Missed Organ Donation Opportunities in Patients With Devastating Brain Injury: A Prospective Population-Based Cohort Study.

Abstract

Determine the incidence and predictors of missed organ donation opportunities. Population-based, prospective cohort study. All adult ICU and PICU (medical, surgical, neurologic, and cardiovascular) and emergency departments (EDs) in a Canadian province with a population of 5 million. Consecutive patients that died with devastating brain injury, regardless of etiology, and were mechanically ventilated in the last 12 hours of life over a period of 42 months. None. Patients were defined as eligible potential donors if they were diagnosed with death by neurologic criteria (DNC), probable DNC (neurologic examination consistent, but without full assessment), or had death by circulatory criteria (DCC) within 2 hours of withdrawal of life-sustaining measures (WLSMs). Missed donation opportunities were defined as occurring when there was no evidence in the medical record that the family of an eligible potential donor was approached regarding donation. Multivariable logistic regression was performed to identify predictors of missed opportunities. There were 3481 patients and 1072 eligible potential organ donors, including 481 with confirmed DNC, 154 with probable DNC, and 437 with DCC within 2 hours of WLSM. There were 172 (16%) missed organ donation opportunities. In multivariable analysis, risk factors included older age (odds ratio [OR] per decade, 1.1 [1.0-1.3]), death in an ED rather than ICU (OR, 5.4 [3.0-10.0]), death in a regional rather than urban hospital (OR, 2.8 [1.7-4.6]), and DCC rather than DNC (6.7 [4.4-10.1]). Missed opportunities were less common when the most responsible physician was a donation specialist (OR, 0.3 [0.2-0.5]). Missed cases categorized as probable DNC were proportionally more common in EDs (45%) than in ICUs (21%; p = 0.0005). Missed organ donation opportunities occur with regularity, especially in EDs and regional hospitals, and among older patients and potential DCC donors. Donation physicians are likely to have a positive impact in reducing missed opportunities.