What is happening with Organ Donation in NSW?

Michael O’Leary Senior Staff Specialist, Intensive Care Service

Royal Prince Alfred Hospital, Sydney State Medical Director, NSW OTDS

National Reform Programme, 2008

“To implement a world’s best practice approach to organ and tissue donation

for transplantation”

National Reform Programme - targets

To achieve 25 donors per million population by 2018

What does the target mean for NSW?

2014 – 92 donors: 12.6 dpmp

2018 – 189 donors to achieve 25 dpmp target

(assuming static NSW population)

Effect of achieving Reform Programme KPIs…

KPIs are:

– 100% potential donors identified

– 100% potential donors have a request made

– ≥75% requests made receive consent

– 70% potential donors become actual donors

In 2014, assuming we are already identifying 100% of donors, had the other targets been achieved, donor number would have been 172 (22.8dpmp)

How is that calculated?

– Possible donors: 92+97+36+21 = 246 (100%)

– Conversations 100% (246), Consents 75% = 185

– Converted 70% = 172

So what am I saying?

Hey, we are generally doing really well with donor identification right now!

BUT, we struggle with donor consenting and conversion

SO, Assuming a static NSW population we still need to realise a minimum of 17 donors/yr, which at 70% conversion means identifying 24 additional potential donors/yr

Optimising effort to identify all possible donors remains an important part of our strategy

Australia outcomes – donors

Jurisdictional variations

NSW vs VIC

Jurisdictional variations

State Brain Deaths, pmp

NSW 19

Qld 20

Vic 23

SA 29

NSW Performance

The hospitals that have received the enhancement have, in general, shown no increase in donor numbers

Extra donors have therefore principally come from non-Network hospitals

Problems with consenting and medical suitability may explain much of the ‘poor’ performance

None the less, difficult to escape the conclusion that there are ‘missed donation opportunities’ in NSW

Gatward J, O’Leary M, Sgorbini M & Phipps P. MJA 2015;202:205-8

ICU deaths: 2 Ward deaths: 8

All aged >65y 3 potential for BD

Pathways to cadaveric organ donation

Donation after Brain Death (DBD)

Donation after Circulatory Death (DCD)

Donor detection

Concentrates on ICUs and Emergency Departments

Open to any staff member to ‘trigger’

Use of clinical triggers – “GIVE”

– Principally focused on patients in the ED

Trigger to non treating staff

Detection of the potential DCD donor

Detection and identification of brain death

Ethical issues

Clinical Trigger – example

75 year old female presents to ED with Grade 5 SAH.

– Neurosurgeon: Discussion with family about unsurvivable nature of injury.

Outcome: Patient extubated in ED.

Question: Did the patient fulfill the GIVE clinical trigger?

Implications of ED triggers

Intensive Care Units have to be willing to admit patients for palliation

– Medical retrieval? Implications – discussion with families? – Who?

– Honesty of approach, explanation of treatment goals – Timing of mention of potential donation – Ethics of medical interventions? o Inotropes, blood transfusions, investigations?

Often do not consider potential DCD cases

What about non-intubated patients?

At present, in patients for whom commencing life sustaining treatment is thought to be futile, subsequent intubation and ventilation for the sole purpose of organ donation (without the specific consent of the donor) would be considered a non-therapeutic intervention and inconsistent with both the Guardianship Act 1987 and current NSW DCD policy. This is because in NSW substitute decision makers (Person Responsible) cannot consent to non-therapeutic interventions.

Donor & Organ Viability

Organ suitability assessments should be made by experts in transplantation

– Intensive Care staff frequently miss identify possible donors as “Not Medically Suitable”

– Exemptions to suitability assessment:

o Patients >70y with no prospect of brain death

o Current cancer diagnosis (except thyroid, bladder, cervical & anal cancers)

o Melanoma at any time

o CJD infection

Training & education, consent procedures

Concept that increasing organ donors is essentially an issue for hospital based staff

All staff should be “on the same page”

– BUT… approach for donation should be reserved to those with specific training and interest

– Approach for donation should, in general, be AFTER diagnosis of brain death or AFTER agreed decision with patient’s family that life-sustaining treatment is to be withdrawn

Family interview

Our role not to prejudge the family’s position

First acceptance …then the donation conversation

– “Decoupling”

Concept – allowing the family to make an enduring decision

Principles – honest presentation of the facts

– Donation is a rare event (opportunity)

– Successful requestor is an advocate for organ donation

– Team approach – pre-briefing vital

Models of consenting

All should involve the use of trained requestors

– Intensivist-led model

– Collaborative model

– Designated requestor model

Concerns?

We are asking ED Specialists to consider the possibility of organ donation as an outcome where treatment is either being limited, withheld or withdrawn

We are NOT asking you to change your considered medical practice in patients with end stage disease where palliation is the appropriate management

We are happy to discuss potential cases at any time – on call SMD available via on call DSC

Questions?