Intensive Care to Facilitate Organ Donation: Can We Emulate the Spanish Experience?

Spain has achieved the highest deceased organ donation activity globally for the last 32 consecutive years with a rate of 48.9 donors per million people in 2023.1 One in every four donors in the European Union and 5% of all donors globally originate in Spain2: an impressive, noteworthy statistic for a population of just 48 million. This continuous improvement has not happened by serendipity. It more likely represents the close collaboration between the Organización Nacional de Trasplantes’ leadership, legislators, and healthcare professional groups, as well as ongoing public solidarity. In the past decade, Spain has successfully implemented controlled donation after circulatory death (cDCD) and intensive care to facilitate organ donation (ICOD) programs, both of which have been suggested as means of substantially increasing the deceased donor pool.3 This has proven to be the case in Spain, where ICOD accounted for 28.8% of deceased donation activity in 2021.4 Many would wish to learn from the Spanish experience and potentially consider implementing ICOD within their own jurisdiction. ICOD is currently defined as the initiation or continuation of intensive care measures to allow incorporation of organ donation into a patient’s end-of-life care plan, when active treatment is deemed futile by the multidisciplinary team.5 ICOD is not a donation pathway, but a process to increase the number of patients entering donation after brain death (DBD) and cDCD pathways. This definition may, however, underplay the challenges involved in implementing an ICOD program. The continuation of intensive care measures to facilitate donation is an essential feature of all deceased organ donation pathways, except for organ donation following euthanasia. It allows time for communicating with the family, ascertaining consent, assessing suitability for donation, organ offering and acceptance, organ allocation, and the retrieval process. ICOD was originally introduced to allow time for progression to brain death followed by DBD. This is now less relevant, as cDCD is possible when brain death does not ensue. On the other hand, the initiation of intensive care measures raises legal, professional, and ethical questions. These include communication and transparency with the family, the legality, and ethics of commencing invasive and potentially distressing interventions for the benefit of others rather than for the patient, and the use of scarce intensive care resources at the end of life. As a result, ICOD is practiced in few countries, and the debate for and against it remains unresolved in the intensive care community.5,6 Spain has addressed these issues by introducing national multidisciplinary recommendations to support the practice,7 an approach similar to that adopted by other countries when implementing cDCD pathways. This has achieved professional and seemingly public acceptance for ICOD. Communication with the family is a crucial step in the ICOD process. In this issue of the journal, García-Sánchez et al.8 present the practices of Spanish transplant coordinators when requesting consent from families for ICOD. They describe the sequential steps taken by transplant coordinators before requesting the family to make a decision regarding ICOD implementation. Most of the steps are also considered as best practice in other donation conversations, and their approach is associated with only 3.8% to 8.2% of families refusing ICOD.4 The authors stress that their approach was developed within the Spanish legal and cultural framework, and that others should take account of the legal and cultural frameworks in which they practice. This is sound advice. For example, one recommendation is that patients, whose donation wishes are not known and whose family are not available to ascertain consent, should be intubated and ventilated to maintain donation potential should they become unstable. This may be accepted in other jurisdictions but may cause legal, professional, and ethical difficulties in some jurisdictions, as it can be perceived as prioritizing utilitarianism over patient autonomy. Equally, while the involvement of trained donation staff in the family approach is associated with a higher consent rate,9 some may prefer the approach for ICOD to be led by the treating medical team to avoid any perceptions of conflict of interest or coercion. Can other countries emulate the success of Spain in substantially increasing deceased donor numbers through ICOD? The continuation of intensive care measures to facilitate donation should be achievable in many countries particularly those with both DBD and cDCD programs. Some countries like the United Kingdom, the United States, and Canada have introduced devastating brain injury (DBI) pathways to avoid the early withdrawal of treatment when this is being considered in intubated patients soon after hospital admission.10 The aim is primarily to avoid the pitfalls of early prognostication in these patients. Secondary benefits are improving end-of-life care and communication with families, and increasing the opportunities for organ donation. Whereas ICOD only admits patients who are considered suitable for organ donation and whose families have already consented to donation, DBI pathways admit all patients with DBI without seeking family consent and irrespective of donation potential (Figure 1). DBI pathways, therefore, cannot match ICOD in terms of donor numbers. Also, DBI pathways do not capture the 34.5% of all ICOD patients who require the initiation of intensive care interventions to maintain donation potential.8 In this situation, each jurisdiction should follow the Spanish lead and develop their own multidisciplinary consensus guidelines. ICOD is defined by the objectives of the process and not by the interventions used to achieve them.5 The Spanish ICOD recommendations may be used by others as a template but as suggested by Garcia-Sanchez et al., jurisdictions should develop guidelines that respect their own local legal, cultural, and professional frameworks. Perhaps in the future guidance will be simply limited to the initiation of intensive care measures to facilitate organ donation, or separated from the guidance regarding the continuation of these measures. When it comes to ICOD, it is unlikely that one size will ever fit all.FIGURE 1.: Possible routes to organ donation for patients admitted with devastating brain injury. Note the much earlier family approach for consent to donation in the ICOD process. ICOD, intensive care to facilitate organ donation; ICU, intensive care unit; WLST, withdrawal of life sustaining treatments.

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