Clinical context

There are over 8,000 people waiting for an organ transplant in the UK. The identification of potential donors in emergency departments (ED) will increase rates of donation and will ensure patients’ previously held wishes are fulfilled.

It has been suggested that the overall incidence of brain stem death in the UK may be falling because patients with catastrophic brain injury are not admitted to critical care and have treatment withdrawn in the ED, meaning formal brain stem death testing is not carried out.

The potential for donation within the ED mainly comes from severely brain injured patients; either from trauma or acute medical catastrophe, eg. sub-arachnoid haemorrhage, or in patients who are post cardiac arrest with return of spontaneous circulation (ROSC).

Best practice

This pathway has been written to advise and guide senior members of ED staff in decision-making around organ donation.

Where a ventilated patient has suffered a catastrophic traumatic or medical event, and the decision has been made that further treatment is futile, a specialist nurse for organ donation (SNOD) should be contacted as the next step.

When the decision has been made that further treatment is futile, it is essential to continue to care for patients in a critical care environment while donation is being considered / explored.

It is important to consider if the patient is likely to progress to brain stem death. Donation via brain stem death results in a greater number of donated organs. The Academy of Medical Colleges and the Intensive Care Society state that best practice is to undergo formal brain stem death testing where brain stem death is likely but irrespective of organ donation. Please seek the advice of your consultant intensivist.

Unless raised by the family, the issue of donation should not be discussed until the decision to withdraw life-sustaining treatment has been understood by the family. It is best practice to ‘decouple’ conversations regarding patient prognosis, treatment futility and death with conversations exploring organ donation, ensuring these two distinct clinical conversations are had at separate times.

When a decision has been made to approach families about organ donation best evidence suggests that a collaborative approach with a senior clinician and a SNOD should be undertaken.

Facilitating donation takes many hours and agreed local policies should guide where the most appropriate environment is to care for these patients (ICU, ED or other capable areas such as theatres / recovery). An agreed local policy should suggest potential alternative areas and staffing.

Patients who die in the ED

Patients in whom further treatment is futile, and who are dying, should routinely be started on the Liverpool Care Pathway.

Patients who die in the ED from any cause may be suitable eye and tissue donors. The next of kin should be offered this routinely and, if they consent, tissue services should be contacted on 0800 432 0559. They can offer advice and will contact the family to answer questions and go through the formal consenting process. Eyes and tissues for donation can be retrieved up to 24 hours after death.