Organ Donation

Organ and tissue donation is an important part of work carried out in the ICU. There are several ways that a person can become a donor:

This section will briefly concentrate on the donation of organs or tissue after death.  In New Zealand, death and organ donation are covered by the Human Tissue Act 2008, which defines death as; when a suitably qualified medical practitioner is satisfied “that the individual concerned is dead”.  There is no actual statutory definition of death.

Any patient who is ventilated in an ICU in New Zealand with a nonsurvivable process should be considered as a possible donor and be discussed with Organ Donation New Zealand and, if not ruled out, have organ donation discussed with the patients Whānau at an appropriate time by someone with experience in donation.

There are relatively few absolute contra-indications to becoming an organ donor once certain conditions are met.  Criteria for suitability are always changing and depend on a number of circumstances.  Hence every potential donor should be discussed with an Intensivist and/or Organ Donation New Zealand (ODNZ).

Absolute Contraindications Include: Haematological malignancy and most but not all, other metastatic malignancies. Very occasionally there may be a potential recipient who’s needs outweigh the risk of transmission of malignant or infectious disease.

There are no age limits to donation after brain death although donation after circulatory death may have some age limits (all ages for liver and renal transplants, <75years for lung transplantation).

Discussions with families are held by an Intensivist when it is considered appropriate and only after the patient’s family understand and have accepted death.  Every step must be well documented in the notes or on the appropriate forms.

Donation after Brain Death

Brain death occurs in the setting of a severe brain injury associated with marked elevation of intra-cranial pressure.  Inadequate perfusion pressure results in a cycle of cerebral ischaemia and oedema and further increases in intra-cranial pressure.  When intra-cranial pressure reaches or exceeds systemic blood pressure, intra-cranial blood flow ceases and the whole brain, including the brainstem, dies. When this has been determined, the patient has died.

Brain Death is Determined By:

Clinical testing, if preconditions are met, or imaging that demonstrates the absence of intra-cranial blood flow.  Imaging methods used are four-vessel angiography or CT angiography if four-vessel angiography is not available. Although due to this being still images rather than live, there is an incidence of false positives (i.e. the diagnosis of some blood flow where there wouldn’t be on angiography).  MRI and TCD are not acceptable and radionuclide is not available in New Zealand.

Death is certified when two clinical medical practitioners have both completed the process required for determination of brain death.  The time of death should be recorded as the time when the second clinical examination to determine brain death is completed or when a second clinician has seen and is satisfied with imaging, and completed documentation.

Care of the Brain Dead Patient

Brain death is often although not always, associated with physiological instability, which may worsen over hours.  This may involve CVS instability including autonomic storm, arrhythmias resulting in cardiac arrest, diabetes insipidus with large fluid losses, hypothermia, anterior pituitary dysfunction, release of pro-inflammatory cytokines, coagulopathy and fibrinolysis.  It is important to identify and treat any of these problems promptly to avoid deterioration or loss of organ function.

The patient requires CVL, arterial line and the routine care and support given to all ICU patients including nutrition, regular turns etc.

ODNZ provides resources in printed form (located in the DCCM Fishbowl) and also on their application regarding care of the potential organ donor.

Identification of potential donors in the emergency department:

Some patients with devastating brain damage, who are not going to survive would not usually be admitted to the ICU. A percentage of these patients might be able to be considered for deceased organ donation. It is recommended that a discussion is had between the ED team, ICU SMO and ODNZ to see if this is a possibility. If this is the case it is also recommended that the patient’s family are made aware that the admission is for end of life cares and consideration of organ donation, not  for any therapeutic benefit to the patient.

Donation after Circulatory Death (DCD)

Donation after circulatory death means that more patients may have the opportunity to become organ donors. The ODNZ app (see below) has more information regarding this process. There are significant logistical and other considerations when compared with donation after brain death.

Tissue Donation

Although tissue donation tends to have a lower profile than solid organ donation in intensive care, it is important that the potential for tissue donation is considered after every death in the ICU, Emergency Department or elsewhere.

The range of tissues that can be donated includes eye, skin and heart valves.