Intimacy or utility? Organ donation and the choice between palliation and ventilation

Aric Bendorf, Ian H Kerridge, Cameron Stewart, Aric Bendorf, Ian H Kerridge, Cameron Stewart

Abstract

Organ donation after brain death provides the most important source for deceased organs for transplantation, both because of the number of potential organ donors that it makes available and also because of the unparalleled viability of the organs retrieved. Analysis of worldwide deceased organ donation rates demonstrates that all countries with high deceased organ donation rates (>20 donors per million population per year) have high brain death rates (>40 brain deaths per million population per year). This analysis makes it clear that countries striving to increase their deceased organ donor rates to world leading levels must increase the rates of donation after brain death. For countries with end-of-life care strategies that stress palliation, advance care planning and treatment withdrawal for the terminally ill, the adoption of initiatives to meaningfully raise deceased donor rates will require increasing the rate at which brain death is diagnosed. This poses a difficult, and perhaps intractable, medical, ethical and sociocultural challenge as the changes that would be required to increase rates of brain death would mean conjugating an intimate clinical and cultural focus on the dying patient with the notion of how this person's death might be best managed to be of benefit to others.

Figures

Figure 1
Figure 1
Deceased donation rates for countries achieving >20 donors per million population per year 1989-2010. Graph demonstrating the general trend toward consistently increasing deceased organ donor rates over time in the countries with the world's highest deceased organ donor rates. This illustrates that decreasing trauma rates have not adversely affected rates of organ donation in these countries. Data from [6,15].
Figure 2
Figure 2
Deceased donation rates per million population by donation after brain death and cardiocirculatory death, 2010. Graphic demonstrating the strong predominance of contribution from donation after brain death (DBD) and minimal donation after cardiocirculatory death (DCD) to deceased organ donation rates of countries with the highest donation rates. pmp, per million population. Data from [6,15].
Figure 3
Figure 3
Brain death rates and 2010 deceased donation rates. Brain death (BD) rates and 2010 deceased donation (DD) rates of countries with published national rates of BD. Graphic demonstrating a high degree of correlation between countries with high (>40 per million population (pmp)) rates of BD and high (>20 pmp) DD rates. The lower DD rates for the UK and Australia correlate with their lower BD rates. Data for DD from [6]. Data for BD from [16] for Spain, [20] for France, [44] for USA midpoint, [38] for Belgium, [45] for the UK, and [46] for Australia.

References

    1. Higginson IJ, Astin P, Dolan S. Where do cancer patients die? Ten-year trends in the place of death of cancer patients in England. Palliat Med. 1998;12:353–363. doi: 10.1191/026921698672530176.
    1. Flory J, Young-Xu Y, Gurol I, Levinsky N, Ash A, Emanuel E. Place of death: US trends since 1980. Health Affairs. 2004;23:194–200.
    1. Diagnosis of Death. Memorandum issued by the honorary secretary of the Conference of Medical Royal Colleges and their Faculties in the United Kingdom on 15 January, 1979. Br Med J. 1979;1:332.
    1. Ariès P. Western Attitudes Toward Death. Baltimore MD: The Johns Hopkins University Press; 1974. Translated by Ranum PM.
    1. Machado C. In: Brain Death - Proceedings of the Second International Symposium on Brain Death. Machado C, editor. Amsterdam: Elsevier Science; 1995. A new definition of death based on the basic mechanisms of consciousness generation in human beings; pp. 57–66.
    1. Council of Europe. International figures on donation and transplantation 2010. Newslett Transpl. 2011;16:25.
    1. Schieppati A, Remuzzi G. Chronic renal diseases as a public health problem: epidemiology, social, and economic implications. Kidney Int Suppl. 2005;98:S7–S10.
    1. Mendeloff J, Ko K, Roberts MS, Byrne M, Dew MA. Procuring organ donors as a health investment: how much should we be willing to spend? Transplantation. 2004;78:1704–1710. doi: 10.1097/01.TP.0000149787.97288.A2.
    1. Smith GP. , II. Law and Bioethics: Intersections Along the Mortal Coil. New York: Routledge; 2012.
    1. Kehl K. Moving toward peace: an analysis of a good death. Am J Hosp Palliat Care. 2006;23:277–286. doi: 10.1177/1049909106290380.
    1. Walter T. Historical and cultural variants on the good death. BMJ. 2003;327:218–220. doi: 10.1136/bmj.327.7408.218.
    1. Beecher HK. A definition of irreversible coma. Report of the ad hoc committee of the Harvard Medical School to examine the definition of brain death. JAMA. 1968;205:337–340.
    1. Bendorf A, Kerridge IH, Kelly PJ, Pussell B, Guasch X. Explaining failure through success: a critical analysis of reduction in road and stroke deaths as an explanation for Australia's low deceased organ donation rates. Intern Med J. 2012;42:866–873. doi: 10.1111/j.1445-5994.2012.02792.x.
    1. Council of Europe. International figures on donation and transplantation - 2005 thru 2010. Newslett Transpl. 2006. pp. 11–16.
    1. International Registry of Donation and Transplantation Deceased Donors Database.
    1. Organización Nacional de Trasplantes. Programa de Garantía de Calidad del Processo de Donación. Evolutivo de Resultados de la AutoEvaluación 1998-2009. Madrid: Organización Nacional de Trasplantes; 2010.
    1. Colheita e Transplantação de Órgãos e Tecidos. Relatório Estatístico 2009. Lisbon: Autoridade para os Serviços de Sangue e da Transplantação;; 2010.
    1. Busic M, Lovrencic-Huzjan A. In: Organ Donation and Transplantation - Public Policy and Clinical Perspectives. Randhawa G. Rijeka, editor. Croatia: InTech; 2012. Action taken to boost donor rate in Croatia.
    1. Organ Procurement and Transplantation Network. Deceased Donors Recovered in the US by Mechanism of Death; and, Deceased Donors Recovered in the US by Circumstance of Death. Washington, DC: US Department of Health and Human Services; 2010.
    1. Agence de la Biomédecine. Rapport annuel 2010. Activités: données essentielles. Paris: Agence de la Biomédecine; 2011.
    1. Oosterlee A, Rahmel A, editor. Eurotransplant International Foundation. Annual Report (2005-2011) Leiden: Eurotransplant International Foundation; 2006.
    1. Centro Nazionale Trapianti, Istituto Superiore di Sanità. Valutazione di qualità dell'attività del trapianto 2000-2009. Rome: Rete Nazionale Trapianti, Centro Nazionale Trapianti, Istituto Superiore di Sanità; 2011.
    1. Bellingham JM, Santhanakrishan C, Meidlinger N, Wai P, Kim J, Niederhaus S, Leverson GE, Fernandez LA, Foley DP, Mezrich JD, Odorico JS, Love RB, De Oliveira N, Sollinger HW, D'Alessandro AM. Donation after cardiac death: a 29-year experience. Surgery. 2011;150:692–702. doi: 10.1016/j.surg.2011.07.057.
    1. Zych B, Propov AF, Armani M, Bahrami T, Redmond KC, Krueger H, Carby M, Simon AR. Lungs from donation after circulatory death donors: an alternative source to brain-dead donors? Midterm results at a single institution. Eur J Cardiothorac Surg. 2012;42:542–549. doi: 10.1093/ejcts/ezs096.
    1. Orman ES, Barritt AS, Wheeler SB, Hayashi PH. Declining liver utilization for liver transplantation in the United States and the impact of donation after cardiac death. Liver Transpl. 2013;19:59–68. doi: 10.1002/lt.23547.
    1. Dominguez-Gil B, Haase-Kromwijk B, Van Leiden H, Neuberger J, Coene L, Morel P, Corinne A, Muehlbacher F, Brezovsky P, Costa AN, Rozental R, Matesanz R. European Committee (Partial Agreement) on Organ Transplantation. Council of Europe. Current situation of donation after circulatory death in European countries. Transpl Int. 2011;24:676–686. doi: 10.1111/j.1432-2277.2011.01257.x.
    1. Nath J, Mellor SJ. Organ transplantation after cardiac death (response) Lancet. 2011;377:203.
    1. Bendorf A, Kerridge IH, McCaughan GW, Myerson B, Stewart C, Pussell BA. 24th International Congress of the Transplantation Society. Berlin: The Transplantation Society; 2012. An international comparison of the effect of policy shifts to organ donation following cardio-circulatory death (DCD) on donation rates after brain death (DBD) and transplantation rates.
    1. Maegele M, Engel D, Bouillon B, Lefering R, Fach H, Raum M, Buchheister B, Schaefer U, Klug N, Neugebauer E. Incidence and outcome of traumatic brain injury in urban area in Western Europe over 10 years. Eur Surg Res. 2007;39:372–379.
    1. Pérez K, Novoa AM, Santamariña-Rubio E, Narvaez Y, Arrufat V, Borrell C, Cabeza E, Cirera E, Ferrando J, García-Altés A, Gonzalez-Luque JC, Lizarbe V, Martin-Cantera C, Seguí-Gómez M, Suelves JM. Working Group for Study of Injuries of Spanish Society of Epidemiology. Incidence trends of traumatic spinal cord injury and traumatic brain injury in Spain, 2000-2009. Accid Anal Prev. 2012;46:37–44.
    1. Andelic N, Anke A, Skandsen T, Sigurdardottir S, Sandhaug M, Ader T, Roe C. Incidence of hospital-admitted severe traumatic brain injury and in-hospital fatality in Norway: a national cohort study. Neuroepidemiology. 2012;38:259–267. doi: 10.1159/000338032.
    1. Sprung CL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, Ledoux D, Lippert A, Maia P, Phelan D, Schobersberger W, Wennberg E, Woodcock T. Ethicus Study Group. End-of-life practices in European intensive care units: the Ethicus Study. JAMA. 2003;290:790–797. doi: 10.1001/jama.290.6.790.
    1. Sprung CL, Maia P, Bulow HH, Ricou B, Armaganidis A, Baras M, Wennberg E, Reinhart K, Cohen SL, Fries DR, Nakos G, Thijs LG. Ethicus Study Group. The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med. 2007;33:1732–1739. doi: 10.1007/s00134-007-0693-0.
    1. Devictor DJ, Nguyen DT. Forgoing life-sustaining treatments in children: a comparison between Northern and Southern European pediatric intensive care units. Pediatr Crit Care Med. 2004;5:211–215. doi: 10.1097/01.PCC.0000123553.22405.E3.
    1. Adhikari NKJ, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet. 2010;376:1339–1346. doi: 10.1016/S0140-6736(10)60446-1.
    1. Feest TG, Riad HN, Collins CH, Golby MG, Nicholls AJ, Hamad SN. Protocol for increasing organ donation after cerebrovascular deaths in a district general hospital. Lancet. 1990;335:1133–1135. doi: 10.1016/0140-6736(90)91134-V.
    1. Ball C, Navsaria P, Kirkpatrick AW, Vercler C, Dixon E, Zink J, Laupland KB, Lowe M, Salomone JP, Dente CJ, Wyrzykowski AD, Hameed SM, Widder S, Inaba K, Ball JE, Rozycki GS, Montgomery SP, Hayward T, Feliciano DV. The impact of country and culture on end-of-life care for injured patients: results from an international survey. J Trauma. 2010;69:1323–1333. doi: 10.1097/TA.0b013e3181f66878. discussion 1333-1334.
    1. Van Gelder F, Van Hees D, De Roey J, Monbaliu D, Coosemans W, Aerts R, Van Raemdonck D, Pirenne J. In hospital retrospective death record registration and review confirms therapy discontinuation as a major cause of under detection of potential donors. Transpl Int. 2007;20(Suppl 2):37.
    1. Kerridge IH, Saul P, Lowe M, McPhee J, Williams D. Death, dying and donation: organ transplantation and the diagnosis of death. J Med Ethics. 2002;28:89–94. doi: 10.1136/jme.28.2.89.
    1. Matesanz R, Coll E, Domiguez-Gil B, de la Rosa G, Marazuela R, Arráez V, Elorrieta P, Fernández-Renedo C, Galán J, Gómez-Marinero P, Martín-Delagebasala C, Martín-Jiménez S, Masnou N, Salmero P, Sánchez-Ibánez J, Serna E, Martínez-Soba F, Pastor-Rodríguez A, Bouzas E, Castro P. Benchmarking in the process of donation after brain death: a metholodology to identify best performer hospitals. Am J Transplant. 2012;12:2498–2506. doi: 10.1111/j.1600-6143.2012.04128.x.
    1. Monette M. British docs urge elective ventilation. Can Med Assoc J. 2010.
    1. British Medical Association. Building on Progress: Where Next for Organ Donation Policy in the UK? London: British Medical Association; 2012.
    1. Stewart CL. Law and cancer at the end of life: the problem of nomoigenic harms and the five desiderata of death law. Public Health. 2011;125:905–918. doi: 10.1016/j.puhe.2011.10.001.
    1. Sheehy E, Conrad SL, Brigham LE, Luskin R, Weber P, Eakin M, Schkade L, Hunsicker L. Estimating the number of potential organ donors in the United States. N Engl J Med. 2003;349:667–674. doi: 10.1056/NEJMsa021271.
    1. National Health Service. Potential Donor Audit Summary: Report for the 12 Month Period 1 April 2010-31 March 2011. London: National Health Service; 2011.
    1. DonateLife Australia. Performance Report 2011. Canberra: Organ and Tissue Authority, Department of Health and Ageing; 2012.

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