3 | Donation after brain death (DBD)

Healthcare Professionals

3.1 Understanding and explaining brain death

What is brain death?

Brain death is when all blood flow to the brain has irreversibly ceased and the whole brain has died. The patient is apnoeic. Ventilation and circulation are mechanically supported which allows function of other organs to continue. Brain death is death that is diagnosed using neurological criteria.

How brain death occurs

Brain death occurs when severe brain damage leads to marked elevation of intracranial pressure. When intracranial pressure reaches systemic blood pressure, intracranial blood flow stops and the whole brain, including the brainstem, dies.

Who can determine brain death?

The ANZICS Statement specifies that:

”Neurological determination of death is carried out by two doctors, one of whom should be a specialist, who must each independently determine death according to this Statement, and meet the requirements of jurisdictional legislation.”

There is no legislative requirement in New Zealand. ODNZ requires that at least one of the two doctors must be a specialist.

Explaining brain death to colleagues

It is important for the OT staff to understand the concept of brain death. Here is an example of how you might explain brain death to your colleagues:

“When the brain is severely damaged it swells, just like muscle or skin when bruised. Sometimes there is bleeding into or around the brain as well.

Because the brain is inside the skull, which is like a closed box, when it swells the pressure inside the skull rises. Sometimes the pressure inside the skull gets so high that it cuts off the blood flow to the brain, like standing on a garden hose stops the flow of water.

When the blood flow to the brain is cut off, the brain dies. This is what is called ‘brain death’. When the brain dies, all of the functions of the brain are permanently lost.”

Here is an example of how you might explain how brain death is determined and the death of the patient.

“Brain death is determined by two doctors who each carry out a very specific and detailed examination of the person. This examination includes finding that the person does not move or respond, even to painful things, does not have reflexes in the nerves that come off the brain and does not breathe when disconnected from the ventilator. Sometimes brain death is determined by x-ray imaging showing that there is no blood flow going to the brain. When the brain has died, the person has died.”

It is very important for OT staff to understand that the patient died in the ICU a number of hours before being transferred to the OT.

3.2 Family agreement and coroner’s consent

Family agreement to organ and tissue donation

ICU staff discuss the option of organ and tissue donation with the family, most commonly after the determination of brain death.

The family can specify the organs and tissues they are willing to donate and this is documented on the Authority for Organ and Tissue Removal Form.

Specific consent is required for donation of organs and tissues for research.

The Authority for Organ and Tissue Removal Form replaces the normal surgical consent form.

Coroner’s consent

The Coroners Act 2006 defines the circumstances where a death must be referred to the coroner. The coroner then may or may not “accept jurisdiction”. In cases where the coroner accepts jurisdiction, removal of organs and tissues cannot proceed without the consent of the coroner.

The requirement or otherwise for referral to the coroner is documented on the Authority for Organ and Tissue Removal Form. Coroner’s consent is obtained by the ICU medical staff.

In cases where the coroner has accepted jurisdiction specific restrictions by the coroner will be documented on the Authority for Organ and Tissue Removal Form.

3.3 Sequence of events after brain death

The patient has devastating brain damage which is likely to be fatal and is on a ventilator.

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ODNZ is contacted to discuss the potential for organ and tissue donation.

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The ICU Link nurse is contacted in some hospitals.

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Blood is taken for the Donor Blood Pack and the ODNZ donor coordinator arranges transport.

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Brain death is determined and documented.

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Donation is discussed with the family.

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The agreement of the coroner is obtained when required. The coroner must consider the family’s views regarding donation.

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Donor information is obtained and required documentation is completed

Medical/Social Questionnaire,

Physical Assessment Form,

Authority for Organ and Tissue Removal Form

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Donor coordinator organises the organ donation.

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Organ donor surgery.

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Family may wish to spend time with their relative.

3.4 Checklist for donation after brain death

Please contact the donor coordinator to discuss any aspect of the donation process.

In this document the term intensivist refers to a senior doctor (specialist or fellow) looking after the patient. In some hospitals this might be an anaesthetist or other specialist. The term any doctor is used when actions do not require a senior doctor to be involved. ICU staff is used when actions could be done by an ICU doctor or ICU nurse.

These procedures for organ donation after brain death are listed in approximate sequence.

TASK	ACTION BY	ACTION
1. Identify the possibility of donation	ICU staff	Please call the donor coordinator to discuss any patient with severe brain damage who is likely to die (09 630 0935).
2. Initial assessment	Donor coordinator/ ODNZmedical specialist	The donor coordinator: asks for preliminary information about the patient (See Section 8.4 of ODNZ Best Practice Guidelines for NZ ICUs) discusses taking of blood for the Donor Blood Pack liaises with the ODNZ medical specialist who then liaises with the intensivist discusses medical suitability with the transplant service(s) if any uncertainty confirms whether donation is possible and which organs and tissues might be donated.
3. Notify ICU Link Nurse	ICU staff	In most hospitals the ICU staff ask the ICU Link nurse to assist.
4. Take blood for the Donor Blood Pack	ICU staff	The labels on the ABO blood tube (pink tube) must be hand-written. Patient labels can be used on all other blood tubes and the laboratory blood form (enclosed in the Donor Blood Pack).Check blood tubes are not out of date.
5. Transport of the Donor Blood Pack	Donor coordinator	The donor coordinator arranges transport of the Donor Blood Pack from the ICU to Auckland. This is done as soon as possible to prevent undue delays for the donor family if donation does go ahead. Blood is only tested after the family has agreed to donation.
5. Transport of the Donor Blood Pack	Donor coordinator	The donor coordinator arranges transport of the Donor Blood Pack from the ICU to Auckland. This is done as soon as possible to prevent undue delays for the donor family if donation does go ahead. Blood is only tested after the family has agreed to donation.
6. Inform family	Intensivist and ICU nurse	The family is informed that brain death is likely to have occurred and that this will be determined by either clinical examination or by demonstration of absent blood flow to the brain.
7. Determination of brain death	Two doctors including at least one specialist	Brain death is determined either by clinical examination or by demonstration of absent cerebral perfusion. In either case there must be evidence of intracranial pathology consistent with the irreversible loss of neurological function. See the ANZICS Statement for details of the clinical examination. See Section 9.1 of ODNZ Best Practice Guidelines for NZ ICUs for details of demonstration of absent cerebral perfusion.
8. Documentation of brain death	Two doctors including at least one specialist	Brain death is documented on the Determination of Brain Death Form.When brain death has been determined by clinical examination, the time of death is recorded as the time when the second clinical examination to determine brain death is completed. When brain death has been determined on the basis of absent cerebral perfusion, the time of death is recorded as the time when the two doctors have completed the Determination of Brain Death Form.
9. Inform family	Intensivist and ICU nurse	The intensivist informs the family that the patient is brain dead and of the time of death. The ICU nurse is present at this family meeting.
10. Discussion of donation with the family	Intensivist and ICU nurse	The intensivist discusses donation with the family. The ICU nurse and sometimes an ICU Link nurse is also present at this family meeting.
11. Discussion with the coroner	Intensivist	The Coroners Act 2006 defines the circumstances where a death must be referred to the coroner. The coroner may or may not “accept jurisdiction”. In cases where the coroner accepts jurisdiction, the removal of organs and tissues cannot proceed without the agreement of the coroner. The intensivist discusses organ and tissue donation with the coroner. The coroner must be informed of the family’s views about donation as the coroner is required to consider these views. The coroner has agreed to donation in some cases of suspected homicide. See Section 8.3. ODNZ Best Practice Guidelines for NZ ICUs.
12. Refer back to donor coordinator	ICU staff	The ICU staff inform the donor coordinator of the outcome of the family discussion. If the family agrees to donation, the donor coordinator requests all the necessary details for donation. See Section 8.4 ODNZ Best Practice Guidelines for NZ ICUs.
13. Routine death documentation	ICU doctor and nurse	Routine death documentation is completed in accord with local hospital practice and kept with the clinical notes.
14. Identification of the deceased	Any ICU doctor or nurse	Where the coroner has taken jurisdiction, the ICU medical staff notify the police before the donor surgery. The ICU staff may need to explain brain death to the police. Showing the Determination of Brain Death Form may assist in understanding that death has occurred. The police will require the family to identify the deceased patient. The ICU staff should try to ensure this is done before the family leaves the hospital and prior to the donor surgery. This is to avoid the family having to return to the hospital.
15. Medical/Social Questionnaire and Physical Assessment Form completed	ICU staff or donor coordinator	The ICU staff or donor coordinator completes the Medical/ Social Questionnaire for Organ and Tissue Donation with a family member(s) and the Physical Assessment Form.
16. Liaison with transplant teams	Donor coordinator	The donor coordinator liaises with the transplant teams and tissue banks to determine which organs and tissues can be donated for transplantation.
17. Notification of ICU staff of any organ and tissues accepted	Donor coordinator	The donor coordinator informs the ICU staff which organs and tissues can be donated for transplantation and any requests for tissues for specific research projects.
18. Authority for organ and tissue removal	ICU staff	ICU staff inform the family which organs and tissues can be donated for transplantation and any requests for tissues for specific research projects. A family representative signs the Authority for Organ and Tissue Removal Form or witnessed verbal consent is obtained. The ICU staff notify the donor coordinator of the outcome of this process.
19. Completion of documentation	Donor coordinator and ICU staff	The donor coordinator ensures that completed forms have all been received from the ICU: Medical/Social Questionnaire Physical Assessment Form Determination of Brain Death Form Authority for Organ and Tissue Removal Form. The Medical/Social Questionnaire must not to be left in the patient notes. The donor coordinator will take the original when they arrive at the donor hospital.
20. Organisation of the donor surgery	Donor coordinator	The donor coordinator liaises with the ICU, OT, anaesthetist (if needed) and the transplant team(s) to arrange the time for the donor surgery. The donor coordinator informs the ICU and OT staff which organs and tissues have been accepted for donation.
21. Crossmatching	ICU staff	ICU staff crossmatch 4 units of RBC for the donor surgery.
22. Medical treatment of the donor in ICU	ICU staff/ODNZ	The ICU staff continue medical treatments to support extra- cranial physiology until the patient is transferred to the OT (see Section 4). They should notify the donor coordinator or the ODNZ medical specialist of any deterioration.
23. Meet the family	Donor coordinator	Unless the family does not want to meet, the donor coordinator meets with the family, answers any questions, offers handprints and locks of hair, determines any requests following the donor surgery and what follow-up the family wishes to receive.
24. Medical treatment of the donor in OT	Anaesthetist	An anaesthetist transfers the patient from ICU to OT and continues medical treatment until aortic cross clamp. ODNZ recommends the use of both neuromuscular blockade and measures to control sympathetic cardiovascular responses during donor surgery. See section 4.7. of ODNZ Best Practice Guidelines for NZ ICUs.
25. Time out in OT	Donor surgeon	The donor coordinator ensures that a Time Out occurs.This includes introduction of all staff and checking of documentation. The Authority for Organ and Tissue Removal Form replaces the usual operation consent form.
26. Care of the deceased patient	Donor coordinator, OT nurses(s), ICU nurse	Following the donor surgery, care of the deceased patient takes place in OT or ICU depending on hospital procedures. In some hospitals the OT is blessed after the donor surgery. The ICU nurse ensures that a suitable room is made available for the family if they wish to spend time with their family member after the donor surgery. In some hospitals, where the coroner has accepted jurisdiction over the death, the police transfer the deceased patient to the mortuary.