ISODP2011 1

Reasons for not formally diagnosing potential donors brain dead:

Donor Action® MRR data from 7 countries

Leo Roels1, Jacqueline Smits2, Bernard Cohen1

1Donor Action Foundation, 2Eurotransplant International Foundation

ISODP20112.

Background

Formal brain death (BD) diagnosis is a crucial step in the process of converting a potential heart-beating donor (HBD) into an actual donor

heart-beating donor identification

severe brain injury

meeting criteria for BD(=potential BD donor)

formal BD diagnosis

actual donor

ISODP20113.

Study aims

• to investigate reasons for not declaring potential donors - who met all criteria for brain death (BD) diagnosis according to national and international BD criteria - formally brain dead

• in 7 countries that have implemented the Donor Action® (DA) methodology* since at least 3 years as a quality assurance tool to optimize their donation rates

*Donor Action® (www.donoraction.org) is an international initiative to alleviate organ shortage. Its DA Program:- identifies how many, where and why potential donors are missed along the donation pathway - highlights staff attitudes, confidence levels and needs re donation related activities, provides corrective measures for identified weaknesses as well as defining roles and responsibilities of health professionals involved in the donation process.

Materials & methods

• Medical Record Review (MRR) data from 59,064 patients

• who died between January 2007 and June 2010

• in 620 critical care units in 228 hospitals

• in Belgium, Croatia, Finland, France, Israel, Poland & Switzerland

• ‘potential HB donor’: any ventilated patient ≤75 years without contra-indications to donation and meeting criteria for brain death (BD) diagnosis (8.8% of all cases)

• MRR data entered into DA System Database for analysis

ISODP20114.

Study cohort:

59,064 records

Ventilated, medically suitable, ≤75 years: 19,683

Meeting pre-conditions for BD diagnosis: 8,134

Potential heart-beating donors: 5,195

ISODP20115.

Results (1)

% potential donors diagnosedbrain dead

34% NOT diagnosed

• on a total of 5,195 patients who met all criteria for formal BD diagnosis (=potential donors), only 3,708 cases were formally diagnosed BD

(= 66% of potential )• highest: Israel (90.7%) • lowest: Poland (38.4%)

BE CR FI FR IL PL CH0

20

40

60

80

100

75

47.7

76.3 75.9

90.7

38.4

59

P<.0001

cardiac arrest, failed resuscitation

BE CR FI FR IL PL CH0

20

40

60

8.8

21.7

14.318.6

47.6

35.7

10.8

ISODP20116.

Reasons for not diagnosing BD

non-identification

average: 22.5%average: 25.8%

BE CR FI FR IL PL CH0

20

40

60

35.7

56.5

10.7 9.6

47.6

18.4

2.1

treatment de-escalation

BE CR FI FR IL PL CH0

10

20

30

12.2

17.4

12.5

17.6

0

7.1

15.6

becoming medically unsuitable

BE CR FI FR IL PL CH0

10

20

30

7.9

4.3

28.6

10.2

0

14.3

8.7

ISODP20117.

Reasons for not diagnosing BD

average: 10,6%average: 11.8%

objections to donate(family approach, registry)

BE CR FI FR IL PL CH0

10

20

30

40

50

22.1

0

14.3 15.8

2.4

11.3

43.3

ISODP20118.

Reasons for not diagnosing BD

average: 15,6%

• family approach before BD diagnosis: good practice?

• non-donor registrations (BE, FR, PL): BD diagnosis futile

consent to donate(family approach, registry)

BE CR FI FR IL PL CH0

20

40

60

80

100

81.1

94.4

86.5

67.3

46.3

75.1

60

ISODP20119.

Consent to donate after BD diagnosis

average: 73%

• Opting-out legislation:- Belgium- Croatia- Finland- France- Poland

• Opting-in legislation:- Israel- Switzerland

P<.0001

Average conversion rates

Finland France Belgium Switzerland Israel Croatia Poland0%

20%

40%

60%

80%

100%

52.5 46.8 44.7 43.1 38.1 36.430.6

23.724.1 25

41

9.3

52.361.6

23.8 29.1 30.315.9

52.6

11.3 13.9

converted potential no BD diagnosis other lossesISODP2011

10.

Average conversion rates of potential into actual donors, vs. not BD diagnosed potential and other donor losses, per country

41.7%

33.9%

24.4%

ISODP201111.

Conclusions

• Markedly different BD diagnosis practices demonstrate a significant room for improvement in donation processes in the 7 countries surveyed.

• On average, nearly 34% of deceased potential donors meeting all criteria for BD diagnosed were missed along the donation pathway, due to:– non-identification– cardiac arrest, failed resuscitation– treatment de-escalation, withdrawal– objections to donate

• DA’s Medical Record Review methodology enables individual hospitals, regions and countries to assess their conversion rates of potential into actual donors and compare their donation performances with other area’s.

ISODP2011 12