End-of-life practices in patients with devastating brain injury in Spain: implications for organ donation

Abstract

Objective: To describe end-of-life care practices relevant to organ donation in patients with devastating brain injury in Spain.

Design: A multicenter prospective study of a retrospective cohort.

Period: 1 November 2014 to 30 April 2015.

Setting: Sixty-eight hospitals authorized for organ procurement.

Patients: Patients dying from devastating brain injury (possible donors). Age: 1 month-85 years.

Primary endpoints: Type of care, donation after brain death, donation after circulatory death, intubation/ventilation, referral to the donor coordinator.

Results: A total of 1,970 possible donors were identified, of which half received active treatment in an Intensive Care Unit (ICU) until brain death (27%), cardiac arrest (5%) or the withdrawal of life-sustaining therapy (19%). Of the rest, 10% were admitted to the ICU to facilitate organ donation, while 39% were not admitted to the ICU. Of those patients who evolved to a brain death condition (n=695), most transitioned to actual donation (n=446; 64%). Of those who died following the withdrawal of life-sustaining therapy (n=537), 45 (8%) were converted into actual donation after circulatory death donors. The lack of a dedicated donation after circulatory death program was the main reason for non-donation. Thirty-seven percent of the possible donors were not intubated/ventilated at death, mainly because the professional in charge did not consider donation alter discarding therapeutic intubation. Thirty-six percent of the possible donors were never referred to the donor coordinator.

Conclusions: Although deceased donation is optimized in Spain, there are still opportunities for improvement in the identification of possible donors outside the ICU and in the consideration of donation after circulatory death in patients who die following the withdrawal of life-sustaining therapy.

Keywords: Brain death; Critical care; Daño cerebral catastrófico; Devastating brain injury; Donación de órganos y tejidos; Emergency medicine; Intensive care units; Medicina de críticos; Medicina de urgencias; Muerte encefálica; Organ transplantation; Tissue and organ procurement; Trasplante de órganos; Unidades de Cuidados Intensivos; Ventilación; Ventilation.