Dr Jorge Brieva

Objective: To implement a best-practice intervention offering deceased organ donation, testing whether it increased family consent rates. Design: A multicentre before-and-after study of a prospective cohort compared with pre-intervention controls. Setting: Nine Australian intensive care units. Participants: Families and health care professionals caring for donor-eligible patients without registered donation preferences or aged = 16 years. Intervention: A multicomponent intervention including offers of deceased organ donation from specially trained designated requesters using a structured conversation separate to end-of-life discussions. Main outcome measure: Proportion of families consenting to organ donation. Results: Consent was obtained in 87/164 cases (53%) during the intervention period compared with 14/25 cases (56%) pre-intervention (P = 0.83). The odds ratio (OR) of obtaining consent during the intervention period relative to pre-intervention was 1.13 (95% CI, 0.48¿2.63; P = 0.78). During the intervention period, designated requesters obtained consent in 55/98 cases (56%), compared with 32/66 cases (48%) in which the medical team managing patient care raised donation (P = 0.34). Factors independently associated with increased consent were: family-raised organ donation (OR, 4.34; 95% CI, 1.79¿10.52; P = 0.001), presence of an independent designated requester (OR, 3.84; 95% CI, 1.35¿ 10.98; P = 0.012), and multiple donation conversations per case (OR, 3.35; 95% CI, 1.93¿5.81; P < 0.001). Consent decreased when patients were of non-Christian religion (OR, 0.18; 95% CI, 0.04¿0.91; P = 0.038) and end-of-life and donation meetings were separate (OR, 0.38; 95% CI, 0.16¿0.89; P = 0.026). Conclusion: Implementation of a multicomponent intervention did not increase consent rates for organ donation, although some components of the intervention exerted significant effect.

Background: Discussing deceased organ donation can be difficult not only for families but for health professionals who initiate and manage the conversations. It is well recognised that the methods of communication and communication skills of health professionals are key influences on decisions made by families regarding organ donation. Methods: This multicentre study is being performed in nine intensive care units with follow-up conducted by the Organ and Tissue Donation Service in New South Wales (NSW) Australia. The control condition is pre-intervention usual practice for at least six months before each site implements the intervention. The COMFORT intervention consists of six elements: family conversations regarding offers for organ donation to be led by a "designated requester"; family offers for donation are deferred to the designated requester; the offer of donation is separated from the end-of-life discussion that death is inevitable; it takes place within a structured family donation conversation using a "balanced" approach. Designated requesters may be intensivists, critical care nurses or social workers prepared by attending the three-day national "Family Donation Conversation" workshops, and the half-day NSW Simulation Program. The design is pre-post intervention to compare rates of family consent for organ donation six months before and under the intervention. Each ICU crosses from using the control to intervention condition after the site initiation visit. The primary endpoint is the consent rate for deceased organ donation calculated from 140 eligible next of kin families. Secondary endpoints are health professionals' adherence rates to core elements of the intervention; identification of predictors of family donation decision; and the proportion of families who regret their final donation decision at 90 days. Discussion: The pragmatic design of this study may identify 'what works' in usual clinical settings when requesting organ donation in critical care areas, both in terms of changes in practice healthcare professionals are willing and able to adopt, and the effect this may have on desired outcomes. The findings of this study will be indicative of the potential benefits of the intervention and be relevant and transferrable to clinical settings in other states and countries. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000815763 (24 July 2013). ClinicalTrials.gov: NCT01922310 (14 August 2013) (retrospectively registered).

The international transplant community has, in recent years, focused on donation after cardiac death (DCD) to provide a means of potentially increasing the availability of donor organs. New South Wales (NSW) Health released their DCD Guidelines in June 2007 following extensive consultation with key stakeholders. The main purpose of the Guidelines is to provide increased donation opportunities for people who wish to become organ donors following their death, but whose illness or injury means they do not meet the brain death criteria. It was recommended that institutions in NSW intending to implement DCD develop specific local protocols for the management of DCD in their relevant services. To this end, the John Hunter Hospital (JHH) and Calvary Mater Hospital (CMH) are conducting a study within their local patient cohort to validate selected existing predictors from the University of Wisconsin Evaluation Tool and United Network for Organ Sharing (UNOS) DCD criteria. The primary aim of the study is to provide clinicians with a useful set of predictors of death within 60 minutes following withdrawal of futile life sustaining treatment. This will enhance the clinicians' confidence in identifying realistic potential DCD donors, assist in resource allocation within the hospital and optimise the patients' and/or families' wishes to donate.

OBJECTIVE: To assess the predictive value of respiratory and haemodynamic variables and opinion of the intensivist for determining how soon death occurs after withdrawal of life-sustaining treatments (WLST). DESIGN: Multicentre prospective observational study. PARTICIPANTS AND SETTING: 83 consecutive adult intensive care patients at John Hunter and Calvary Mater Hospitals, Newcastle, New South Wales, for whom a decision was made to withdraw life-sustaining treatment between March 2007 and March 2008. MAIN OUTCOME MEASURES: Data were collected before initiation of palliation. Primary outcome was to recognise in a multivariate analysis the parameters associated with a time to death < or = 60 minutes after WLST. RESULTS: 81 patients underwent WLST: 79 died, and two survived to be discharged from hospital. Thirty-six patients (45%) died within 60 minutes of WLST, and 45 (55%) survived 60 minutes or longer. Mean ICU stay before WLST was 4.8 days (range, 1-85 days). Mean time from WLST to death was 6:31 h (range, 1 minute to 31 days). A modified University of Wisconsin assessment tool showed no statistical association with the time from WLST to death (P = 0.09). The adapted United Network for Organ Sharing tool, systolic blood pressure, APACHE II score, ventilatory dependence, oxygen disruption, Glasgow Coma Scale (GCS) score and staff specialist opinion all showed a statistically significant association with time from WLST to death (P < 0.05). CONCLUSIONS: It is possible to predict the time from WLST to death accurately using a tool that combines GCS, respiratory and haemodynamic parameters and intensivist opinion. These results require validation in a large multicentre study.