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Key Policies for Donation Success in Canada

To ensure transplant success for all Canadians every hospital should be have the following procedures in place

Donation after cardiac death (DCD) may allow potential donors previously not eligible for deceased organ donation to now donate their organs expand the opportunity for people who wish to be donors to donate – and increases the availability of deceased donor organs.

What is Donation After Cardiac Death?

There are two primary types of deceased organ donation: donation after circulatory determination of death (DCD) or donation after neurologic criteria (DND). In cases of DCD, “life-sustaining therapy is withdrawn and organs are recovered after death is declared by absence of circulation”.(1) Shemie et al. has provided national recommendations for donation after cardiocirculatory death in Canada.(2) Expanding the donor pool to include DCD donors is important given that the number of patients dying from neurologic death is decreasing.(3)

Success of Donation After Cardiac Death

A recent article published in the Canadian Medical Association Journal (CMAJ) by Rao et al. (2017) evaluate the effect of introducing DCD in 2006.(1) The researchers found that implementation of DCD led to an increase of 57% from 578 donors in the pre-DCD era (2002/2003 to 2005/2006) to 905 donors in the recent DCD era (2010/2011 to 2013/2014). Early kidney transplant outcomes from DCD donors in Ontario have also been reported to be excellent and similar to those from DND donors.(4) Another study from a Canadian transplant program of kidneys from DCD donors also reported favorable outcomes.(5) Finally, another recent Canadian study also showed that simultaneous pancreas and kidney transplants from DCD donor have comparable outcomes to NDD donor organs.(6)

Which provinces have a DCD program?

British Columbia, Ontario, Quebec and New Brunswick currently has donation after cardiac death programs.

First DCD Donor in Canada

Sarah Beth was the first DCD donor in Canada. You can watch an interview with her parents at:

http://www.cbc.ca/fifth/blog/interview-with-the-first-dcd-donors-parents

References

  1. Rao V, Dhanani S, MacLean J et al. Effect of organ donation after circulatory determination of death on number of organ transplants from donors with neurologic determination of death. Canadian Medical Association Journal 2017; 189: E1206–E1211.
  2. Shemie SD, Baker AJ, Knoll G et al. Donation After Cardiocirculatory Death in Canada. Canadian Medical Association Journal 2006; 175: S1–S1.
  3. Kramer AH, Zygun DA, Doig CJ, Zuege DJ. Incidence of neurologic death among patients with brain injury: a cohort study in a Canadian health region. Canadian Medical Association Journal 2013; : cmaj.130271.
  4. Hernadez-Alejandro R, Wall W, Jevnikar A et al. Organ donation after cardiac death: donor and recipient outcomes after the first three years of the Ontario experience. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 2011; 58: 599–605.
  5. Moser M, Sharpe M, Weernink C et al. Five-year experience with donation after cardiac death kidney transplantation in a Canadian transplant program: Factors affecting outcomes. Canadian Urological Association Journal 2012; 6: 448–452.
  6. Anderson PT, Aquil S, McLean K, McAlister VC, Sener A, Luke PP. First Canadian experience with donation after cardiac death simultaneous pancreas and kidney transplants. Canadian Journal of Surgery 2017; 60: 323–328.

Hospital Donation Physicians promote a culture of donation inside their hospital by providing educational support and sharing expertise with hospital staff. Their role is to help ensure that no family misses the opportunity to create a life-saving legacy for a loved one by choosing donation.

Why are they important?

Donation physicians are in-hospital physicians with key responsibilities in deceased organ and tissue donation. These donation physicians provide leadership to improve donation performance, accountable to their respective hospital and are remunerated for their activities. The Canadian Blood Services recommends the implementation of donation physician specialists to improve donation and transplant systems in Canada.(1) Specifically, their role may include “donor identification, direct care of potential donors, education of the public and of health care providers (HCPs), and administration of the decreased donation program.”(2) In other countries, donation system changes that included a hospital donation specialist role was associated with an increase in deceased organ donation rates.(1) Shemie et al. developed an ethics guide to help inform the hospital donation physician role.(3)

British Columbia, Manitoba and Ontario have hospital donation specialists.

References:

  1. Shemie SD, MacDonald S. Improving the process of deceased organ and tissue donation: a role for donation physicians as specialists. CMAJ : Canadian Medical Association Journal 2014; 186: 95–96.
  2. MacDonald SI, Shemie SD. Ethical Challenges and the Donation Physician Specialist: A Scoping Review. Transplantation 2017; 101: S27.
  3. Shemie SD, Simpson C, Blackmer J et al. Ethics Guide Recommendations for Organ-Donation–Focused Physicians: Endorsed by the Canadian Medical Association. Transplantation 2017; 101: S41–S47.
  4. Fifty physicians to champion organ and tissue donation in Ontario hospitals. (n.d.). Retrieved October 10, 2017, from http://www.newswire.ca/news-releases/fifty-physicians-to-champion-organ-and-tissue-donation-in-ontario-hospitals-560932261.html
  5. Jones, K. (2015, January 17). Physicians engaged to lead on organ donation in Ontario. Retrieved October 10, 2017, from http://hospitalnews.com/physicians-engaged-lead-organ-donation-ontario/
  6. Physicians Engaged to Lead on Donation in Ontario. (n.d.). Retrieved October 10, 2017, from http://www.marketwired.com/press-release/physicians-engaged-to-lead-on-donation-in-ontario-1978155.htm

Making it mandatory for hospitals to contact the provincial organ procurement organization/program before withdrawing life support from patients can significantly increase in the number of potential organ donors.

What is it?

  • Mandatory referral, or routine notification is the process in which all potential donors are referred to an organ procurement organization.
  • There are currently a variety of mandatory referral models used in Canada.
  • An early referral allows an organ procurement organization enough time to test the potential donor for medical suitability and to approach the family for consent to deceased organ donation
  • For example, in Ontario, the Trillium Gift of Life Network Act states that:
    • “(1) A designated facility shall notify the Network as soon as possible when a patient at the facility has died or a physician is of the opinion that the death of a patient at the facility is imminent by reason of injury or disease.”(1)

Which provinces have implemented mandatory referral?

British Columbia, Alberta, Manitoba, Ontario, Quebec, New Brunswick currently has mandatory referral.

What is the success of mandatory referral policy?

References:

  1. Trillium Gift of Life Network Act, R.S.O. 1990, c. H.20 [Internet]. Ontario.ca2014; [cited 2017 Oct 9] Available from: https://www.ontario.ca/laws/view
  2. Domínguez-Gil B, Murphy P, Procaccio F. Ten changes that could improve organ donation in the intensive care unit. Intensive Care Medicine 2016; 42: 264–267.
  3. Robertson VM, George GD, Gedrich PS, Hasz RD, Kochik RA, Nathan HM. Concentrated professional education to implement routine referral legislation increases organ donation. In: Transplantation proceedings. Elsevier, 1998; 214–216