Non-heart-beating organ donation in Canada: Time to proceed?

Non-heart-beating organ donation in Canada: How to proceed?

Sam D. Shemie MD.CM Division of Critical Care Montreal Children’s Hospital Associate Professor of Pediatrics McGill University

Honourary Staff Department of Critical Care Medicine Hospital for Sick Children University of Toronto

Chair, Canadian Forum on Severe Brain Injury to Neurological Determination of Death

Christopher Doig MD Department of Critical Care Medicine Associate Professor of Medicine University of Calgary Foothills Hospital Multisystem Intensive Care Unit Calgary Health Region

Chair of the Donation Committee Canadian Council for Donation and Transplantation

Graeme Rocker DM Professor of Medicine Dalhousie University Critical Care Program Queen Elizabeth II Health Sciences Center Halifax

President, Canadian Critical Care Society.

Philip Belitsky MD Director, Transplantation Services Queen Elizabeth II Health Sciences Centre Professor of Urology Dalhousie University Halifax

Chair, Canadian Council for Donation and Transplantation

The gap between demand and availability for transplantable organs has generated substantial attention from provincial and federal governments and professional societies. The “dead donor rule” ensures that only those patients who have died are eligible for donation. In Canada, the primary post mortem source of transplantable organs comes from patients with irreversible severe brain injury and who are determined dead by brain death criteria (heart beating donors). In their recent commentary, Drs. Knoll and Mahoney suggest that patients who die after cardiac arrest i.e. non-heart-beating donors (NHBD, should be also be considered as a source of transplantable organs. As Knoll and Mahoney suggest, NHBD do represent a potentially significant source of transplantable organs. Important issues to be addressed are how NHBD programs should develop within the context of ethical, medical, and technical standards that would ensure public confidence and encourage widespread national acceptance.

Fundamental additions to the way organ donation is approached in Canada would seem most appropriate if all other conventional approaches with brain death donation had been optimally explored. For example, the College des Medecins du Quebec reviewed all deaths in Quebec in the year 2000. Of all patients who appeared brain dead, 23% were not identified. Of those patients diagnosed with brain death, 24% of families were not approached for consent to donation. These failures to optimize traditional strategies are national in scope and are currently being addressed.

Acknowledging variability in the recognition, diagnosis and documentation of brain death, the Canadian Council for Donation and Transplantation (CCDT) sponsored a national Forum entitled ‘Severe brain injury to neurological determination of death” in April 2003. The mandate of the CCDT is to provide advice to the Federal, Provincial and Territorial Conference of Deputy Ministers of Health in support of their efforts to coordinate donation and transplantation activities. The Forum assembled over 90 multidisciplinary representatives of all services involved in the care of patients with severe brain injury, including experts in emergency medical and trauma services, critical care, neurology, neurosurgery, end of life care, organ donation and transplantation. Standards were developed that address the optimal management of severely brain injured patients who may evolve to brain death, including the option of organ donation as a part of standard care at the end of life. These recommendations for standards of practice will be available October 2003.

A similar Forum is required to develop recommendations and standards for NHBD. In their position paper , the Canadian Critical Care Society (CCCS) called for a moratorium on NHBD protocols without prior national discussions. The CCDT is preparing to initiate such a national discussion, with input and recommendations derived from representatives of the relevant health care professions and of broader society. Planning for this initiative is scheduled for 2004. As stated in a previous commentary in the CMAJ , the CCCS is committed to collaborate on all issues of organ and tissue donation and the CCDT welcomes such a commitment.

1. Knoll GA, Mahoney JE. Non-heart-beating organ donation in Canada: Time to proceed? CMAJ 2003;169(4):302-3.

2. Potential organ donors in Quebec Hospitals. Year 2000.Transplantation committee report. College des Medecins du Quebec, 2003. http://collegedesmedecins.qc.ca/uploadedfiles/transplantationEng.pdf

3. Shemie SD, Doig C, Belitsky P. Advancing toward a modern death: the path from severe brain injury to neurological determination of death. CMAJ 2003;168(8):993-5.

4. Canadian Critical Care Society position paper on organ and tissue donation. http://www.canadiancriticalcare.org.

5. Rocker GM, for the CCCS working group on organ and tissue donation. Organ and tissue donation in the intensive care

Conflict of Interest:

None declared