Difficulty with organ donation

Todd Fraser on 24-06-2010

A 23 year old man has suffered a severe brain injury and associated facial injuries in a motor vehicle accident. Clinically he shows no sign of brain function, and a nuclear medicine perfusion scan is performed to assess his suitability for organ donation. A verbal report is obtained and suggests residual cerebral perfusion exists. He becomes modestly unstable haemodynamically and the family withdraw consent to donation. However, a second radiologist completes the formal report and believes the scan shows no flow. How would you manage this situation?

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James Doyle wrote 07-09-2010 12:31:25 pm
A few points here that i can think of
Firstly i would suggest that a request for consent for organ donation not be made until brain death has been diagnosed.
If consent is subsequently withdrawn even after initially being given then after ensuring that all of their queries have been answered, these wishes must of course be upheld
In this instance the management would then be inline with the clinical picture, which is bleak, and so a withdrawal the only option.

In terms of the issue of diagnosis of brain death:
Current ANZICS guidelines continue to state that brain death is a clinical diagnosis. Therefore brain death can be daignosed in this chap clinicallly as suggested in the case study (as long as the physiological condition allows). It seems that given this story the facial trauma may preclude this from occuring.

So if we are left with radiological determination then a consesus and formal report must be obtained from the radiologists and if necessary a repeat study could be on the cards. However in real life, with the current delicacy of our organ donation programme, if their is any doubt as to the diagnosis of brain death then one must not proceed to organ donation, shame as it is with such 'pristine' organs!!

Todd Fraser wrote 07-10-2010 05:08:05 pm
That's about right James. Agreed, I think you need to preserve the integrity of the process at all costs. I've always been loathe to discuss organ donation with a family until at least a clinical examination is consistent with brain death, or a scan confirms it. I don't think we can afford to have the public lose faith in the process, nor the families lose faith in us. Approaching them for permission for organ donation before confirmation of brain death risks the perception of a conflict of interest.

Todd Fraser wrote 07-11-2010 10:13:32 pm
The American Neurology Academy issued new guidelines for diagnosing brain death in June 2010. One of the more striking recommendations is that only one examination is sufficient for the diagnosis to be made.

Neurology. 2010;74:1911-1918