Deceased donor organ donation

The donation process begins long before any retrieval: it begins when someone in the intensive care unit identifies a possible donor and the deceased person's own wishes are properly established. Two things determine the outcome — that the confirmation of death is carried out in a formally unimpeachable way, and that the donor's organs are maintained physiologically for as long as the assessment takes. The task of the health service is to give effect to the deceased person's wishes, not to persuade anyone.

This article describes the process as it is regulated in Swedish law and practice; the legal framework, the consent model and the time limits differ between countries.

The two pathways

flowchart TD
  A[A possible donor is identified in the ICU] --> B{Does the patient develop total brain infarction during ventilation?}
  B -- Yes --> C[DBD pathway]
  B -- No, a decision to withdraw life-sustaining treatment --> D[DCD pathway]
  C --> E[Establish the wish to donate: the donation register, a donor card, statements made, the next of kin]
  D --> E
  E --> F{A positive or unknown position?}
  F -- An expressed refusal --> G[Donation is not carried out]
  F -- Yes or unknown --> H[Organ-preserving treatment, contact with the donation specialist nurse and the transplant coordinator]
  H --> I[Medical donor assessment: serology, cultures, organ function, history]
  I --> J{Pathway}
  J -- DBD --> K[Two clinical neurological examinations at least two hours apart, with apnoea testing]
  K --> L[Certification of death, then retrieval with the circulation maintained]
  J -- DCD --> M[Life-sustaining treatment is withdrawn, palliative care, circulatory arrest]
  M --> N[A five-minute no-touch period, certification of death by indirect criteria]
  N --> O[Prompt transfer to theatre, retrieval]

Indications

• An intensive care patient with severe brain injury in whom total brain infarction is judged possible during ongoing ventilation (DBD).
• An intensive care patient in whom a decision has been made to withdraw life-sustaining treatment, in whom total brain infarction is not expected to occur within a reasonable time, and in whom death is judged likely within 180 minutes of treatment being withdrawn (DCD).
• DCD additionally requires that the next of kin understand and accept the basis for the decision to withdraw treatment. If there is conflict about that decision, DCD must not be raised — the two decisions must never be conflated.

There is no absolute upper age limit. Suitability is determined organ by organ in consultation between the intensive care physician and the transplant service.

Contraindications

• An expressed refusal by the deceased — in the donation register, on a donor card, or through statements made to the next of kin.
• Active malignancy with a risk of transmission (an individual assessment; certain tumour types are not a bar).
• Untreated generalised infection, or certain transmissible agents according to the current transmission risk assessment.
• In DCD: patients in whom death must be confirmed after a 20-minute no-touch period, for example after poisoning, since this is not compatible with a DCD process.

The assessment of medical suitability is made by the transplant team. Never rule out a possible donor on your own on grounds of age or medical history — contact the transplant coordinator and let the assessment be made there.

Consent and the law

Swedish law is based on presumed consent: a person who has not expressed opposition is presumed to have consented to donation. The person's wishes are established in this order:

1. The donation register held by the Swedish National Board of Health and Welfare, checked after the decision to withdraw treatment has been documented.
2. A donor card and written expressions of intent.
3. Statements made verbally to the next of kin.

Since the change in the law in 2022, the next of kin no longer have a right of veto based on their own view. Their role is to convey what the deceased person themselves thought. This does not diminish the importance of the conversation: the next of kin must be informed before organ-preserving treatment is started, and a conversation conducted with time, clarity and respect is also what makes the decision hold afterwards.

Organ-preserving treatment — treatment given solely for the sake of the donation — may continue for at most 72 hours from the decision to withdraw treatment, and may be given only if it does not cause more than minor pain or suffering. After certification of death by direct criteria, the circulation and ventilation may be maintained for at most 24 hours for the purpose of donation.

Procedure

Confirmation of death by direct criteria

Death is confirmed by a registered medical practitioner with specialist qualifications who is thoroughly familiar with clinical neurological examination. Before the first examination, confounding factors must be excluded: drug effects (wait the equivalent of five half-lives), a core temperature below 35 °C, metabolic and endocrine disturbance, and a systolic blood pressure below 90 mmHg. A chain of events that explains the condition must be demonstrable.

At both examinations, all of the following must be present:

• Unconsciousness with no response to speech, touch or pain.
• No spontaneous eye movements and no movements of the face, jaw or tongue.
• Fixed pupils, mid-sized or dilated.
• Absent corneal reflex.
• Absent gag reflex.
• Absent vestibulo-ocular reflex.
• No change in heart rate on pressure over the eyeballs or on carotid massage.
• No spontaneous respiration, verified by an apnoea test.

The examinations must be performed at least two hours apart. The patient is certified dead after the second apnoea test.

The apnoea test

1. Preoxygenate with 100 % oxygen for about 10 minutes.
2. Check that the baseline PaCO₂ lies between 4.5 and 6 kPa.
3. Disconnect the ventilator and provide oxygen passively.
4. Observe the chest and abdomen continuously for 5–10 minutes.
5. The test is complete when the PaCO₂ has risen by at least 2.7 kPa and reached at least 8 kPa with no respiratory movements observed.
6. Stop the test if the saturation falls below 85 %, the systolic blood pressure falls below 90 mmHg, or arrhythmias occur — and then supplement instead with four-vessel angiography or a nuclear medicine study.

When cerebral angiography is required

Four-vessel angiography — or a nuclear medicine study — is mandatory when the clinical examination is not sufficient:

• A metabolic or pharmacological effect on brain function cannot be excluded.
• A core temperature below 35 °C.
• An unclear cause of the total brain infarction.
• An isolated process in the brainstem or the posterior fossa — here the clinical criteria can be met without the cerebrum being dead.
• Any component of the examination cannot be performed or interpreted, for example with facial injuries or with chronic obstructive pulmonary disease that makes an apnoea test impossible.

The angiography is performed by a radiologist with specialist qualifications, as two studies at least 30 minutes apart, and must show absent intracranial circulation.

The DCD process

1. The decision to withdraw treatment is made on purely medical grounds and is documented — before the question of donation is raised.
2. The wish to donate is established, and the donation specialist nurse and the transplant coordinator are contacted.
3. The next of kin are informed in detail about what DCD involves, including that retrieval will not be possible if death does not occur within the time frame, and that tissue donation may then be an alternative.
4. Life-sustaining treatment is withdrawn with palliative care, in the place specified by local procedure, with the next of kin present if they wish.
5. On circulatory arrest, the five-minute no-touch period begins. No interventions may be undertaken during this time; the next of kin may hold the dying person's hand. If there is autoresuscitation or a return of spontaneous respiration, a new five-minute period begins.
6. Death is confirmed by indirect criteria, after which the deceased is taken promptly to theatre. Cold perfusion should have been started within 30 minutes of the circulatory arrest.

Medical care of the donor

After total brain infarction the central regulation collapses: vasodilatation, diabetes insipidus, hypothermia and pulmonary compromise appear in turn. Donor care is ordinary intensive care with clear targets — it is not passive waiting.

Complications

• Haemodynamic collapse during donor care, with the loss of organs as a consequence.
• Marked hypernatraemia as a result of untreated diabetes insipidus.
• Ventilator-associated pneumonia and atelectasis that render the lungs unusable.
• Arrhythmias and cardiac arrest during the apnoea test.
• In DCD: the patient does not die within the time frame and retrieval cannot be carried out — this must be prepared for with the next of kin in advance.
• A prolonged process and protracted uncertainty for the next of kin.

Aftercare and follow-up

After retrieval the deceased must be prepared so that the next of kin can say goodbye in the usual way. Offer a follow-up conversation — many relatives have questions only weeks later, and being told that the donation was of benefit matters a great deal.

The documentation must cover the whole chain: the decision to withdraw treatment, how the wish to donate was established, the information given to the next of kin, both neurological examinations with the times, the blood gases from the apnoea test, any angiography, and the time of certification of death. The certificate of death is sent to the Swedish Tax Agency and the cause of death certificate to the National Board of Health and Welfare according to the usual procedure. In unexplained deaths the police must be contacted before the donation process continues.

Set aside time for a debriefing conversation within the team. Donation processes are demanding for the staff as well.

Common pitfalls

• Failing to identify the possible donor. The commonest reason that donation does not take place is that the question is never asked.
• Conflating the decision to withdraw treatment with the question of donation. The decision to withdraw treatment is made first, on medical grounds, and is documented.
• Asking the next of kin what they themselves want. The question is what the deceased person thought.
• Omitting to check the donation register.
• Relying on clinical examination alone in an isolated posterior fossa process — angiography is required there.
• Abandoning the apnoea test and interpreting it as inadequate evidence instead of proceeding to angiography.
• Forgetting hypothermia and drug effects as confounding factors before the first examination.
• Neglecting donor care during the diagnostic process — the organs are lost during the hours that the assessment takes.
• Ruling out a donor on your own instead of letting the transplant coordinator make the assessment.