GUEST EDITORIAL

doi: 10.1111/j.1478-5153.2012.00509.x

Strategies to increase organ donation:the role of critical care practitionersIn December 2011, the National Insti-tute for Health & Clinical Excellence(NICE) published clinical guideline 135entitled ‘Organ donation for transplan-tation: Improving donor identificationand consent rates for deceased organdonation. . .;’ (NICE, 2011). It is envis-aged that this guideline will augmentthe work of the Department of Health(2008) organ donation task force. Thisguideline made 28 recommendations.The key issues and their implicationsfor critical care practitioners will bediscussed in this editorial.

Transplantation has a major role inmanaging patients with organ failureof the kidneys, liver, pancreas, heartand lungs. Currently more than 8000people in the UK are waiting for atransplant with the figure is rising by5% each year. The aging populationand the anticipated surge in type 2diabetes, which subsequently increasesincidence of kidney failure, indicatesthat patients awaiting transplantationare likely to increase a further 50%(NICE, 2010). Each year 1000 peopledie, that is three people a day, whilstwaiting for a transplant.

The UK Transplant survey (2003)found that 90% of the public supportedorgan donation. However, 38% of thefamilies’ of potential donors refuseddonation to take place following braindeath and 42% refused following circu-latory death (NICE, 2010).

Currently Europe has an average of17·8 donors per million people, how-ever, the UK has one of the low-est rates at 15·5 donors per millionpeople. Spain has the highest ratein Europe with 35 donors per mil-lion people (NICE, 2010). Discussionsat NICE frequently centred aroundthe processes involved in the Spanishmodel of donation, and what could

be learnt from their systems. How-ever, despite the government being inadmiration of the Spanish donationstatistics; doubts were raised that ifthe UK could meet these outcomes.The Spanish model involves differentapproaches to obtaining family con-sent. In addition, the Spanish systemoffers financial assistance with funeralexpenses and other incentives that UKculture may not want to embrace. Itwas uncertain whether the UK has thatmany patients per million who meet thebrain death criteria and this casts doubtas to whether Spain and the UK havethe same number of eligible donors.

The Spanish transplant teams retrieveonly a small number of organs fol-lowing donation after circulatory death(DCD). In the UK, the reductions indonation following Brain death (DBD)have led to an increase in DCD.Whether the Spanish rates are achiev-able or not, the UK does need to eval-uate current inequalities in order tomake organ donation a usual part ofNHS practice. This means that fami-lies of all potential organ donors areapproached and supported, irrespec-tive of factors such as ethnicity andreligion. The NICE guideline providesUK practitioners with guidance on howto identify, refer, gain consent and man-age the organ donation process.

GUIDELINEThe guideline consists of 28 recommen-dations which can be divided into threesections which relate to the organisa-tion of the:

Identification,ReferralConsent and approach processes for

a possible donor.The General Medical Council (GMC)

provides guidance to medical staff

on clinical responsibility for patientswho are potential donors. The GMCembraces the philosophy that donationshould be routine and best practice,taking into consideration patient pref-erences and respecting this decisions.Unfortunately, the Nursing & Mid-wifery Council (NMC) has not beenso decisive in providing clear direc-tion for nursing staff. NICE (2011) andthe Department of Health (2008) nowendorse donation decisions as part ofend of life care planning and the NMCmay need to review its position in lightof this.

IDENTIFICATION OFPOTENTIAL ORGAN DONORSNICE advocate the use of clinicaltriggers to identify a potential organdonor. There are numerous stud-ies (Wood et al., 2003; Madsen andBogh, 2005; Opdam and Silvester, 2006;Aubrey et al., 2008; Moller et al., 2009;Petersen et al., 2009 ) that show health-care professionals fail to recognisepotential donors and miss opportu-nities for potential organs for trans-plantation. A recommendation is thatin order to identify potential suitabledonors, a system of using clinical trig-gers be introduced. These clinical trig-gers are defined when a patient has acatastrophic brain injury, for example,cerebral haemorrhage and has absenceof one or more cranial nerve reflexesand has a Glasgow Coma Scale (GCS)of 4 or less that is not explained bysedation. If these clinical triggers aremet, there should be a referral to theSpecialist Nurse for Organ Donation(SNOD). These triggers aim to definea standardised point of referral andobservational studies demonstrate astatistical increase in the identifica-tion of potential donors when used to

112 © 2012 The Author. Nursing in Critical Care © 2012 British Association of Critical Care Nurses • Vol 17 No 3

Guest Editorial

screen all intensive care patients (Bairet al., 2006; Shafer et al., 2008). How-ever, it is understood that a proportionof patients identified by these initialtriggers will survive.

NICE recommend anticipated deathsare discussed with a SNOD. Thisincludes the intention to withdraw life-sustaining treatment in patients (NICE,2011). Six studies (Burris and Jacobs,1996; Robertson, 1998; Shafer et al.,1998; Dickerson et al., 2002; Shafer et al.,2008; Graham et al., 2009) reported anincrease in the number of donationswhen required referral was used inhospitals. Required referral is notstandard practice in many critical careunits and emergency departments andwould require careful implementation.

NICE advocate that medical andnursing staff involved in the care ofthe patient, the SNOD and whererelevant a local faith representative,should be involved in the planning andinitial approach for organ donation.This is a significant departure fromformer practice where a single doctor,nurse or other professional wouldapproach a family to seek consent fororgan donation. The NICE guidelineoutlines best practice on how toapproach and obtain consent in amanner that provides families withthe necessary information to makean informed decision about donationbut also maximises potential consentrates. The guideline provides explicitexamples of how donation should bediscussed using positive language, forexample, ‘by becoming an organ donoryour relative has a chance to saveand transform the lives of so manyothers. . .;’. Apologetic or negativelanguage (e.g. ‘I am asking you becauseits policy. . .;’ or ‘I am sorry I have to askyou. . .;’) reduces consent for donation.Open-ended questions, for example,‘how do you think your relative wouldfeel about organ donation?. . .;’ provideopportunity for the multi-professionalteam to assess the patient’s and theirrelatives’ wishes and allows them torespond to questions in a supportiveand informative manner. Throughout

the process, the primary focus is onthe care and dignity of the patientregardless of whether the donationtakes place.

The NICE recommendations arebased upon research and with theexplicit aim to maximise consent rates.In order to produce a NICE guideline,the GDG make recommendations fromthe research that has been evaluatedagainst GRADE assessment criteria.GRADE criteria are biased towards therandomised controlled trial (RCT) asthe gold standard of research in thehierarchy of evidence. GRADE crite-ria are very useful when assessingthe effectiveness of a treatment orintervention, for example, therapeutichypothermia following cardiac arrest.However, the organ donation guide-line proved to be a challenge to theGDG. The GRADE criteria does noteffectively assess the quality of qualita-tive studies that predominate in organdonation research.

This guideline was to determinehow to maximise donation and gainconsent. Most of the evidence inthis area was collected via qualitativeresearch design. For example, Had-dow (2004) undertook a qualitativestudy analysing donor and non-donorfamily accounts of their communica-tions with health care professionals.This study provided an informativeand credible account of how rela-tives perceived health professionals atthis time. Although Haddow’s studyprovided rich data on communicationthat informed the final recommenda-tions, against the GRADE criteria thisstudy was classed as ’very low qualityevidence. . .;’.

In my opinion, for this guideline to besuccessfully adopted and implementedinto practice, there are four key factorsthat need to be considered:

First, the education and training ofhealth care professionals in relationto these recommendations. NICE andthe Department of Health (2008) rec-ommend that all staff involved incaring for donor patients should begiven training. The NICE guideline

(2011) advises on the necessary skillsand training that all health profes-sionals should require when workingwithin critical care. Protected studytime needs to be given to staffs whoattend training on donation manage-ment if the UK is ever going to reducethe number of patients on the organtransplant waiting list.

Second, nurses have a vital role toplay within the MDT when identifyingand caring for potential donors. Thereis evidence that nurses provide theemotional support that is beneficial tofamilies when they are first approachedabout organ donation (Jacoby et al.,2005). As critical care nurses, we mustnot forget the significance of supportingrelatives through and involving them inend of life care and donation decisions.

Third, the impact of local Trust organdonation committees on local NHSTrust policy and embedding a culturethat organ donation is routine for end oflife care should not be under estimated.Local Trust donation committees needto look at strategies to implementthese recommendations into front-linepractice and look at audit criteria tomeasure compliance (NICE, 2011).

Finally, the most significant influ-ence on implementing this guidelinelies with nurses, but in particularthe SNOD’s. Since the Department ofHealth (2008) task force recommenda-tions, it has now been common prac-tice for SNOD’s to be based withinlocal Intensive Care Units rather thanallocated to referral transplant cen-tres. For the ambitions of the guide-line to be realised, the SNOD’s roleis crucial; and they must be acceptedas a vital member of the multi-disciplinary team. On-going invest-ment and recruitment of SNOD’s arepivotal for this NICE guideline tobecome routine practice.

In conclusion, the NICE guidelineprovides best practice recommenda-tions for all health professionals. Theapproach has three strands, educationand training, Trust Donation Commit-tees and the local presence of SNODs.These three factors will hopefully help

© 2012 The Author. Nursing in Critical Care © 2012 British Association of Critical Care Nurses 113

Guest Editorial

to provide more donors and organs fortransplantation that will improve thequality of life for so many patients.

Tim CollinsNurse Representative for NICE GDG for

Organ Donation,ICU Clinical Nurse Educator,

Maidstone & Tunbridge Wells NHS TrustE-mail: tim.collins@nhs.net

REFERENCESAubrey P, Arber S, Tyler M. (2008). The organ

donor crisis: the missed organ donorpotential from the accident and emergencydepartments. Transplantation Proceedings 40:1008–1011.

Bair H, Sills P, Schumacher K, et al. (2006).Improved organ procurement throughimplementation of evidence-based practice.Journal of Trauma Nursing 13: 183–185.

Burris G, Jacobs A. (1996). A continuous qualityimprovement process to increase organand tissue donation. Journal of TransplantCoordination 6: 88–92.

Department of Health. (2008). Organ DonationTask Force. DH.

Dickerson J, Valadka AB, Levert T, et al. (2002)Organ donation rates in a neurosurgical

intensive care unit. Journal of Neurosurgery97: 811–814.

General Medical Council. (2010). Treatmentand care towards the end of life: goodpractice in decision making. GMC.

Graham J, Sabeta M, Cooke J. (2009). A sys-tem’s approach to improve organ donation.Progress in Transplantation 19: 216–220.

Haddow G. (2004). Donor and nondonor fam-ilies’ accounts of communication and rela-tions with healthcare professionals. Progressin Transplantation 14: 41–48.

Jacoby L, Breitkopf C, Pease E. (2005). A quali-tative examination of the needs of familiesfaced with the option of organ donation.DCCN - Dimensions of Critical Care Nursing24: 183–189.

Madsen M, Bogh L. (2005). Estimating theorgan donor potential in Denmark: aprospective analysis of deaths in intensivecare units in northern Denmark. Transplan-tation Proceedings 37: 3258–3259.

Moller C, Welin A, Henriksson B, et al. (2009).National survey of potential heart beatingsolid organ donors in Sweden. Transplanta-tion Proceedings 41: 729–731.

NICE. (2010). Organ donation: final scope.http://www.nice.org.uk/nicemedia/live/12952/50890/50890.pdf (accessed 19/01/12).

NICE. (2011). Organ donation for trans-plantation: improving donor identificationand consent rates for deceased organ

dona-tion. http://publications.nice.org.uk/organ-donation-for-transplantation-improving-donor-identification-and-consent-rates-for-deceased-cg135 (accessed 3/01/12).

Opdam H, Silvester W. (2006). Erratum: ‘‘Poten-tial for organ donation in Victoria: an auditof hospital deaths’’ (2006) vol. 185 (250-254)). Medical Journal of Australia 185: 408.

Petersen P, Fischer-Frohlich C, Konigsrainer A,et al. (2009). Detection of potential organdonors: 2-year analysis of deaths at aGerman university hospital. TransplantationProceedings 41: 2053–2054.

Robertson V, George G, Gedrich P. (1998). Con-centrated professional education to imple-ment routine referral legislation increasesorgan donation. Transplantation Proceedings30: 214–216.

Shafer T, Durand R, Hueneke M. (1998). Texasnon-donor-hospital project: a program toincrease organ donation in communityand rural hospitals. Journal of TransplantCoordination 8: 146–152.

Shafer TJ, Wagner D, Chessare J, et al. (2008).US organ donation breakthrough collabora-tive increases organ donation. Critical CareNursing Quarterly 31: 190–210.

Wood D, Dargan P, Jones A. (2003). Poisonedpatients as potential organ donors: postalsurvey of transplant centres and intensivecare units. Critical Care 7: 147–154.

114 © 2012 The Author. Nursing in Critical Care © 2012 British Association of Critical Care Nurses