Missed opportunities for organ donation in patients with intracranial haemorrhage at the emergency department: A single-centre study

Abstract

Background:

The demand for transplantable organs has increased in Singapore. However, organ donation has been consistently lower than international standards. Donation after brain death (DBD) most commonly follows intracranial haemorrhage (ICH).

Objective:

Our aim was to identify missed opportunities for organ donation among those who presented to the Emergency Department (ED) and died following ICH.

Methods:

A retrospective study was carried out for all cases of ICH presenting to the ED from 1 January 2013 to 31 December 2017. The patients’ medical records were reviewed for identification of potential donors and actualisation of organ donation.

Results:

There were 615 cases of ICH, with a mortality rate of 6.0%. Among those who died, 28 (75.7%) died in the Intensive Care Unit (ICU) and nine (24.3%) patients had withdrawal of care in the ED. Thirty patients (81.1%) were potential donors but organ donation was actualised in only three (8.1%) patients. Thirteen organs, as well as heart valves and iliac vessels were retrieved from the organ donors for transplantation.

Conclusion:

There were missed opportunities for organ donation. EDs have an important role to play in the national organ donation programme by identifying potential donors for organ donation and considering admitting these patients to ICU to facilitate organ donation.

Keywords

Brain death emergency department intensive care unit organ donation transplant

Introduction

Solid organ transplantation has progressed rapidly since the early days in 1950s. Over the past 60 years, improvements in immunosuppression, technical innovation and overall clinical development in the field of transplantation have increased the survival rates of solid organ transplantation significantly.^1,2 Furthermore, the survival benefits and cost effectiveness over traditional therapies such as haemodialysis has made solid organ transplants the modern treatment of choice for end-stage organ failure.^3,4 This has resulted in a burgeoning demand for transplantable solid organs worldwide. A total of 126,670 solid organs were transplanted worldwide in 2015 compared with 100,900 in 2008, yet this still falls below 10% of the global need for transplantation.⁵ Similarly, the demand for transplantable organs has increased in Singapore, with 446 patients still on the waiting list for organ transplant as of June 2018 (Table 1).⁶

Table 1.

Status of organ donation in Singapore.

Organ	Number of patients on waiting list	Number of deceased donor transplants	Number of living donor transplants
Kidney	314	38	43
Heart	13	6	-^
Liver	58	19	21
Cornea	59	441	-^
Lungs	1	2	-^
Pancreas	1	0	-^

^ - Not obtained from living donor.

Since the inception of organ transplantation in Singapore, several government policies have been introduced with the intent of increasing the supply of transplantable organs. The Medical Therapy, Education and Research Act (MTERA) in the 1970s, the Human Organ Transplant Act (HOTA) in 1987 and subsequent amendments in the 2000s represent stepwise refinements in the governmental policies to improve the number of organ donations in Singapore. The launch of a public awareness campaign, ‘Live On’, supplemented further efforts at increasing the societal consciousness and acceptance of organ donation.⁷ These combined efforts enabled a viable organ transplantation programme in Singapore. From 2010 to 2016, the deceased and living organ transplant rate for both liver and kidney ranged between 13 and 18.7 organs per million population (pmp) and deceased donor rates were between 2.83 and 5.42 organs pmp. Although these efforts sustained the organ transplantation programme, Singapore’s rates have been consistently lower than international standards. Deceased donor rates in similarly developed countries such as the Netherlands (14.71 pmp), Australia (20.7 pmp), the United Kingdom (21.5 pmp), the United States (30.76 pmp) and Spain (40 pmp), far exceed local numbers.⁵

HOTA allows organ procurement from a patient who is legally dead, defined by brain or cardiac death. In brain death, there is an irreversible loss of all functions of the entire brain, including brainstem; and in cardiac death, there is an irreversible cessation of circulatory and respiratory function.⁸ Donation after brain death (DBD), most commonly due to intracranial haemorrhage (ICH) from road traffic accidents, is the traditional source of organs for transplant. These patients often present first at the Emergency Department (ED), making the ED a key location to identify donation opportunities. Organ donation has also been advocated as an integral part of end-of-life care in the ED.^9,10 Despite these, ED remains an underutilised source of potential donors.^11,12 Our aim was to identify missed opportunities for organ donation among those who presented to the ED and died following ICH. We hypothesised that there were potential donors who were missed, resulting in missed opportunities for DBD in the ED. Gaps should be bridged to allow EDs to take on an important role of facilitating organ donation in the national transplant programme.

Materials and methods

Setting

This study was conducted in the ED of an urban tertiary centre which sees about 150,000 patients a year.

Design

A retrospective review was carried out from 1 January 2013 to 31 December 2017. All cases presenting to the ED with ICD-10 diagnosis codes containing ICH, both traumatic and non-traumatic, were included. The patients’ medical records were accessed for data collection and tabulated in a standardised form. Information including demographics, clinical progress from the ED to hospital discharge or death, and details of any organ donation performed were collected for analysis. Any information which was not documented was analysed as not present. Potential organ donors were identified among those who died using the criteria listed in Table 2.

Table 2.

Criteria for identifying potential organ donors

(1) Singapore citizen or permanent resident
(2) Age 21 years or older
(3) No history of systemic malignancy
(4) No evidence of septicaemia or active infection
(5) Negative for Hepatitis C and Human Immunodeficiency Virus (HIV)
(6) No mental disorder

Adapted from: Ministry of Health, Singapore. Manual on organ donation and transplantation. 5th ed. Singapore; 2018.¹⁵

Statistical Methods

Statistical analysis was performed using SPSS version 22 (SPSS, Chicago, L). Categorical data were presented as frequency with percentage.

Results

There were 615 cases of ICH presenting to the ED during the study period, averaging about 51 cases per month. Thirty-seven patients died, giving a mortality rate of 6.0% for this series. Among those who died, 28 (75.7%) died in the ICU and 9 (24.3%) patients had withdrawal of care in the ED. Thirty patients (81.1%) were potential donors but organ donation was actualised in only three (8.1%) patients (Figure 1). The reasons for exclusion as potential donor were underlying malignancy (n=4, 10.8%), sepsis (n=2, 5.4%) and positive for HIV (n=1, 2.7%). Thirteen organs, as well as heart valves and iliac vessels were retrieved from the organ donors for transplantation (Table 3).

Figure 1.

Donors among patients who died from intracranial haemorrhage.

Table 3.

Donor organs transplanted.

Donor	Organs Transplanted
A	• 2 kidneys • 2 corneas
B	• 2 kidneys • 2 corneas • 1 liver
C	• 2 kidneys • 1 cornea • 1 liver • Heart valves • Iliac vessels

Discussion

DBD is the key contributor of organs for transplantation in Singapore. The actualisation of organ donation can yield a significant number of organs for the patients requiring them, as evidenced by the 13 organs harvested from three donors in our report. However, the proportion of actualised organ donors was only 8.1% among all who died from ICH. Furthermore, almost a quarter of them died in the ED, with two-thirds being potential organ donors who were missed. Therefore, mechanisms should be instituted to address these missed opportunities for organ donation starting from the ED, as well as to allow EDs to work with ICU and the transplant team in order to facilitate organ donation for the national transplant programme.

First, referral for organ donation should begin in the ED, which is often the first contact point for potential donors. In Spain, the Organizacion Nacional de Trasplantes (ONT) is in charge of the coordination of donation, procurement, and transplantation activities with a strong legislative framework.¹³ The backbone of ONT is the physicians who lead the efforts in advocating and coordinating organ donation when a patient dies under circumstances that allow for it. This duty is not only that of ICU intensivists but also that of emergency physicians (EPs). By extending the focus of organ donation to the ED, an increased pool of available donors and actualised organ donations can be anticipated. Based on a multi-institutional ED review in North America, patients referred from the ED are over three times more likely than inpatients to be organ donors, and contribute a greater number of organs procured per donor.^12,14 Therefore, referral for organ donation should be an established process within the EDs in Singapore. Patients who suffered neurological damage with Glasgow Coma Scale score of 3–4 and where end-of-life issues are being discussed with the next-of-kin should be referred to a transplant coordinator as potential donors.¹⁵

However, this strategy can be difficult to implement in the EDs. EDs deliver emergency care and combat critical illness at the front line. Although public health matters are within the scope of practice of EPs, identifying and caring for potential organ donors receive little attention, as the organ procurement process is perceived to be in tension with the provision of acute resuscitative care in the ED. This is reflected by the almost negligible amount of time and effort devoted to organ donation in the training curriculum, resulting in a lack of awareness and attention to organ donation in the ED.^11,16 Indeed, there is perception among EPs about the difficulty in raising the issue of organ donation and a lack of confidence in coping with this additional burden.^11,17

The second strategy to consider is intensive care admission to facilitate organ donation (ICOD). The Neurocritical Care Society has recommended that for patients with devasting brain injury and in whom early limitation of aggressive treatment is being considered, care should not be withdrawn in the ED as these patients should be admitted to the ICU for a period up to 72 hours to allow sufficient opportunity for end-of-life care planning and consideration of organ donation.¹⁸ This meant that instead of withdrawal of life-supporting therapy leading to demise in the ED, EPs and ICU intensivists should admit patients to the ICU with the aim of incorporating organ donation at the end of their lives. Rather than providing aggressive care directed at saving lives, ICOD will involve management strategies directed at organ preservation (Table 4). ICOD has the potential to increase the pool of potential donors with organ donation being actualised 50–60% of the time.^19-21

Table 4.

Management strategies for organ preservation in donation after brain death for the emergency department.

Maintenance of haemostasis with preservation of vital signs.
Ensure adequate oxygenation while avoiding lung injury.
Cautious fluid resuscitation with urine output monitoring.
Correction of electrolytes and maintaining normoglycaemia.
Avoid hypothermia, acidosis and coagulopathy.

In DBD, the clinical team aims to obtain assent from the patient’s legally accepted representative as consent is not required under HOTA.⁷ In stark contradistinction, the process for consideration of ICOD first requires the agreement of the next-of-kin to withdraw medical therapy in the context of medical futility, and only after that consent is sought, then the clinical team can proceed to initiate or continue life-sustaining therapy with the aim of organ donation. The next-of-kin needs to be engaged sensitively to have a clear understanding of the order of priorities in this delicate issue, and then to consider the possibility of allowing their loved ones to donate their organs. Therefore, a new paradigm in family communication is needed to facilitate ICOD. In Singapore, to compound the difficulties of this delicate and information-intensive conversation, there is often a large extended family expecting to be involved in the decision-making process. In such settings, it is common for misunderstanding and disagreements to ensue, thus delaying the time-critical decision on ICOD. Furthermore, the lack of understanding about the concept of brainstem death, as well as religious, ethnic and cultural influences on the concepts of death, the sanctity of the human body and the need to preserve it in its entirety after death can further complicate the communication process.^22-26 It is thus evident that communication in a sensitive and timely manner is the greatest barrier for ICOD from the ED. Therefore, there is a need for trained and skilled communicators to work alongside the transplant coordinator, to guide the family through a number of critical steps within a compressed time frame at the ED.

Aside from the challenges of communication, ICOD also presents potential sources of ethical conflicts and dilemma. One such conflict is the concern about the potential discomfort associated with interventional procedures for life-sustaining therapy, which will not be of any benefit to the patient or in their best interests. On the other hand, a person’s best interests are increasingly recognised to include values and beliefs which may include wishes for organ donation. Next, the intensivist managing the patient admitted for ICOD, if also involved in pronouncing medical futility in the ED, may be perceived to have conflict of interest. The next-of-kin may erroneously perceive that the intensivist made the pronouncement in order to procure the patient’s organs. Furthermore, the medical community needs to understand the need to utilise scarce intensive care resources for organ donation. To balance these considerations, an ICOD programme requires the support of the entire nation, acknowledging the opportunity costs and the potential benefit it can bring to potential recipients.

To ensure the sustainability of ICOD programmes, establishing their credibility in the eyes of the public is important but potentially challenging. We need to harmonise the management of devastating brain injuries across institutions and offer unified criteria for defining further therapeutic options and establishing medical futility. Furthermore, there is a need of an established criterion to support clinical management of potential donors in the event that potential donors from the ED ultimately survive to hospital discharge. In this age of social media, these apparent differences in the management and definitions of medical futility can be quickly amplified in the public forum.^27-29 From a systems viewpoint, to support ICOD in Singapore we need to reevaluate our training of clinical personnel, optimise current management structure and regulatory frameworks, and garner support from the various institutions and the ministry.³⁰

A suggested workflow to reduce missed opportunities for organ donation in the ED is presented in Figure 2.^18,31,32 Further studies and departmental audits would be necessary so that specific barriers could be identified and modifications could be made to improve the workflow for individual EDs.

Figure 2.

Suggested workflow.

Although the focus of this study was on missed opportunities for organ donation in the ED, we found that the actualisation of organ donation among potential organ donors in the ICU was also low, suggesting that there may be missed opportunities in the ICU as well. While more than a third of potential donors may be excluded due to underlying medical conditions, the most common barrier to organ donation in the ICU was lack of consent or refusal by next-of-kin.^33,34 Other barriers identified include absence of a standardised and systematic process to identify potential donors, ruling out of potential donors without consulting the transplant coordinator, lack of hospital policies and processes to support organ donation, limited understanding of prognosis and organ donation by next-of-kin, as well as poor communication by the medical team.^34,35 The impact of these barriers would need to be examined specifically in the local ICU context so that practical steps may be taken to improve our practice.

Limitations

A retrospective review of medical records was carried out as organ donation was a rare event. The most significant limitation was imprecise or missing information due to documentation by the attending team. Although we have based our identification of a potential donor based on local guidelines,¹⁵ we were unable to elucidate exact reasons why organ donation was not actualised in a potential donor unless they were documented. For instance, a potential donor might have been registered as objector of the HOTA, therefore opting out of organ donation. We were unable to determine how many patients were in this category as we had no access to the list of objectors of HOTA. Also, communication with the next-of-kin and timely referral to the transplant coordinator are important processes in organ donation, but we were unable to ascertain the exact content of any discussion between the attending team and next-of-kin, as well as the extent of involvement, if at all, of the transplant coordinator at the ED.

We have limited the study population to those with ICH, which is the most common cause for DBD. This was due to logistical reasons, as it would not be feasible to conduct a study to identify missed opportunities for organ donation in all causes of DBD since the list would be inexhaustive and the numbers would be very low in some causes to draw any conclusion. By excluding other causes of primary brain death such as thrombotic cerebrovascular accidents, cerebral damage, intracranial neoplasm and intracranial infections, we could only provide a glimpse into the potential problem and not provide the complete picture. Nonetheless, the findings of our study were enough to warrant further efforts to improve the process of organ donation in the ED so that future opportunities would not be missed.

Lastly, we reported the experience of organ donation in a single-centre ED. We recognise that the generalisability of our findings depends on the presence of existing protocols for identification and referral of potential donors in the ED, as well as current collaborative efforts between ED and ICU for organ donation. It is inevitable that the ED will become a key location to identify and manage potential donors. By sharing our experience, we highlight the need for EDs to be equipped to take on a more important role in the national transplant programme. This includes leadership roles in the development of protocols for referral of potential donors and ICOD, as well as driving behavioural changes and practices through training and education so as to promote acceptance and widespread implementation of these protocols.³⁶ Ultimately, we hope that this report will serve as a guide for future collaborations between hospitals and relevant authorities to further delineate the problem and develop strategies to enhance our national organ donation programme.

Conclusion

There is a need for greater awareness and involvement of EDs in identifying potential donors for organ donation and ICOD so that missed opportunities for organ donation can be minimised. To optimise the process of organ donation, policies and protocols supported by available resource and adequate training needs to be in place. Regular review will further help to identify areas of improvement. EDs will need to rise up to their instrumental roles in improving our national organ donation programme.

Footnotes

Author contributions

Pek Jen Heng: Participated in research design, performance of the research, data analysis and writing of the paper. Ho Vui Kian: Participated in writing of the paper. Ng Wei Sheng: Participated in performance of the research. Tousif Kabir: Participated in data analysis and writing of the paper. Tiah Ling: Participated in data analysis and writing of the paper. Koh Yexin: Participated in writing of the paper.

Availability of data

The datasets generated and/or analysed during the current study are available from corresponding author.

Declaration of Conflicting Interest

The authors declare that there is no conflict of interest.

Ethical approval

No ethical approval was required as per institutional protocol.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jen Heng Pek

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