The family conversation regarding organ donation needs to include the possibility that donation cannot go ahead, and to clearly outline the process which will go ahead, the timeline, the necessary testing, the paperwork, the possible inconvenience for the rieving family and the paramount importance of careful attention to high quality comfort care. At all times the deceased will be treated with dignity and respect, regardless of whether or not the donation takes place.
Question 8 from the second paper of 2009 and Question 26 from the first paper of 2017 have both explored this area. Both have a patient with a "non survivable injury", in one case a head trauma and in another an out of hospital cardiac arrest. In both cases the family brought up the topic of donation. The candidates were then invited to "outline the points that should be discussed with the family".
In this topic there are several domains:
- Generic discussion points related to organ donation
- Specific discussion points related to DCD
- Specific discussion points related to donation with a brain-dead organ donor
The best resource for these sorts of questions is of course going to be the ANZICS Statement on Death and Organ Donation (here linked to the 3.2 version of the document). Knowing this document inside out is satisfactory preparation for just about any CICM exam question on this topic. However, it is certainly a very long document. To save precious moments, the time-poor exam candidate may wish to extend their sensory filaments directly into section 5.6.2 ("Discussion of DCD with the family", p. 49). Specifically, that section has a point-form list, starting with "The discussion with the family should include the following points". This is essentially the answer to Question 8 from the second paper of 2009 and Question 26 from the first paper of 2017. Comparing that point-form section to the college answers reveals marked similarities; to the extent that it would never have made it through Turnitin. Insofar as exam preparation goes, this is helpful. It means that a review of whatever the college examiners have historically used in their answers will be roughly equivalent to reading the ANZICS statement, thus sparing the exam candidate from the need to do both.
Generic discussion points related to organ donation
- Under most Australian and NZ legislations, organ donation can only take place "if the deceased patient had expressed a wish or given consent to donation of issue, which had not been revoked, and had not expressed an objection to donation".
- Donation should not proceed if the family disagrees.
- Consent for organ donation can be withdrawn at any time.
- Though Australian state legislation refers to the consent of a "senior available next-of-kin", any member of the family may raise concerns about organ donation.
- Though there may not be unanimous support for organ donation within the family, such consensus is required which would represent "agreement as defined by the family".
Inconveniences for the family, for their patience with which we are grateful:
- Detailed questions about their loved one will be asked by the donation coordinator
- Many forms will need to be signed by the family
- The senior next of kin may be approached to give consent to various procedures such as bronchoscopy, angiography etc.
- Consent for bloods and serologies will be required
- Testing for hepatitis virus and HIV will take place
Discussion points related to to donation after circulatory death
Reassurance of high standards:
- Patient-centered care with a focus on dignity and respect will be continued throughout the process, irrespective of whether or not donation takes place
Pre-conditions for donation after circulatory death:
- Treatment withdrawal is in the patient’s best interest, and is agreed upon by the family and all relavant medical staff involved
- The family agree to organ donation after death is confirmed (or, more rarely, the competent patient may give consent)
- The decision to withdraw treatment is made independently of the decision to go ahead with organ donation
- Circulatory death is confirmed
Ongoing treatment which is unhelpful to the patient, but which maintains organ viability:
- There are certain procedures and techniques which may be required to either maintain organ viability pre-retrieval, or to ascertain their suitability.
- These may include such benign procedures as the injection of subcutaneous heparin, or such invasive procedures as bronchoscopy or antemortem insertion of femoral cannulae and injection of 20,000 units of heparin prior to withdrawal.
- These may go ahead if the patient or family have consented to organ donation and have no objections to these interventions, nor do they contribute to death or compromise the quality of otherwise comfort-directed care.
Conditions during and after treatment withdrawal
- Location for withdrawal can be variable and is open for negotation
- Possible locations include ICU, OT or a room close to the OT
- "Comfort care" including anxiolytics and analgesics can be administered at any time up until death
- If the patient does not die wthin the specified timeframe, such "comfort care" will continue (in the ICU or at another suitable location, such as a palliative care unit).
- It is unethical to make any changes to management which might be seen to hasten the dying process
Inconveniences for the family:
- After the withdrawal, there may be little time for the family to spend with their loved one
- The organ retrieval process takes time and is an imposition on the grieving time
- Following organ retrieval, the family may spend time with their loved one, but this may not be in the ICU and may instead take place in the viewing room of the mortuary (or a similar location)
- The timing of death is unpredictable
- If death does not occur within a specific time frame, organ donation may not be possible (but tissue donation may still be possible)
- Organ removal surgery may reveal medical reasons for organ donation not to proceed
- The Coroner may decide that a post-mortem examination is necessary (depending on the circumstances of death), which may either limit the range of organs available for donation or preclude the possibility of donation altogether.