‘To improve organ donation rates, we need to look at every death in ICUs and EDs’

An audit of hospital deaths focused on potential organ donations could offer crucial information about missed opportunities, according to experts in organ donation.

Dr Alan Gaffney, intensive care physician at Beaumont Hospital and clinical lead for organ donation in the Royal College of Surgeons of Ireland (RCSI) hospital group, argues that to improve the rate of organ donation in Ireland, information on missed opportunities for organ donation is needed.

“Currently, we don’t really know what we are missing, but to improve organ donation rates, we need to look at every death in Intensive Care Units (ICUs) and Emergency Departments and ask if it could have been an organ donation or was it considered for organ donation. We also need to know if the family was approached and if so, how? And did the person go on to be an organ donor,” explains Dr Gaffney.

Ireland currently has a lower level of organ donations than many nearby countries. And while this can partly be explained by our younger population and fewer deaths, experts believe it may also be due to missed opportunities for organ donation. Less than 10 per cent of those who die in ICUs are potential organ donors. Most of these individuals have suffered a devastating brain injury.

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Dr Gaffney, who worked with the National Office of Clinical Audit on the 2022 feasibility study on the need for a national clinical audit on organ donation practises, says that increasing levels of organ donation also depends on having the specialist organ donation personnel in every ICU department in the country. Currently, there are organ donation nurse managers attached to each hospital group but not in each hospital.

“Having key organ donation personnel in every ICU department, training ICU staff in organ donation and having information from the potential donor audit collected in real time by organ donation specialists and available quickly is what makes a difference to organ donation rates,” says Dr Gaffney.

Experts on organ donation suggest that legislation which would change organ donation from opt-in to opt-out is less impactful on numbers of organs donated. “There is no evidence that opt-out legislation [as proposed in the Human Tissue Bill] has ever led to sustained increase in organ donation rates,” says Dr Gaffney.

In the forward to the Potential Donor Audit Feasibility Study, Beatriz Dominguez-Gil, Director General of the Spanish National Transplant Organisation says that a potential donor audit also offers information on whether the profile of potential donors is changing over time. "A Potential Donor Audit is essential for identifying those hospitals and units with excellent performance, to learn of good practices that can be transferred to other centres," she writes.

Carol Moore, chief executive of the Irish Kidney Association says that some hospitals are good at identifying potential donors while others aren't. "Identifying a potential donor can create more work for healthcare professionals who are already under huge pressures. Once a donor is identified, that person will occupy an ICU bed until he/she is brought to an operating theatre to retrieve the organs. This puts doctors in a difficult situation if there is a need for ICU beds," says Moore.

Dominguez-Gil also says that promotional campaigns [for organ donation] or reforming existing legislation toward an opt-out system have never proven to result in sustained improvements in organ donation. Spain is deemed to be the world leader in organ donation.

Over 28,000 transplants were performed in the EU-28 in 2020 which covered 27 per cent of patients active on waiting lists that year. In 2020, some 11 patients died each day in the EU while awaiting an organ.

The disparity between supply and demand of organs for transplantation is expected to keep growing as a result of ageing populations and more diseases that lead to end-stage organ failure.

Ireland ranks 28th in terms of organ donation rates out of 72 countries worldwide, according to the Global Observatory on Donation and Transplantation (2021). Rates of organ donation are 18 per million population (pmp) in Ireland compared to 25 pmp in Britain.

The World Health Organisation has called on governments and healthcare professionals to pursue self-sufficiency in transplantation and to develop deceased organ donation to its maximum therapeutic potential.

The former director of the Spanish National Transplant Organisation said, “we should never blame the population; if people donate less, it must be something we [the health professionals] have done wrong”.

Dr Gaffney adds, “our job is to make sure a system is in place so that anyone who could be an organ donor, can be and with the help of a potential donor audit, we can see if we have given the opportunity to every person where the opportunity could be given.”

A new steering group is currently being set up to roll out a pilot potential organ donor audit in one hospital in each of the six hospital groups, funded by the HSE’s Organ Donation Transplant Ireland (ODTI).

Organ donor awareness week runs from April 23rd-30th. Organised by the Irish Kidney Association with ODTI, this year’s theme is #ShareYourWishes, asking the public to ensure their family knows whether they are willing to donate their organs if the opportunity arises. At any one time, there are between 550 and 600 people active on waiting lists for organ transplants including heart, lung, liver, kidney and pancreas.