Intensive Care Professionals and Deceased Organ Donation

National Symposium on Organ Donation and Transplantation 2011Oslo, Norway November 18 2011

Sam D. Shemie MDDivision of Critical Care, Montreal Children’s Hospital

Medical Director, Extracorporeal Life Support Program

McGill University Health CentreMontreal Children’s Hospital/MUHC Research Institute

Professor of Pediatrics, McGill University

The Bertram Loeb Chair in Organ and Tissue DonationFaculty of Arts, University of Ottawa

Medical Director, Donation, Canadian Blood Services

Norway and Canada: Cultures dominated by Winter

Midas winter tires, advertisement

Most people think the strongest will in humansis the will to survive. It’s not.

It’s the will to keep things familiar.

Dag Sorensen, Stockholm, 2010

Source: International, IRODat as of December 2010; Canada, CORR

International Comparison of Deceased Donor rates (NDD + DCD) per million population 2009

Transplanted Organs pmp per Year

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Kiki Smith, Untitled, inv. 89.2000, with thanks, Musée des beaux-arts de Montréal

Extracorporeal Life SupportTechnology from Biology

Ventricular Assist Device

Complete and Irreversible Arrest of Heart Function

All vital organs:

Heart, Lung, Liver and Kidney,

can be supported by technologyor replaced by transplantation.

Brain Function and Blood Flow as the Basis of Life

Accepted medical practice has been clearly defined.

1. Clinical criteria based on absent brainstem function- it is a clinical diagnosis

2. Ancillary demonstration of absent brain blood flow

- CT angiography, nuclear perfusion scan, MR angiography

The Neurological Determination of Deathin Canada

Shemie (FRG) et al, CMAJ, 2006Shemie et al, CJNS, 2008

www.blood.ca

http://video.bloodservices.ca/Streaming/nddvideo/

Brain Death Instructional Video

Dialysis:$70,000/patient/year

Renal Transplant:$15,000/patient/year (45K year one)

ECMO or VAD:$10-15,000/patient per day

Cost ComparisonsBridge versus Transplant

Lifetime probability of receiving a transplant for individuals on the waiting list, by age* and gender

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*Based on age added on the waiting list

Canadians have a 30-40% probability of never receiving an organ transplant.

Shemie et al, Am J Transplant, 2011

If this patient dies on the waiting list, what will the heart transplant surgeon say to the family?

“We tried our best, but unfortunately, a donor did not arrive in time”

Is this true?

Intensive Care Transplantation

Protecting Lives

“It’s just a big aggravation for physicians”

Canadian ICU Doctor’s comments re: organ donation (anonymous) 2005

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HSC TorontoImpact of an ICU Based Organ Donation Team

Retrospective: 1990-1997, informal commitment.Prospective: 1998-2002, formal team.

24x7 service, ICU physician, nurse coordinatorchaplaincy, social work

* p = 0.006 **p = 0.003

* **

Lessons from Spain

Unless you define the joband fund people to do the jobthe job does not get done very well.

Its not just about ‘getting organs’.

Organ donation is not something you do to people, its something you offer people.

It is a standard part of end-of-life care.

It is the responsibility of the Critical Care and Neurocritical care professionals to provide these services

Canadian Blood Services www.blood.ca

National Health Policy for ICU Organ Donation

1. Severe Brain Injury to Neurological Determination of Death (Brain Death)

April 2003 Shemie (FRG) et al, CMAJ, 2006

2. NDD to Organ Procurement: (Donor Management) Feb 2004 Shemie (FRG) et al, CMAJ, 2006

3. Donation after Cardiocirculatory Death (DCD/NHBD) Feb 2005 Shemie (FRG) et al, CMAJ, 2006

4. Brain Blood Flow (Brain Death)Nov 2006 Shemie (FRG) et al, CJNS, 2008

5. Donation Physician Specialists in a National System Feb 2011

Health System in CanadaCanada Health Act Principles but

Provincial Delivery of Services Principles

1. Public administration

2. Comprehensiveness

3. Universality

4. Portability

5. Accessibility

The Provinces/Territories of Canada are responsible for the funding, administration and delivery of health care services.

ICU’s are almost exclusively ‘closed’ units

TRANSPLANT PROGRAMS

2010 Statistics*

2153 organs transplanted

• 1234 kidneys• 443 livers• 167 hearts• 178 lungs

3171 on waitlists(active)

• 511 withdrew from lists

• 247 died while waiting

468 deceased organ donors

*CORR e-statistics

ORGAN PROCUREMENT PROGRAMS 10 Provincial OPOs

The need for a multi-stakeholder planning process

Volpe Report

DM Report/ ACHS

CCDT merges with CBS

CCDT established

NationalCoordinatingCommittee

Alberta Framework for

Action

Citizens Panel (ON)

CDM Report/ CCDT

QC Minister/ CEST

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Canadian Donation PerformanceNeed for Redesign

What are the Principle Goals of an Organ Donation and Transplant System?

1. Serve the needs of potential transplant recipients= ‘underserviced population’= perform as many transplants as possible

2. Do so in an ethical, legal, safe and equitable manner

3. Provide the opportunity to donate without compromising the duty of care to the dying patient or living donor

The journey towards self-sufficiencyDesigning a system to improve OTDT

performance in Canada

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FINAL RECOMMENDATIONS

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• 25 recommendations in total—13 for TDT and 12 for ODT

• Completed and sent to Federal, Provincial and Territorial Deputy Ministers of Health in April 2011

• Presentation at June 2011 Conference of Ministers

1. # people who die and are eligible2. Identification of eligible deaths3. ED to ICU triage4. Referral and consenting5. Organ donor management6. Organ utilization7. DCD programs

Variables Impacting on Deceased Organ Donation

1. Mechanical ventilation

2. Unresponsive coma (GCS 3-5)

3. Fixed and dilated pupils

What Does “Appear to be Brain Dead” Mean?What Does “Appear to be Brain Dead” Mean?= Clinical Trigger= Clinical Trigger

Withdrawal of All Active TreatmentWide Variation in United Kingdom ICU’s

Wunsch et al, Int Care Med, 2005

European Variation in End-of-Life Care 37 ICU`s, prospective, (n=4248)

Adapted from Sprung et al, Ethicus Study, JAMA, 2003

%

Evolving Brain Protective Therapies

Direct ventricular drainage (Brain Trauma Foundation J Neurotrauma, 2000)

HypothermiaHead Injury (Hutchison et al)

Cardiac Arrest (Bernard et al NEJM, 2002)

(HCASG et al NEJM, 2002)

Decompression Craniectomy (Schneider et al Acta Neurochir Suppl 2002)

Perceived Causes of Emergency Room Overcrowding in Canada

Bond et al, Healthcare Quarterly, 2007

85% = Lack of Admitting Beds

Ontario Emergency-to-ICU Triage

April 98-March 998/11 adult neurosurgical centers in Ontario

3447 ER patients with severe brain injury referred as direct admissions to neurosurgical ICU.

45/141 patients meeting criteria for potential donation were refused admission.

- died in ED or returned to sending facility.

Tenn-Lyn et al, Can J Anaesth. 2006

Shemie’s Unproven Theory

Time from brain injury to death

ICUCapacity

International Donation after Cardiac Death Donor Rates 2009 pmp

Source: International, IRODat as of December 2010; Canada, CORR

Physician DisinterestLow Volume Exposure

• 1-2% of all deaths are eligible for donation– approx. 10% of ICU deaths are brain death

• For an ICU with 1000 admissions per year:– 3% pediatric ICU mortality

= 3 donors per year– 12% adult ICU mortality

= 12 donors per year

No intrinsic reason for physicians caring for ICU patientsto develop skill or commitment to donation,

or research interest except ‘it’s the right thing to do’

Bigger challenge in ‘open units’

Donation Physician Consultation Participants Feb 2011International ExpertsDr. Xavier Guasch, Spain

Dr. Dale Gardiner, UK

Dr. Raghaven Murugan, Pittsburgh

Dr. Gerry O’Callaghan, Australia

Canadian Critical Care SocietyDr. Chip Doig, Calgary

Dr. Alison Fox Robichaud, Hamilton

Dr. John Drover, Kingston

Dr. Brendan McCarthy, Winnipeg

Dr. John Granton, Toronto

Dr. Robert Fowler, Toronto

Dr. Giuseppe Pagliarello, Ottawa

EthicistsDr. Franco Carnevale, Montreal, Qc

Dr. Bashir Jiwani, Surrey, BC

ICU based OPO Medical DirectorsDr. Sonny Dhanani, TGLN, Ottawa,

Dr. Greg Grant, BC Transplant, Vancouver

Dr. Jim Kutsogiannis, Northern Alberta

Dr. Andeas Kramer, Southern Alberta

Dr. Steve Beed, Halifax

Dr. Jean-Francois Lize, Quebec Transplant

IntensivistsDr. Ian Ball, Kingston, ONDr. Tony Best, Grand Prairie, AB Dr. Mark James, Saskatoon, SKDr. Brian Kavanagh, Toronto, ONDr. Stephan Langevin, Quebec City, QCDr. Sharon Peters, St. John’s, NLDr. Jag Rao, Regina, SKDr. Mike Sharpe, LondonDr. Shavaun MacDonald, Saskatoon

Canadian Neurosurgical SocietyDr. Brian Toyota,Vancouver, BC

Canadian Assoc Emergency PhysiciansDr. John Tallon, Halifax

OPOMr. Louis Beaulieau, Quebec TransplantMs. Janet MacLean, TLGNDr. Frank Markel, TGLNMr. Laszlo Kalmar, BC Transplant,

CBSKimberly YoungSherri KashubaMathias Haun

Donation Physicians: Why?

1. OTD is a medical, economic and socially critical issue2. International successes3. Intensivists are the gatekeepers of most aspects of the donation

process- pivotal and undeniable role4. Benefit for families5. A physician’s position on these matters influences other

professionals and the hospital culture6. A lot of us can do this, but there are people who can do it better

eg. palliative care model, ECMO model, neurocritical care, cardiac critical care

Greg Grant, Steve Beed Emily Macvean, with thanks

The Evolving Future of Deceased Donation

1. The “professionalization of donation services”2. Organ donation as a subspecialty of ICU services lead

by funded ICU physicians supported by donor coordinators

• 24x7 multi-hospital clinical service for all forms of deceased donation

• Quality assurance• Performance metrics and accountability• Clinical training and academic development• Clinical trials, research and innovation

Intensivist Lead Donation Management ServiceUniversity of Pittsburgh Medical Center

Increases Organ Utilization in Brain Dead Donors

Singbartl et al, SCCM 2010

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