancing neuroprognostication and maintaining the opportunity for organ and tissue donation

“…In those cases where continued physiological support will have no benefit for prognostication or neurological outcome, physicians should refer patients to their provincial organ donation organization prior to WLSM. In accordance with the Potential Organ Donor Identification and System Accountability guideline, 7 patients who meet the following criteria should be considered potential organ donors and referred to the organ donation organization:…”