From hesitation to appreciation: the transformation of a single, local donation-nurse project into an established organ-donation service.

This study evaluates the transition from a local project to promote organ donation to a permanent county-based donation service inspired by the Spanish model. To address the problem of declining donation rates, a project with one donation-specialized nurse (DOSS) was initiated at a single neuro-intensive care unit. This project was later expanded into a permanent on-call service consisting of seven DOSSes, covering a large urban county. During the different periods (before, during project and during permanent service), the DOSS function's effect on donation rates was significant, and the number of eligible donors that became actual donors increased from 37% to 73% and 74%, respectively. The effect on family vetoes was as prominent with a decrease from 34% to 8% and 14%. The staff appreciation of the DOSS function was also evident during the periods; all areas included in the questionnaire (family care, donor care and staff support) have improved greatly owing to the DOSS. The transition from a single, local donation-nurse project, to an on-call service with several DOSSes covering a large urban county was a success considering the donation rates as well as the staff's appreciation. Hence, organizational models from abroad can be adjusted and successfully adopted.

Obstacles to organ donation in Swedish intensive care units.

OBJECTIVE: To identify obstacles to organ donation in Swedish intensive care units. DESIGN: A survey exploring attitudes and experiences of organ donation activities was sent to half of all anaesthetists and all neurosurgeons in Sweden (n=644). Total response rate was 67%; 69% from the anaesthetists and 54% from the neurosurgeons. RESULTS: Neurosurgeons had more experiences of caring for potential donors and requesting donation than anaesthetists. Twenty-seven percent of the anaesthetists were not confident with clinical neurological criteria for brain incarceration. Nine per cent found donation activities solely burdensome, and 14% wanted an external team to take over the donation request. A quarter regarded the request definitely as an extra load on the family, and more than half of the respondents had refrained from asking in emotionally strained situations. Forty-nine per cent had a neutral approach to relatives when requesting donation while 38% had a pro-donation approach. Thirty-six per cent terminated ventilator treatment for a potential donor without waiting for total brain infarction. Lack of resources in the ICUs resulted in not identifying a possible donor according to 29% of respondents. Knowing the prior wish of the deceased was regarded as the single most important factor that facilitated the work with organ donation for the intensivists. CONCLUSIONS: The identified obstacles (neutral approach of donation request, ethical problems concerning the potential donor and the relatives, varying competence in diagnosing total brain infarction, and lack of intensive care bed resources) require tailored efforts in order to increase organ donation. Checking these factors can be used as a quality control when analysing donation activities at hospitals.

[Non-therapeutic ventilation of potential donor is ethically acceptable. It allows time to consider for both the family and the personnel]. / Etiskt acceptabelt med icke-terapeutisk ventilation av môjlig organdonator. Ger såvål närstående som sjukvårdspersonal rådrum.

In the debate on organ donation it has been argued that all medical care of patients in intensive care units should be undertaken solely for the good of the patient and that it is wrong to initiate non-therapeutic ventilation in order that such a patient may later become an organ donor. We argue against this view. We think the ethically relevant instant is not the time of death but the point where the physicians deem it pointless to undertake curative measures. We envisage two cases for such non-therapeutic ventilation. One is when a patient is deemed to be in a terminal state (for example after having suffered significant intra-cranial bleeding), and there are no curative measures to be taken. In this case the patient is unconscious and the decision for ventilator treatment must be taken with short notice. Here we recommend that such patients are put on ventilators and the relatives are consulted afterwards. The other case is when a patient, already ventilated, is in a terminal state, unconscious, and the physicians deem that curative measures no longer can be taken. In this case we recommend that ventilation be continued. In both cases, such a policy might provide more organs for transplantation. It could benefit many and it will hurt no one.

[Obstacles for recruiting organ donors in intensive care units can be overcomed. Identified obstacles are attitudes, ethics, resources and competence, as shown by an inquiry]. / Hindren för organdonation i intensivvården kan överbryggas.

The aim of this study was to identify obstacles for recruiting organ donors in the ICU. All specialists in neurosurgery and half of the specialists in anaesthesiology in Sweden were surveyed. Response rate was 67%. The following obstacles were identified: A neutral approach of the physicians when requesting organ donation of the families instead of a pro-donation approach; ethical problems concerning non-therapeutic ventilation and requesting donation of grieving families; varying competence in diagnosing brain infarction; lack of resources at the ICU. Suggestions for organizational and educational improvements are given.

Salvage of an acutely ruptured thoracic aortic aneurysm during CPR.

PURPOSE: To report the successful endovascular treatment of a ruptured thoracic aortic aneurysm during cardiopulmonary resuscitation. CASE REPORT: A 72-year-old woman with a type B aortic dissection treated conservatively for 8 years was referred for rupture of a 16-cm aneurysm of the descending thoracic aorta. During transfer to the operating room, the patient suffered cardiac arrest; cardiopulmonary resuscitation (CPR) was initiated. A few minutes later during CPR, the surgical procedure began with a cutdown of the right femoral artery and insertion of a guidewire and an aortic occlusion balloon, which was inflated at the origin of the left subclavian artery (LSA). Blood pressure was immediately measurable. By only partially deflating the occluding balloon, a thoracic stent-graft was advanced above it and deployed at the origin of the LSA while rapidly deflating and retracting the occluding balloon. Three stent-grafts were required to cover 27 cm of the descending aorta. The patient was partly ventilator dependent for 3 months due to a massive pleural hematoma that was not evacuated. At the 10-month follow-up, the patient is fully recovered without any sign of respiratory dysfunction or any other sequela. CT scans reveal that the massive hematoma is almost completely resolved. CONCLUSIONS: This case illustrates that optimal collaboration between anesthesiologists, interventional radiologists, and vascular surgeons with appropriate resources can significantly expand the possibilities of emergent treatment in the face of aortic rupture.