Prácticas clínicas al final de la vida en pacientes con daño cerebral catastrófico en España: implicaciones para la donación de órganos / End-of-life practices in patients with devastating brain injury in Spain: implications for organ donation

OBJETIVO: Describir las prácticas clínicas al final de la vida relevantes para la donación de órganos en pacientes con daño cerebral catastrófico en España. DISEÑO: Estudio multicéntrico prospectivo de una cohorte retrospectiva. Periodo: 1 de noviembre de 2014 al 30 de abril de 2015. Ámbito: Sesenta y ocho hospitales autorizados para donación. PACIENTES: Pacientes fallecidos por daño cerebral catastrófico (posibles donantes). Edad: 1 mes-85 años. Variables de interés principales: Cuidado recibido, donación en muerte encefálica, donación en asistolia controlada, intubación/ventilación, notificación al coordinador de trasplantes. RESULTADOS: Se identificaron 1.970 posibles donantes. La mitad recibió tratamiento activo en una Unidad de Críticos (UC) hasta evolucionar a muerte encefálica (27%), sufrir una parada cardiorrespiratoria (5%), o hasta la limitación de tratamiento de soporte vital (19%). Del resto, un 10% ingresó en una UC para facilitar la donación y el 39% nunca ingresó en una UC. De los pacientes que evolucionaron a muerte encefálica (n=695), la mayoría derivaron en una donación eficaz (n=446; 64%). De los pacientes fallecidos tras limitación de tratamiento de soporte vital (n=537), 45 (8%) se convirtieron en donantes en asistolia eficaces. La ausencia de un programa de donación en asistolia controlada fue el motivo más frecuente de no donación. El 37% de los posibles donantes falleció sin intubar/ventilar, fundamentalmente porque el profesional responsable no consideró la donación tras descartar intubación terapéutica. El 36% de los posibles donantes no fue notificado al coordinador de trasplantes. CONCLUSIONES: Aunque el proceso de donación está optimizado en España, existen oportunidades para la mejora en la detección de posibles donantes fuera de UC y en la consideración de la donación en asistolia controlada en pacientes fallecidos tras limitación de tratamiento de soporte vital

OBJECTIVE: To describe end-of-life care practices relevant to organ donation in patients with devastating brain injury in Spain. DESIGN: A multicenter prospective study of a retrospective cohort. Period: 1 November 2014 to 30 April 2015. SETTING: Sixty-eight hospitals authorized for organ procurement. PATIENTS: Patients dying from devastating brain injury (possible donors). Age: 1 month-85 years. Primary endpoints: Type of care, donation after brain death, donation after circulatory death, intubation/ventilation, referral to the donor coordinator. RESULTS: A total of 1,970 possible donors were identified, of which half received active treatment in an Intensive Care Unit (ICU) until brain death (27%), cardiac arrest (5%) or the withdrawal of life-sustaining therapy (19%). Of the rest, 10% were admitted to the ICU to facilitate organ donation, while 39% were not admitted to the ICU. Of those patients who evolved to a brain death condition (n=695), most transitioned to actual donation (n=446; 64%). Of those who died following the withdrawal of life-sustaining therapy (n=537), 45 (8%) were converted into actual donation after circulatory death donors. The lack of a dedicated donation after circulatory death program was the main reason for non-donation. Thirty-seven percent of the possible donors were not intubated/ventilated at death, mainly because the professional in charge did not consider donation alter discarding therapeutic intubation. Thirty-six percent of the possible donors were never referred to the donor coordinator. CONCLUSIONS: Although deceased donation is optimized in Spain, there are still opportunities for improvement in the identification of possible donors outside the ICU and in the consideration of donation after circulatory death in patients who die following the withdrawal of life-sustaining therapy

End-of-life practices in patients with devastating brain injury in Spain: implications for organ donation. / Prácticas clínicas al final de la vida en pacientes con daño cerebral catastrófico en España: implicaciones para la donación de órganos.

OBJECTIVE: To describe end-of-life care practices relevant to organ donation in patients with devastating brain injury in Spain. DESIGN: A multicenter prospective study of a retrospective cohort. PERIOD: 1 November 2014 to 30 April 2015. SETTING: Sixty-eight hospitals authorized for organ procurement. PATIENTS: Patients dying from devastating brain injury (possible donors). Age: 1 month-85 years. PRIMARY ENDPOINTS: Type of care, donation after brain death, donation after circulatory death, intubation/ventilation, referral to the donor coordinator. RESULTS: A total of 1,970 possible donors were identified, of which half received active treatment in an Intensive Care Unit (ICU) until brain death (27%), cardiac arrest (5%) or the withdrawal of life-sustaining therapy (19%). Of the rest, 10% were admitted to the ICU to facilitate organ donation, while 39% were not admitted to the ICU. Of those patients who evolved to a brain death condition (n=695), most transitioned to actual donation (n=446; 64%). Of those who died following the withdrawal of life-sustaining therapy (n=537), 45 (8%) were converted into actual donation after circulatory death donors. The lack of a dedicated donation after circulatory death program was the main reason for non-donation. Thirty-seven percent of the possible donors were not intubated/ventilated at death, mainly because the professional in charge did not consider donation alter discarding therapeutic intubation. Thirty-six percent of the possible donors were never referred to the donor coordinator. CONCLUSIONS: Although deceased donation is optimized in Spain, there are still opportunities for improvement in the identification of possible donors outside the ICU and in the consideration of donation after circulatory death in patients who die following the withdrawal of life-sustaining therapy.