Intensive care for organ preservation: A four-stage pathway

Abstract

Objective Intensive care for organ preservation (ICOP) is defined as the initiation or pursuit of intensive care not to save the patient's life, but to protect and optimize organs for transplantation. Analysis When a patient has devastating brain injury that might progress to organ donation this can be conceptualized as evolving through four consecutive stages: (1) instability, (2) stability, (3) futility and (4) finality. ICOP might be applied at any of these stages, raising different ethical issues. Only in the stage of finality is the switch from neurointensive care to ICOP ethically justified. Conclusion The difference between the stages is that during instability, stability and futility the focus must be neurointensive care which seeks the patient's recovery or an accurate neurological prognostication, while finality focuses on withdrawal of life-sustaining therapy and commencement of comfort care, which may include ICOP for deceased donation.

Organ donation in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

“…Donation benefits donors by respecting their autonomous medical wishes for donation. In brain dead patients where a plan for donation has been established, intensive management is often needed for organ preservation 59. CPR lies on this management spectrum.…”

“…DNR directives during initial life-saving care should not be assumed to account for the unique circumstance of DCDD. When donation potential exists, it is imperative that the OPO discuss the option of providing CPR and other treatments for donors and relay this information to the healthcare team 59. Surrogates should be offered the option of allowing or declining CPR while waiting for withdrawal of life-sustaining therapy for planned DCDD.…”

“…In brain dead patients where a plan for donation has been established, intensive management is often needed for organ preservation. 59 CPR lies on this management spectrum. However, the visual and physical aspects of CPR may be disturbing or may cause psychological stress in families or providers, even though CPR is much less invasive than the actual organ recovery, which has already been designated.…”

“…When donation potential exists, it is imperative that the OPO discuss the option of providing CPR and other treatments for donors and relay this information to the healthcare team. 59 Surrogates should be offered the option of allowing or declining CPR while waiting for withdrawal of life-sustaining therapy for planned DCDD. In this situation, since CPR is not intended to be life-saving for the donor, it should only be implemented with prior consent.…”

Current status of organ donation after brain death in the UK

“…Once death using neurological criteria has been confirmed, the emphasis of patient management changes from one of aiming to either neuro-prognostication accurately or restoring health and function, to one of aiming to provide intensive care for organ preservation [47] for successful organ transplantation. The progressive brainstem compression that accompanies neurological death leads to a predictable series of pathophysiological changes that are summarised in Table 2 [48].…”