Identification and eligibility

Identifying a potential organ donor

When, despite efforts to save a person’s life, that person’s medical and surgical treatment options are exhausted and no hope for recovery or survival remains, organ donation becomes a possibility. Organ donation saves lives and provides loved ones with an opportunity to honour the wishes of their beloved relative at this end-of-life juncture. Moreover, the donation can bring comfort to a grieving family.
 

A single donor can save up to eight lives by donating organs, while also helping as many as 20 other people recover quality of life through a tissue donation. 

 

Identifying a potential donor is the shared responsibility of all health professionals working in ERs and ICUs.

 

Who is a potential organ donor?

A potential organ donor is a mechanically ventilated patient of any age with severe primary neurological damage. Moreover, some patients may present with severe neurological damage that is secondary to an end-stage organ failure such as pulmonary or cardiac failure. In most cases, these people are diagnosed with:

  • stroke
  • cerebral anoxia (following cardiopulmonary arrest, hanging, drowning, poisoning, etc.)
  • encephalopathy
  • major, severe head trauma

 

Potential organ donor eligibility

Once a potential organ donor has been identified, contact Transplant Québec or the organ donation liaison/resource nurse at your institution to verify the potential donor’s eligibility. If necessary, Transplant Québec will speak with those in charge of the appropriate transplant programs to gauge their interest in the potential donor that has been identified. This consultative process leads to a decision about the patient’s eligibility as an organ donor.

Potential organ donor eligibility is determined on a case-by-case basis

A well-established risk-management procedure is applied by all of Quebec’s 15 transplant programs  and takes into account the health status of the people on the waiting list at the time of referral. For example, based on this premise, an elderly potential organ donor with a history of medical problems could be eligible at one point but not at another.

Hence the importance of contacting Transplant Québec directly or, if necessary, through your institution’s organ and tissue donation liaison/resource nurse, in order to assess the eligibility of the potential donor in question.

In some situations, ancillary tests could be requested in order to assess the potential donor’s eligibility.

Following this consultative process, four possible options emerge:

  1. The patient is deemed ineligible as a potential donor, which terminates Transplant Québec’s consultative role in this instance.
  2. The patient is deemed eligible as a potential donor and his or her health improves, at which point Transplant Québec’s consultative role ends.
  3. The patient is deemed eligible as a potential donor and, regardless of whether or not medical treatment is pursued, the diagnosis progresses to one of brain death. The patient is thus considered a potential donor with neurological determination of death (NDD) and is referred to Transplant Québec.
  4. The patient is eligible as a potential donor and, regardless of whether or not medical treatment is pursued, a severe neurological and functional prognosis is established by two physicians who have the recognized medical skills this type of patient requires and are independent of the transplant programs.

 

The question of whether to withdraw life‑sustaining treatment is then considered jointly by the treatment team and the family. If the patient does not respond to neurological determination of death (NDD) criteria, he or she is considered a potential donor following determination of cardiac death (DCD) and is referred to Transplant Québec.

Potential donor after neurological determination of death (NDD)

All patients declared dead in accordance with brain death criteria are potential organ donors of the "neurological determination of death" or NDD type.

Neurologically determined death is defined by "irreversible loss of the capacity for consciousness combined with the irreversible loss of all brainstem functions, including the capacity to breath" (Canadian Neurocritical Care Group 1999; Canadian Council for Donation and Transplantation 2003). NDD involves the interruption of blood flow to the brain leading to loss of brain function. NDD requires an established ethology and the absence of confounding factors. 

 

Declaring brain death

Two clinical examinations are required and must be conducted by two physicians who are independent of both the retrieval team and the transplant team; the results of the examinations must be noted in the patient’s file.

  • The first NDD must take place at the health centre where the donor was identified.
  • The second examination to confirm NDD takes place at the retrieval centre.

The patient’s legal date and time of death is that of the first declaration of brain death, which is then confirmed by the second examination.

 

Ancillary tests

When it is impossible to assess all minimum clinical criteria such as the presence of a confounding factor (hypothermia, severe metabolic disorders, major facial trauma, etc.), an ancillary test is recommended. The objective of such a test is to demonstrate the absence of intracerebral blood flow in order to confirm NDD.

The ancillary tests recommended by the Canadian Council for Donation and Transplantation (CCDT) are:

  • cerebral angiography
  • the isotope imaging technique (scintigraphy)

 

For more on neurological determination of death (NDD), refer to:

For assistance with neurological determination of death or for any questions about organ donation, contact Transplant Québec at 1-888-366-7338.

 

Potential organ donor following determination of cardiac death (DCD)

All patients who have suffered a severe neurological or functional injury that is irreversible and offers no hope of recovery, who require life-sustaining treatment and do not meet neurological determination of death (NDD) criteria, may be potential donors following determination of cardiac death (DCD).

In the presence of a potential CDD donor, the severe neurological and functional prognosis announced to the family must, in the informed opinion of the physicians involved, be irreversible and confirmed by two physicians with the recognized skills required for this type of patient.

The decision to withdraw life-sustaining treatment is taken jointly, without consideration of organ donation, by the family and the treatment team and is made in the patient’s best interest based on his or her expressed or assumed wishes.

Life-sustaining treatment is therefore withdrawn in an operating room or an adjacent room, and the family may be present at the moment of death. Two physicians independent of the transplant team will confirm the death, after which the organs will be retrieved.

In CDD-type donors, the patient’s death typically occurs within an hour (or in rare cases, up to two hours) following the withdrawal of life-sustaining treatment. Depending on the attending physician’s assessment, a tool can be used to evaluate the probability of death following the withdrawal of life-sustaining treatment. The ICU physician may use the Wisconsin scale (*French version only) if deemed appropriate. 

For more information about CDD-type organ donors, refer to:

 

 

Any mechanically ventilated patient with severe, irreversible neurological damage

Severe prognosis determined by the treatment team

Donation after brain death

Donation after cardiocirculatory death

  • Conclusive examination and neurological determination of death (NDD)
  • Referralto Transplant Québec and search for patient’s consent in the two existing consent registries
  • Support to the family ,announcement of the severe prognosis
  • Death confirmed by two physicians
  • In conclusive examination and neurological determination of death (NDD)
  • Referral to Transplant Québec and search for patient’s consent in the two existing consent registries
  • Discussion with the family and treatment team about the severe prognosis and the withdrawal of life-sustaining treatment
  • Verification of the family’s understanding of their loved one’s death
  • Family approached (by the treatment team, liaison/resource nurse) and offered the organ donation option
  • Verification of the family’s understanding of the severe prognosis and of the withdrawal of life-sustaining treatment
  • Family supported while they decide on whether or not to withdraw life-sustaining treatment. Family given time to decide
  • Family’s decision to withdraw life-sustaining treatment is confirmed
  • Support provided to the family as they decide
  • Family’s consent is confirmed
  • Patient’s hemodynamic stability is maintained during the assessment and allocation of organs
  • Family is approached (by the treatment team, liaison/resource nurse) about the organ donation option
  • Family’s consent is confirmed
  • Patient’s hemodynamic stability is maintained during the assessment and allocation of organs
  • Patient is transferred to the operating room
  • Organs are retrieved
  • Patient is transferred to the operating room, life-sustaining treatment is withdrawn, in family’s presence if desired
  • Comfort care is provided
  • Cardiocirculatory determination of death is confirmed by two physicians
 
  • Organs are retrieved
 Excerpt from: Standard protocol for organ donation following cardiocirculatory determination of death (CDD) – Transplant Québec (December 8, 2010)