Number of deaths by neurological criteria, and organ and tissue donation rates at three critical care centres in Canada.

PURPOSE: Comparative organ donation rates are expressed per million population and by this measurement, Canada lags behind other countries. These estimates do not account for differing demographics and health patterns of populations which can result in different rates of death by neurological criteria and subsequent donation rates. We sought to measure directly the number of deaths by neurological criteria, the associated donation rates, and the reasons for the differences. METHODS: A prospective evaluation of deaths by neurological and cardiorespiratory criteria in the critical care areas of three major adult Canadian tertiary care centres over a seven month period was undertaken. Patients were assessed for eligibility for organ and tissue donation and ultimate disposition. RESULTS: Annualized rates of death by neurological criteria varied from 2.3%-7.5% (8.6-28 patients) of all deaths. Conversion to actual donors ranged from 20-86%, with family refusal rates accounting for most of this variation. There were only three cases of suspected death by neurological criteria where a complete examination was not performed. CONCLUSIONS: There is substantial geographic variability in the rate of neurological death and actual organ donation rates in these Canadian tertiary care centres. These variations are principally related to regional differences in demographics of brain injury, referral patterns and donation consent rates, rather than lack of identification of potential donors.

Family perceptions of end-of-life care in an urban ICU.

OBJECTIVES: As most Canadians die in hospital, the final contact of family members with their loved ones is frequently in an unknown and uncomfortable environment. Family members are integral to the end-of-life decision-making process and are vital contributors to the comfort of dying patients. A quantitative study was conducted in three critical care areas where the stated goals were to provide not only quality care to patients, but also support to families. The researchers sought to determine levels of satisfaction with care, visitation, support, comfort and pain measures. METHOD: Three hundred surveys were mailed to next of kin who had a loved one die in the critical care areas of an urban tertiary care centre within the prior three years. Survey questions covered such issues as perceptions regarding the decision to stop life supports, access to the patient, access to physicians and nurses and information regarding the patient's status, support provided by the hospital, and organ donation attitudes. FINDINGS: Multiple regression analysis revealed that three factors predicted perceptions of overall quality of care: 1) being informed by nurses and physicians of any changes, 2) having the same group of nurses provide care, and 3) having one individual act as the family contact. Together these factors accounted for 52% of the variance in perceptions of care. Two factors accounted for 59% of the variance in dissatisfaction with the information received: 1) the perception that physicians did not spend enough time answering family questions, and 2) that the family was not present when the patient died. IMPLICATIONS: Consistency in nursing care and provision of information to family members may be difficult in the fast pace of an ICU, but are reasonable program objectives considering the positive influence this has on perceptions of care. Further, flexible visitation policies which maximize access between family members and both their dying loved one and health care professionals appear to have a beneficial effect on satisfaction.

Trauma and tribulation: the experiences and attitudes of operating room nurses working with organ donors.

BACKGROUND: In the past two decades, significant medical advances have resulted in remarkable success and survival rates for organ recipients. However, the rates of donation have not kept pace with the demand, resulting in a critical shortage of available healthy organs. It has been suggested that the attitudes of medical personnel towards organ retrieval is a key success factor in improving organ donation. Yet there is evidence that those closest to the process of procurement are the most negative. AIMS AND OBJECTIVES: This study sought to examine the attitudes towards organ donation of operating room nurses and their experiences of participating in the procurement of organs for transplant, in order to unravel factors that contribute to their attitudes. METHODS: This study relied upon in-depth qualitative interviews with 14 operating room nurses who participated in organ procurement in a large urban trauma centre. RESULTS: The results of this study suggest that the process of organ procurement is highly stressful and raises many concerns for operating room nurses. Factors, which added to participants' distress, include organizational factors such as strained relationships within surgical teams, concerns about the dignity of the patient and the well-being of the family and exposure to death and trauma. CONCLUSIONS: Experiences of nurses participating in surgical removal of organs for transplantation resulted in personal feelings of distress and negative attitudes to the issue of organ donation which may be transmitted to others and undermine organ procurement efforts. RELEVANCE TO CLINICAL PRACTICE: The concerns of these vital members of the organ procurement team should be heeded and actions taken to reduce their distress and improve their attitudes towards donation.

Cost-effectiveness of organ donation: evaluating investment into donor action and other donor initiatives.

Initiatives aimed at increasing organ donation can be considered health care interventions, and will compete with other health care interventions for limited resources. We have developed a model capable of calculating the cost-utility of organ donor initiatives and applied it to Donor Action, a successful international program designed to optimize donor practices. The perspective of the payer in the Canadian health care system was chosen. A Markov model was developed to estimate the net present value incremental lifetime direct medical costs and quality adjusted life years (QALYs) as a consequence of increased kidney transplantation rates. Cost-saving and cost-effectiveness thresholds were calculated. The effects of changing the success rate and time frame of the intervention was examined as a sensitivity analysis. Transplantation results in a gain of 1.99 QALYs and a cost savings of Can$104,000 over the 20-year time frame compared with waiting on dialysis. Implementation of an intervention such as Donor Action, which produced as few as three extra donors per million population, would be cost-effective at a cost of Can$1.0 million per million population. The cost-effectiveness of Donor Action and other organ donor initiatives compare favorably to other health care interventions. Organ donation may be underfunded in North America.