Untapped pool of deceased organ donors prompts calls for change in ICUs

Libby Lynch remembers clawing for every breath as she lay in intensive care, waiting for a set of new lungs.

The combination of cystic fibrosis and pneumonia had plunged her into respiratory failure.

"I couldn't focus on anything else, just struggling to breathe," Ms Lynch said.

"Family were coming in to see me. I could see it in their eyes they were coming to say goodbye."

The 31-year-old had been put on the urgent transplant list, triggering a nationwide call-out for compatible lungs.

"I vaguely remember just wanting [the transplant], thinking: 'bring it to me. Bring it to me now'.

As she was mentally preparing for death, an ICU nurse told her she was to be prepped for surgery. She was going to have a lung transplant.

Four months on and Ms Lynch barely coughs anymore. She has grieved for the stranger whose organ donation allowed her to live, and thinks often about their family.

She doesn't know how her donor died; whether they were brain dead or died a circulatory death.

Australia has large untapped pool of potential deceased organ donors that could save the lives of hundreds of patients waiting on transplant lists, suggests a new study published Monday in the Medical Journal of Australia.

Less than 2 per cent of Australians die in a way that allows them to donate their organ. Most deceased organ donors come from brain-dead patients, but the number of donations after circulatory death (DCD) has been growing. In 2016 DCD made up one-quarter of all deceased organ donors.

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The researchers analysed DonateLife data of patients who died in an intensive care unit or emergency department across the 75 Australian hospitals between July 2012 and December 2014.

They identified DCD patients whose organs were donated, those who would have been ideal DCD donors but did not have their organs donated, and patients who met a set of expanded criteria to become DCD donors but did not become donors.

Of 8780 DCD patients, organ donation was not discussed with the families of 61 per cent of ideal potential donors (193 patients) and 72 per cent of those expanded criteria cases (313 patients).

"That's potentially another 416 kidney transplants, 117 lungs, 41 livers and seven potential heart transplant recipients," senior author and intensive care specialist at the Alfred Hospital in Melbourne Professor David Pilcher said.

If 60 per cent of these families had consented to organ donation Australia's donation rate would have jumped from 16.1 per million population in 2014 to 21.3 per million population, the researchers reported.

Surgeon Amanda Robertson works on a donor kidney at Melbourne Private Hospital. The lost pool of patients could have meant 416 kidney transplants.

Surgeon Amanda Robertson works on a donor kidney at Melbourne Private Hospital. The lost pool of patients could have meant 416 kidney transplants. Photo: The Age

"We know these patients are out there, and we know that finding this potential pool of donors will impact the lives of organ recipients," Professor Pilcher said.

They were typically older, dying of non-neurological conditions and were more likely to have chronic diseases compared to actual donors.

"Historically many of them wouldn't have been considered for organ donation," professor Pilcher said.

Their conditions may have prevented some of their organs being healthy enough to donate, but they could perhaps donate one or two, Professor Pilcher said.

"They may have terrible lung disease but could donate kidneys," he said.

The study's expanded criteria also lifted the age of potential donors, lengthened the time-to-death after patients were taken off cardio-respiratory support, and relaxed some exclusions like smoking history and renal risk factors.

"There has been an assumption that people who have chronic conditions or certain lifestyle choices can't be organ donors, but often they can and should be considered," Professor Pilcher said.

"Some people who were smokers don't have lung disease and in theory someone who was a drinker could become a liver donor.

"It just increases the level of complexity when it comes to assessing their suitability to make sure there is not damage or disease to that organ," he said.

Increasing the pool of potential DCD patients could mean more hearts available for transplant. The donor heart reanimated and beating after circulatory death in the ex vivo perfusion rig. 
Breagha's new heart in the ex vivo perfusion rig or heart-in-a-box.

A donor heart re-animated and beating in the ex vivo perfusion rig, after circulatory death. Increasing the pool of potential DCD patients could mean more hearts available for transplant. Photo: St Vincent's Hospital, Sydney

There was no standardised DCD suitability criteria, and it was hard to predict when patients would die after being taken off life support, which could be stopping many doctors from considering them for organ donation, the study authors said.

They recommended assessing all end-of-life patients in intensive care units for organ donation.

"We'd like to see a situation where considering a person for organ donation becomes a routine part of end of life care [in ICUs]," Professor Pilcher said.

"It doesn't change the way we treat a patient or whether a person would be taken off cardio-respiratory support ... it changes the timing of that conversation," he said.

Circulatory deaths fit with what most Australians understand death to be, Dr Sam Radford, the Organ and Tissue Authority's deputy state director of DonateLife in Victoria, said.

"The heart stops, breathing stops and blood-flow to all parts of the brain and body stop," he said.

DCD also encompassed a wider ranges of conditions than brain-dead donors, including stroke, spinal cord injuries, liver disease, heart attack, and fatal infections.

A number of hospital ICUs have already adopted routinely considering organ donation referrals for patients nearing death, and Australia is now ranked sixth in the world for the number of DCD per million population.

Dr Radford said clinicians were increasingly recognising DCD donors, and acknowledging that outcomes for patients who received DCD organs were good.

"We've got a responsibility to transplant recipients to explore all opportunities so they have the best chance at a good outcome," he said.

1400 Australians and their families are at any one time waiting for a transplant.

Individuals can register as a donor on DonateLife's Australian Organ Donor Register.

The story Untapped pool of deceased organ donors prompts calls for change in ICUs first appeared on The Sydney Morning Herald.

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