Authors: Tim Rogerson, Katja Empson / Editors: Tim Rogerson, Katja Empson / Codes: CC13, CC19, CMP2, HMP2 / Published: 03/12/2014
Key Learning Points
Consider organ donation in all patients who are intubated and a plan has been made to withdraw care.
The specialist nurse for organ donation is key to the process and should be involved as soon as a decision to withdraw treatment has been made.
A collaborative approach between the SN:OD and the clinician is most likely to result in family members consenting to organ donation.
Familiarise yourself with local policy, get involved with the organ donation committee and get to know your local team.
Why is organ donation relevant to emergency physicians?
Almost all EM physicians are involved in end of life decisions and palliative care. Managing the dying patient is something we do frequently. Often this will be uncontrolled; the patient is being actively resuscitated and dies despite ongoing efforts however sometimes after an initial period of treatment and investigation a decision is made that it is not in a patients best interest to have further treatment and a plan is made to withdraw treatment. In this more controlled situation there is a potential for patients to become organ donors. The subsequent of deceased organ donation is a natural part of this process and we should consider it for all patients who die in the EU.
It’s sad fact that a number of people die everyday whilst waiting for an organ transplant. People waiting for a transplant often have an extremely poor quality of life, in addition to this they and their families live daily with what must become an ever increasingly anxious and stressful wait to find out if a suitable organ will become available. We understand from our practice how unwell patients who are undergoing renal replacement therapy can be and the huge impact being dependent on dialysis can have on their day to day lives. For thes patients a renal transplant is life changing treatment. Furthermore its also clearly documented how undergoing a transplant is cost effective for the NHS and society as a whole.
There is evidence that shows that Emergency departments are missing significant numbers of potential organ donors. We need to address this by ensuring that we are knowledgeable about which patients could be potential donors and how to facilitate this to ensure that it happens, and that we are engaged in the process at a hospital level so that EU is represented on organ donation committees for instance.
Identification of Patients
There are a number of key stages in the facilitating organ donation. The fundamental key stage but perhaps one of the most difficult for us as emergency physicians is the decision to withdraw life sustaining treatment. This is not related to organ donation for hopefully obvious ethical reasons. Guidelines for the withdrawal of treatment can be found in key documents produced by the GMC; and all clinicians must be familiar with this document; it sets out best practice for clinicians managing patients at the end of life. Essentially a decision to withdraw treatment should be made by two clinicians both of whom have more than five years experience and at least one should be a consultant. Clinical advice should be sought from specialists as appropriate so for instance neurosurgeons and intensivists. So a decision to withdraw treatment should not be made by a single doctor. It must be clearly documented in the patient notes how the decision was made and other clinicians involved must be named. This decision must be communicated to next of kin and relatives of the patient in a timely but sensitive manner.
Once the decision to withdraw treatment has been made it is then appropriate to consider the potential for organ donation; the only absolute requirement at this stage is that the patient is intubated; there are some other contraindications and an age limit to organ donation but most regions would be happy to discuss all cases that fulfill this requirement. Again it would be appropriate to check local policy but certainly in our hospital we encourage all referrals as we hope thereby not to encourage clinicians to assume that donation will not be possible due to underlying co-morbidities.
The referral is made to the Specialist Nurse for organ donation, they require some basic information about the patient and use this to do a couple of important things. They check the organ donation register and are able to find out whether the patient has registered, they also use the clinical information to make some preliminary enquiries about the suitability of the patient for donation. In our organization we make these preliminary enquiries usually without discussion with the family as it is unnecessary to approach the family to discuss organ donation if it is not going to be possible to facilitate it
At this stage in Cardiff we also liaise closely with the intensive care unit; we are unable to facilitate organ donation directly from the Emergency Unit for a number of reasons so it is a prerequisite that the patient can be transferred to the ITU in order for the process to go ahead. Realistically the time from referral to donation usually takes between 12 and 24 hours, there are a number of tests and investigations that must be undertaken after consent and the retrieval teams must be mobilized. Most emergency units will not be in a position to care for patients over this period of time. It is also the case that in order to maximize the potential for donation patients should have specific critical care interventions; again this would be the expertise of the average emergency physician.
Finally we come to the stage when we can approach the family for organ donation. Our protocol in the UHW ensures that all of these stages are met prior to approaching the family and this is really important. Emergency medicine doctors and nursing staff are often very keen and interested in organ donation and by no means do we want to discourage this but unfortunately it often leads to those clinicians or nursing staff raising the question of organ donation before it is appropriate.
It is hugely important that the specialist nurses are present at the time of the approach, if possible their presence when breaking bad news and discussing withdrawal of treatment can also be an advantage. Specialist nurses go through a very thorough training programme and they are truly experts in communicating with family members. Its true also that many emergency physicians are skilled communicators and might be frustrated by this collaborative approach or feel that it is their role as the patients clinician to make the approach, perhaps there is also an element of discomfort at being observed by a professional who you dont know well or work with often. However there is lots of evidence that families are more likely to consent to donation if the specialist nurse is involved. What we try and advocate in our hospital is a discussion between the clinician breaking bad news, the bed side nurse and the specialist nurse to plan the approach. It is a difficult subject and much as there are huge time pressures as an emergency physician in everything we do, we need to get this rig ht for families and for this reason it is important not to rush the conversation. It might take sometime for the family to accept that withdrawal of treatment is the appropriate option, it might require a couple of conversations over and hour or so. The SN:OD has had training with this in mind; for instance I know of cases where the family have asked “there must be something else you can do?” well perhaps it seems obvious to us now but to the nurse that that question was addressed to it it became her cue to raise the subject of donation that was the next stage in her mind unfortunately for the family they were still working through the idea that their loved one had an irreversible brain injury they were still looking for some sort of miracle surgery raising the subject of organ donation at that stage is usually a disaster for the family they must first have accepted that death is inevitable otherwise the idea of donating an organ is clearly abhorrent.
The other reason to involve the SN:OD is that they are knowledgeable about the process of organ donation which can be a complex subject. You might find yourself fielding questions from the family that you are not in a position to answer; who will get the organs? How long will it take? What will the scar look like? Etc etc
New legislation in wales
Its an interesting time to be involved with organ donation in Wales. The Human Transplantation Act 2013 Wales is currently in the implementation phase, it will become law from December 1st 2015. Essentially it is a law about consent. Residents of Wales over the age of 18 will have three choices; register a wish to donate their organs in the event of their death, register there wish not to become an organ donor or do nothing In the event that no choice is made it will be presumed that a person would want to donate their organs.
A number of other European countries already operate with this framework and for some of those countries rates of donation are very high; Spain for instance. Also its quite well known that most people state that they would like to be donors in the event of their death but don’t register this intent.
In terms of practice we wont really see much difference in how families are approached, families will still need to give consent for the process to go ahead even if the potential donor has deemed consent. The reason for this is that there is potential harm to grieving families if their loved one was to donate organs when they object or feel distressed by the process. In practice we know that families rarely object if people have deemed consent by signing the organ donor register.
One of the main benefits of the change in legislation is the education campaign that the Welsh Government is running, promoting that families talk to each other about their decision.