The letter from Drs Cottle and Dean [1] illustrates a number of barriers to successful organ donation facing critical care practitioners and also highlights the importance of authoritative resolution if such opportunities are not to be lost in the future.

It may be assumed that death would have occurred quickly after withdrawal of ventilatory support, if brain stem death had occurred (despite lack of testing), and as such, viable non-heart beating donation should have been feasible.

Therefore, it is unclear as to why the patient’s organs were not accepted by the transplant teams, since if primary function was satisfactory for beating heart retrieval, and there was no other contraindication to donation, there was no apparent reason for declining  liver and kidney retrieval after a predictably short dying process.  Therefore, the criteria for refusal should be made more explicit than currently practised, and should be rigorously audited if potential donors are not be lost by this mechanism.

The second problematic issue of certifying death by neurological criteria in the presence of metabolic disturbance, is acknowledged.  However, the primary principle that clinical testing supplanted objective investigations, not because of superiority, but because of the feasibility of certifying death by these criteria in institutions, without such specialised support, justifies the use of confirmatory testing in these circumstances. This is endorsed by the new Academy Code of Practice referenced by the authors.

Both conventional and CT angiography have been deployed in our institution, as in other UK institutions, to confirm the absence of intracranial blood flow and to consolidate the clinical diagnosis of brainstem death, in the presence of unquantified but predictably high levels of therapeutic barbiturates or other metabolic confounders.  This has been accepted by our local coroner as having legal equivalence, and as defensible justification for progressing to beating heart donation. 

In the context of near universal adoption of digital radiology and image transfer, technical advice on the procedure and support for interpretation of CT angiography [2] should be available around the clock from regional neurosurgical centres.  This ‘barrier’ is also capable of resolution, therefore, if there is an effective national strategy to implement the principles set out in the Academy Code of Practice.

In summary, Drs Cottle and Dean highlight an important problem facing intensive care practitioners and if professional support for organ donation is to be ensured, these aspects which are outside our immediate control should be addressed with the same rigour as the current ‘required referral’ and the audit process for identifying ‘lost’ potential donors on the ICU.

It is hoped that the UK Donation Ethics Committee, established in line with the recommendations of the Organ Donation Taskforce [3], will address these problematical areas.

 Dominic Bell¹, Paul Murphy² 

1 Consultant in Critical Care, The General Infirmary at Leeds

2 Consultant in Critical Care, NHSBT Clinical Lead for Organ Donation The General Infirmary at Leeds

1. Cottle D, Dean P. Ethical issues and donor numbers. Anaesthesia 2010; 65:82
2. Frampas E, Videcoq M, de Kerviler E, et al.  CT Angiography for Brain Death Diagnosis. Am J Neuroradiol 2009;30:1566 –70
3. Organs for Transplants: A report from the Organ Donation Taskforce. Department of Health. London January 2008