**4. Practical issues with organ donation after brain death**

donations. However, organ donation also needs to be socially accepted, and public opinion

Organ donation has traditionally been possible only after brain death. It now includes donations after cardiac death (DCD), which is increasing in European countries, North America, and Australia. However, the majority of deceased donor organs continue to be from donations after brain death (DBD). DCD are from donors who do not meet the criterion for brain death, and whose cardiac function stopped before the organs were procured. The cessation of cardiac function could have occurred spontaneously or initiated deliberately. There are two types of DCDs, controlled and uncontrolled. In controlled DCD, the donor is withdrawn from life support and his or her family has given written consent for organ donation in a controlled environment. The clinical steps for controlled DCD are shown in **Figure 2**. In uncontrolled DCD, the donor died in the emergency department or elsewhere in the hospital before consent for organ donation was obtained. Catheters are placed in the femoral vessels to cool

DCD now accounts for 17% of the 31,812 donors reported to the Global Observatory on Organ Donation and Transplantation in 2015 [1]. DCD is used in a limited number of countries, because of legislative and ethical obstacles, lack of technical expertise, and/or insufficient organizational capabilities [2, 8]. There are also differences in DCD practices, including differences in legislative and ethical frameworks, patterns of end-of-life care, and approaches for the treatment of patients with cardiovascular arrest outside of the hospital [9]. Although transplant outcomes from organs obtained from DCD donors are appropriate overall, they need improvement [9]. It is generally accepted that DCD can substantially increase the avail-

**3. Deceased donation: Donations after brain death versus Donations** 

should change before the change of social system.

6 Organ Donation and Transplantation - Current Status and Future Challenges

organs and infuse perfusate until consent can be obtained.

ability of deceased donor organs with optimal results.

**Figure 2.** Clinical steps for controlled DCD.

**after cardiac death**

The clinical course of patients with severe brain injury varies depending on the degree of injury and the clinical decisions made by the primary physician. The latter are impacted by legislative and ethical frameworks, as well as patterns of end-of-life care. Organ donation is one of the options in end-of-life decision, which must be considered in every patient who may become brain dead (**Figure 3**). Organ donation counseling is an essential step that should be incorporated in end-of-life decisions.

Although the consent rate for organ donation in Europe is 50–80% with approximately 85% of families being requested to donate, only 50% provide consent. Other studies have confirmed these findings [10–14]. It is important to identify potential cases of brain deaths and obtain informed consent for organ donation from the families of the patients. Because most countries have an opt-in system, voluntary consent is considered an essential factor in organ donation. Only a small portion of these brain-dead donors are being used for solid-organ transplantation, primarily because of the low percentage of families who consent to donation [15]. Several studies have evaluated the factors associated with these types [1–4, 12, 14–16], which are listed in **Table 2**.

How to ask for an organ donation correctly is another important practical issue. The physician should call an Organ Procurement Organization (OPO) coordinator before meeting with the family of a potential donor and it must be a standard practice. Including an OPO coordinator in conversation is critical to successfully counsel families. Studies have shown that the time spent with an OPO coordinator is strongly associated with a family's decision to donate organs [15]. Incomplete or inaccurate information about the donation process may limit consent. Furthermore, the early involvement of an OPO coordinator is the best way to deliver complete and accurate information to families. Discussion of common fears and misinformation about organ donation should be part of the organ donation request process during counseling. Important questions families typically have regarding organ donation focus on the process, physical impairment during organ recovery, and the way the organs are used.

**Figure 3.** Clinical pathways of potential brain-dead donor. LST, Life-Supporting Treatment; DBD, Donation after Brain Death.

counseling, and precise information with supportive care must be given if the families need more information (**Figure 4**). Common reasons families refuse organ donation include the

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OPO coordinators can counsel families on these specific topics. Families are often concerned about the physical impairment and pain sensation associated with preserving the donor's body or thinking that the donor will feel the pain. In addition, a significant portion of families believes that the surgery causes excessive physical damage. These are significant concerns associated with decision making in families. Therefore, it is important that the medical staff or a transplantation coordinator offers specialized information about this subject during counseling. Efforts to address families' concerns are an important step toward gaining consent to donate. OPO coordinators can provide the right information to families and address negative

following:

**1.** Protecting and respecting the body

**5.** Wish to keep the body intact

**2.** Fear that the surgery will disfigure the body

**8.** Financial incentives do not influence the decision

perspectives on organ donation (**Figure 5**).

**Figure 4.** Early involvement of OPO counseling.

**3.** Belief that their loved ones have already experienced enough trauma

**6.** Observation of a lack of respect for the deceased by the hospital staff **7.** Gift of life is frequently considered by the relatives to be a sacrifice

**4.** Concerns about the wholeness and integrity of the dead body

Age Religion Cause of death Wish to terminate life support Wish for organ donation **Health-care factors** *Request factors* Timing and preparation for decision Decoupling Time to decide Accurate information before decision *Behavior of care professionals* Care for patient and relatives Supportive communication Critical events before request Respect for patients Care professional's attitude toward organ donation **Family factors** *Prior knowledge and opinion* Family culture Religion Education Information about brain death Information about organ donation Opinion about who has to decide *Decision making* Emotional stress and grief Family relationship Agreement among relatives Economic status Financial incentives

**Table 2.** Factors affecting deceased donation.

In addition, incentives for organ donations are a topic of interest. Most physicians cannot deliver enough information about these topics to the families. The early involvement of OPO coordinators is easy, and a definite solution for this problem has been recommended in many studies. A physician must be accompanied by an OPO coordinator before beginning family counseling, and precise information with supportive care must be given if the families need more information (**Figure 4**). Common reasons families refuse organ donation include the following:


OPO coordinators can counsel families on these specific topics. Families are often concerned about the physical impairment and pain sensation associated with preserving the donor's body or thinking that the donor will feel the pain. In addition, a significant portion of families believes that the surgery causes excessive physical damage. These are significant concerns associated with decision making in families. Therefore, it is important that the medical staff or a transplantation coordinator offers specialized information about this subject during counseling. Efforts to address families' concerns are an important step toward gaining consent to donate. OPO coordinators can provide the right information to families and address negative perspectives on organ donation (**Figure 5**).

**Figure 4.** Early involvement of OPO counseling.

In addition, incentives for organ donations are a topic of interest. Most physicians cannot deliver enough information about these topics to the families. The early involvement of OPO coordinators is easy, and a definite solution for this problem has been recommended in many studies. A physician must be accompanied by an OPO coordinator before beginning family

**Patient factors**

Decoupling Time to decide

Wish to terminate life support Wish for organ donation **Health-care factors** *Request factors*

8 Organ Donation and Transplantation - Current Status and Future Challenges

Timing and preparation for decision

Accurate information before decision

Care professional's attitude toward organ donation

*Behavior of care professionals* Care for patient and relatives Supportive communication Critical events before request

Respect for patients

*Prior knowledge and opinion*

Information about brain death Information about organ donation Opinion about who has to decide

Emotional stress and grief Family relationship Agreement among relatives

**Table 2.** Factors affecting deceased donation.

**Family factors**

Family culture Religion Education

*Decision making*

Economic status Financial incentives

Age Religion Cause of death

**Figure 5.** Key negative perspectives on organ donation.

The decision to donate is often forced on families during complex clinical situations, at a time when they may be shocked and stunned, and ill-equipped to make a decision [16–19]. It can be difficult to accept the death of a loved one, and many family members are not prepared to understand the medical concept of brain death because of emotional stress. In addition, one of the most stressful situations is when a family member has to make this type of decision without his or her previously specified opinion about organ donation. Even when counseling is done correctly, nearly half families refuse to donate. However, some of the families refuse to donate to avoid the request as a nonresponse. Frutos et al. suggest discussing organ donation as an option more than once with relatives who initially refuse or are unsure [20]. Relatives should also have the opportunity to spend time with the donor and say their final farewell. More than one-third of relatives regret declining to donate soon after the funeral [18].

Decoupling is one of the best principles in which making a donation request is delayed until the family understands that brain death is the same as death and has the opportunity to realize that their loved one is dead (**Figure 6**). This principle of waiting to discuss organ donation until the family is ready to make end-of-life decisions is important to correctly timed request. The principle of decoupling is a well-known way to increase the consent rate for organ donations [25]. In a study by the Kentucky Organ Donor Affiliates in 1989–1990, researchers reported that the consent rate increased from 18 to 60% if there was a separation between when death is pronounced and the approach for organ donation [25]. However, decoupling frequently becomes impossible when the hemodynamics of a potential donor worsens. The patient's attending physician may feel an ethical conflict about providing active or invasive life-support care that seems to have no therapeutic benefit on the patient's recovery and appears to have significance solely for maintaining organ quality, especially when the family's opinion about organ donation is not specified yet. This frequently occurs in the emergency department or the intensive care unit [26]. In addition, decoupling is sometimes not consistent with the current recommendation of early referral to the OPO coordinator [26]. If we profoundly believe that there is value in organ donation, a more flexible high-dimensional strategy is needed when a potential donor is progressing to circulatory death. Identifying a potential brain-dead donor is the fundamental step for a successful donor action program. The typical steps of actual organ donation in the intensive care unit are illustrated in **Figure 7**. OPO coordinators or transplantation teams typically identify only a small portion of potential brain-dead donors. If the OPO coordinator approached the families and appropriate counseling was performed, the families consent is an invincible one. A tight screening system must be established to increase the rate of identification of potential donors in the intensive care unit. The generally accepted criteria for potential deceased donors are shown in **Table 3**.

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**Figure 7.** Multiple steps for organ donation after brain death in intensive care unit.

**Figure 6.** Principle of decoupling.

Emotional upheaval in acutely bereaved families and lack of clarity on brain death cause dissonance and distress that adversely affect decision making in families and grieving over time [21–23]. Several factors have been shown to affect decision making in family members [12, 14, 15]. The complex situation and emotional stress make it difficult for families to understand the nature of brain death and accept the actual death of their loved one. This ultimately impacts the decision-making process regarding organ donation. Multiple factors negatively affect the decision to donate and lead to time delay for the final decision. A final decision may require several hours to days. This time delay, though justifiable, can be associated with the refusal to donate or failure of a successful donation. In one study, researchers reported that a delay in decision making does not reflect a negative attitude about organ donation, but a reasonable and necessary amount of time for deliberation [24]. Therefore, the medical attendant and OPO coordinator should continue their efforts to maintain organ viability and consider extended repetitive counseling to encourage donation.


**Figure 6.** Principle of decoupling.

The decision to donate is often forced on families during complex clinical situations, at a time when they may be shocked and stunned, and ill-equipped to make a decision [16–19]. It can be difficult to accept the death of a loved one, and many family members are not prepared to understand the medical concept of brain death because of emotional stress. In addition, one of the most stressful situations is when a family member has to make this type of decision without his or her previously specified opinion about organ donation. Even when counseling is done correctly, nearly half families refuse to donate. However, some of the families refuse to donate to avoid the request as a nonresponse. Frutos et al. suggest discussing organ donation as an option more than once with relatives who initially refuse or are unsure [20]. Relatives should also have the opportunity to spend time with the donor and say their final farewell. More than one-third of relatives regret declining to donate soon

Emotional upheaval in acutely bereaved families and lack of clarity on brain death cause dissonance and distress that adversely affect decision making in families and grieving over time [21–23]. Several factors have been shown to affect decision making in family members [12, 14, 15]. The complex situation and emotional stress make it difficult for families to understand the nature of brain death and accept the actual death of their loved one. This ultimately impacts the decision-making process regarding organ donation. Multiple factors negatively affect the decision to donate and lead to time delay for the final decision. A final decision may require several hours to days. This time delay, though justifiable, can be associated with the refusal to donate or failure of a successful donation. In one study, researchers reported that a delay in decision making does not reflect a negative attitude about organ donation, but a reasonable and necessary amount of time for deliberation [24]. Therefore, the medical attendant and OPO coordinator should continue their efforts to maintain organ viability and consider

after the funeral [18].

**Figure 5.** Key negative perspectives on organ donation.

10 Organ Donation and Transplantation - Current Status and Future Challenges

extended repetitive counseling to encourage donation.

**Figure 7.** Multiple steps for organ donation after brain death in intensive care unit.

Decoupling is one of the best principles in which making a donation request is delayed until the family understands that brain death is the same as death and has the opportunity to realize that their loved one is dead (**Figure 6**). This principle of waiting to discuss organ donation until the family is ready to make end-of-life decisions is important to correctly timed request. The principle of decoupling is a well-known way to increase the consent rate for organ donations [25]. In a study by the Kentucky Organ Donor Affiliates in 1989–1990, researchers reported that the consent rate increased from 18 to 60% if there was a separation between when death is pronounced and the approach for organ donation [25]. However, decoupling frequently becomes impossible when the hemodynamics of a potential donor worsens. The patient's attending physician may feel an ethical conflict about providing active or invasive life-support care that seems to have no therapeutic benefit on the patient's recovery and appears to have significance solely for maintaining organ quality, especially when the family's opinion about organ donation is not specified yet. This frequently occurs in the emergency department or the intensive care unit [26]. In addition, decoupling is sometimes not consistent with the current recommendation of early referral to the OPO coordinator [26]. If we profoundly believe that there is value in organ donation, a more flexible high-dimensional strategy is needed when a potential donor is progressing to circulatory death.

Identifying a potential brain-dead donor is the fundamental step for a successful donor action program. The typical steps of actual organ donation in the intensive care unit are illustrated in **Figure 7**. OPO coordinators or transplantation teams typically identify only a small portion of potential brain-dead donors. If the OPO coordinator approached the families and appropriate counseling was performed, the families consent is an invincible one. A tight screening system must be established to increase the rate of identification of potential donors in the intensive care unit. The generally accepted criteria for potential deceased donors are shown in **Table 3**.


**Table 3.** Criteria for referral of a potential donor.
