WORKING GROUP 5: FOSTERING PROFESSIONAL OWNERSHIP OF SELF-SUFFICIENCY IN THE EMERGENCY DEPARTMENT AND INTENSIVE CARE UNIT Leaders: Alexander Capron, Alex Manara, and Gerry O'CallaghanMembers: Wahyuningsih Andi, Danica Avsec-Letonija, Gabriel Danovitch, Francisco Del Rio, Ehtuish Ehtuish, Steffen Groth, Niels Grunnet, Anni Kuusvek, Tong Kiat Kwek, Ko Kyung-Soon, PG Mahipala, Francesco Procaccio, and Victor-Gheorghe Zota The Critical Role of Emergency Department and Intensive Care Unit Professionals Organ donation is a distinct, time-critical medical process that provides individuals with end-stage organ failure access to transplantation and its life saving, and life changing, benefits. Transplant programmes can rely on living-related donors to meet some of the need for donated kidneys, but self-sufficient donation programmes require a robust system of donation from deceased persons (not only hearts, livers, and lungs but also kidneys). The majority of deceased donor organs originate in EDs and ICUs, but in most countries currently, organs are obtained from only a small minority of ED and ICU patients who would be potential donors.For a country (or region) to achieve self-sufficiency in organ donation, health professionals (principally physicians and nurses) involved in acute health care need to be aware of their indispensable role in identifying potential donors, in using their expertise in the medical management of these critically ill, dying patients in a manner that allows and facilitates donation, and in encouraging the families of these patients to consider donation and supporting them as they do so.To be successful, organ procurement programmes must, therefore, seek to engage healthcare professionals in planning and executing organ donation in their facilities, especially in EDs and ICUs. Doctors and nurses need to become aware of their responsibilities to the broader community and the relevance of their skills to organ donation; further, they must have confidence to support the delivery of this service. Healthcare professionals who participate in this work deserve to have their skills and endeavors recognized by their peers, policy makers, funders, and the community. Conditions for Self-Sufficiency a. ICU and ED doctors and nurses are aware of the need for organ donation and therefore want to facilitate it; b. ICU and ED doctors and nurses know how to facilitate organ donation and have the educational, technical, legal, and ethical tools to do so; c. ICU and ED doctors and nurses are supported by their colleagues, hospitals, and health authorities in facilitating organ donation; d. Identified doctors and nurses in EDs and ICUs are recognized as experts in this area and in educating their colleagues about it; e. These doctors and nurses are expected to take the lead in enabling their ED or ICU to provide this service, including appropriate counseling for families. Goals for Each Country/Region Barriers to achieving Goals 1 and 2: * ICU/ED physicians and nurses are not aware of the extent of the need for organs and the crucial role the ICU can play in meeting that need; * ICU/ED physicians and nurses do not see organ donation as a part of their responsibility in caring for patients (potential donors) and families; * ICU/ED physicians and nurses believe that responding to need for organs would represent a conflict of interest with their obligations to dying patients; * ICU/ED physicians are not familiar or comfortable with determining death in donors or are not, or do not feel, competent to perform relevant tests; * Specific resources or expertise are not always available in a timely manner to support the diagnosis of brain death (e.g., cerebral angiography); * ICU/ED physicians and nurses are not compensated or rewarded for the time spent in facilitating organ donation; * Limited ICU/ED resources restrict the ability of physicians and nurses to be involved in organ donation; * ICU/ED physicians and nurses face, or believe they will face, difficult ethical and legal issues in caring for potential organ donors; * Organ procurement staff are not available in a timely fashion to interact with ICU/ED patients and their families; * The country lacks adequate infrastructure/resources to procure and use organs for transplantation.Barriers to achieving Goal 3: * Cultural factors in a country preclude using techniques that work in EDs and ICUs elsewhere; * Organizational factors (from national to institutional level) interfere with importing techniques that work in other EDs and ICUs; * The public does not understand or accept the goals of organ donation and believes that ethical conflicts exist when physicians and nurses in EDs and ICUs are involved in organ procurement. Recommendations and Solutions Image Tools Governments should: 1. Develop clear legal and ethical frameworks to guide ICU and ED professionals in the care of potential donors, including: a. Standards for determining death that are enacted by the legislature and accepted by the public; b. Tests and methods that physicians can readily use to apply these standards in EDs and ICUs; c. Clear statements, at institutional and governmental levels, regarding the responsibility of various care providers to donors and recipients. 2. Provide clear and unambiguous guidance from the ministry of health (and other responsible authorities) and hospitals to ensure individual intensivists and ED physicians and nurses are not vulnerable when aiding organ donation processes.Professional Bodies should: 1. Offer training and guidance for ED and ICU nurses and physicians on how to identify potential donors, communicate with family, determine death, optimize donor physiology, and interact with OPO and transplant team. Specifically, this should cover: a. Clear guidance on how treatment decisions are reached (e.g., for patients with severe neurologic injuries) in the context of potential organ donors and on the circulatory and neurologic criteria for determining death; b. Clear protocols on how to manage dying process for patients whose deaths will be determined on circulatory or neurologic grounds; c. Clear protocols on the optimization of donor physiology in brain dead donors to maximize the number of organs donated and the quality of those organs; d. Education for nurses and physicians on how to make donation an understandable and acceptable choice for families of dying patients. 2. Support the development of academic and scientific research activity in the emergency and intensive care communities to create a professional investment in the best practice approaches that emerge.Hospitals Should: 1. Give local ED and ICU staff “ownership” of solving the problems and developing protocols for managing the care of potential donors. 2. Identify individuals within the ICU or ED team who can act as role models or “champions” to increase the profile of organ donation within individual ICUs and EDs and provide education for the team on all relevant issues. 3. Appoint donor coordinators within hospitals to facilitate communications among ICU/ED staff, bereaved families, and transplantation services. 4. Include the possibility or potential for organ donation in every end-of-life care pathway within the ICU and ED (Fig. 7). 
Figure 7 Image Tools 5. Improve the interface between ICUs/EDs and the local transplant team and responsible national authority. 6. Identify strategies to minimize the effects of lack of resources on the conversion of potential donors to actual donors. 7. Audit outcomes of the donation process within each ICU/ED and hospital to allow potential areas for improvement to be identified and achievable targets to be set. Examples and References Examples of National Guidance on Death Diagnosis A code of practice for the diagnosis and confirmation of death. Academy of Medical Royal Colleges.The ANZICS Statement on Death and Organ Donation [ed. 3]. Australian and New Zealand Intensive Care Society, 2008. Examples of National Legal/Ethical Guidance on Issues Relevant to Donation Legal issues relevant to non-heartbeating organ donation. Welsh Assembly Government Department of Health.Organ and tissue donation after death for transplantation: Guidelines for ethical practice for health professionals. Australian Government National Health and Medical Research Council. Example of Expert Panel Guidance on Diagnosis of Death Bernat JL, Capron AM, Bleck TP, et al. The circulatory-respiratory determination of death in organ donation. Crit Care Med 2010; 38: 972. Examples of Individual ICU Initiatives to Increase Donation by Starting NHBD Schemes Thomas I, Caborn S, Manara AR. Experiences in the development of non-heart beating organ donation scheme in a regional neurosciences intensive care unit. Br J Anesth 2008; 100: 820.Akoh JA, Denton MD, Bradshaw SB, et al. Early results of a controlled non-heart-beating kidney donor programme. Nephrol Dial Transplant 2009; 24: 1992. Factors Influencing Consent Rates Simpkin AL, Robertson LC, Barber VS, et al. Modifiable factors influencing relatives' decision to offer organ donation: Systematic review. BMJ 2009; 338: b991.ACRE Trial Collaborators. Effect of “collaborative requesting” on consent rate for organ donation: randomized controlled trial (ACRE trial). BMJ 2009; 339: b3911.Shafer TJ. Improving relatives' consent to organ donation. BMJ 2009; 338: b701. Analysis of the Effect of “Presumed Consent” Kwek TK, Lew TW, Tan HL, et al. The transplantable organ shortage in Singapore: Has implementation of presumed consent to organ donation made a difference? Ann Acad Med Singapore 2009; 38: 346. Source; http://journals.lww.com/transplantjournal/Fulltext/2011/06151/Report_of_the_Madrid_Consultation__Part_2__Reports.7.aspx
