Many potential donor organs are currently lost because of misunderstanding of the law. John Coggon and colleagues clarify what is permissible in non-heart-beating donation

Organ transplantation saves and transforms lives. Failure to secure consent for organ retrieval is widely regarded as the single most important obstacle to transplantation. A soft opt-out system of consent for deceased organ donation was introduced into Wales in December 2015, whilst England maintained the existing opt-in system. Cumulative data on consent rates in Wales were compared with those in England, using a two-sided sequential procedure that was powered to detect an absolute difference in consent rates between England and Wales of 10%. Supplementary risk-adjusted logistic regression analysis examined whether any difference in consent rates between the two nations could be attributed to variations in factors known to influence UK consent rates. Between 1 January 2016 and 31 December 2018, 8192 families of eligible donors in England and 474 in Wales were approached regarding organ donation, with overall consent rates of 65% and 68%, respectively. There was a steady upward trend in the proportion of families consenting to donation after brain death in Wales as compared with England and after 33 months, this reached statistical significance. No evidence of any change in the donation after circulatory death consent rate was observed. Risk-adjusted logistic regression analysis revealed that by the end of the study period the probability of consent to organ donation in Wales was higher than in England (OR [95%CI] 2.1 [1.26-3.41]). The introduction of a soft opt-out system of consent in Wales significantly increased organ donation consent though the impact was not immediate.

Purpose of review The recently developed donation after circulatory death (DCD) heart transplant technique, pioneered by Papworth Hospital in the UK, involves the use of extracorporeal perfusion technologies to restart the donor heart in situ and thereby restore the donor's own circulation, after first isolating the donor's cerebral circulation. By restoring the circulation in the deceased donor, even if the cerebral circulation is excluded, the Papworth technique challenges the acceptability of death determination in DCD. Recent findings This study uses as its exemplar case the Papworth DCD heart technique to review and make wider comment about death determination in DCD. We seek to answer three challenges to ethical propriety raised by the Papworth technique: death determination using the permanence standard (common to all DCD practice); restoration of heart contractility and circulation in the body; and active prevention of the restoration of brain circulation by use of a cross-clamp to isolate the cerebral circulation. Summary The Papworth technique for heart DCD does not compromise the permanence standard for declaring death and therefore respects the dead donor rule in the UK, but perhaps elsewhere the law would need to change to refer to the cessation of circulation in the brain.

In 2010, a publication reviewing the contemporary state of paediatric organ donation in the UK was published in this journal.1 At the time, there was little antecedent data or practical consideration of this in the literature or indeed from national bodies tasked with improving and saving lives through organ donation and transplantation. In the intervening period, much of the infrastructure to facilitate organ donation has been addressed as part of national drives. Significant and specific child health-targeted actions such as guidance on the diagnosis of death using neurological criteria in neonates created the potential for donation after brain death (DBD).2 Additionally, publications from the now disbanded UK Donation Ethics Committee (UKDEC) on donation from children3 4 and guidance from the National Institute for Health and Care Excellence (NICE) determined organ donation to be part of or included in routine end of life care at all ages.5 The Royal College of Paediatrics and Child Health (RCPCH) has also included organ donation considerations prominently in its latest ethical and legal framework ‘Decisions to Limit Therapy’.6 However, the overall increase in donation rates seen across the general population over this period has not been replicated in children, with rates remaining static (figure 1). Figure 1 Deceased paediatric donors, transplants and active transplant list in the UK. More recently, National Health Service Blood and Transplant (NHSBT) has commissioned a paediatric subcommittee of the National Organ Donation Committee, and donation after circulatory definition of death (DCD) from babies has now occurred in several neonatal and paediatric units, including from a number of babies affected by anencephaly. This paper reviews national data on organ donation from children in the UK, paediatric unit-specific performance variations and the impact of these various interventions on organ donation from children and identifies areas for future improvement. …

Between 1 April 2012 and 31 March 2015, 263 of the 2244 families in the UK whose loved ones had registered to donate organs for transplantation after their death on the NHS Organ Donor Register chose to override this decision; an override rate of 11.7%. Multivariable logistic regression analysis was applied to data relating to various aspects of the family approach in order to identify factors associated with such overrides. The factors associated with family overrides were failure to involve the Specialist Nurse for Organ Donation in the family approach (odds ratio 3.0), donation after circulatory death (odds ratio 2.7) and Black, Asian or Minority Ethnicity (odds ratio 2.7). This highlights the need to further engage with these groups in exploring donation as an end of life choice, and suggests that there may be, from the perspective of the family, fundamental differences between donation after brainstem death and circulatory death. It further adds to the body of data linking involvement of the Specialist Nurse for Organ Donation in the family approach to improved UK consent rates.

Donation after circulatory death (DCD) donors are becoming an increasingly important population of organ donors in Europe and worldwide. We report the state of the art regarding controlled DCD donation describing the organizational and technical aspects of establishing a controlled DCD programme and provide recommendations regarding the introduction and development of this type of programme.

The refusal rate for organ donation in the UK is 42%, among the highest in Europe. We extracted data on every family approach for donation in UK ICUs or Emergency Departments between 1st April 2012 and 30th September 2013, and performed multiple logistic regression to identify modifiable factors associated with consent. Complete data were available for 4703 of 4899 approaches during the study period. Consent for donation after brain death was 68.9%, and for donation after circulatory death 56.5% (p < 0.0001). Patient ethnicity, knowledge of a patient's wishes and involvement of a specialist nurse in organ donation in the approach were strongly associated with consent (p < 0.0001). The impact of the specialist nurse was stronger for donation after circulatory death than for donation after brain death, even after accounting for the impact of prior knowledge of patients' wishes. Involvement of the specialist nurse in the approach, encouraging family discussions about donation wishes and promotion of the organ donor register are key strategies to increase UK consent rates, and are supported by this study.

We read with interest the article titled ‘First neonatal organ donation in the UK’ by Atreja and Godambe1 received widespread media coverage in the UK recently. The team should be commended for this milestone achievement. The surgical teams should also be congratulated for embracing the immense challenge of retrieving and transplanting kidneys from such a small donor, a feat which only handful of centres in the UK would undertake due to anxieties that we have previously described.2 ,3 Organ donation from very young donors is a rare occurrence in the UK, which is a testament to our outstanding neonatal and paediatric care but may also reflect overall lower donation rates compared with …

Some of the seminal steps toward the recognition and definition of brain death were European. There is a general consensus on both the medical concept of brain death in Europe as well as the minimum fundamental clinical standards that are required for its diagnosis-the absence of consciousness, brainstem reflexes, and the ability to breathe in the absence of reversible or confounding conditions. Two aspects of brain death determination are addressed in this article. The authors analyze how brain death is diagnosed across Europe, identifying both the similarities and differences that exist between countries (the latter mainly concerning ancillary tests, timing, and the number of physicians involved in the brain death determination). In addition, they describe the very considerable variations in when brain death determinations are made between and within individual European countries, and propose that they are due to differences in the end-of-life care practices in patients with irreversible brain injuries, medical attitudes, and organ donation practices. Although legislation is available to standardize the brain death diagnosis process in most individual European countries, there are still disparities across Europe as a whole. The current variation in practice makes a continental consensus for the definition of brain death imperative.

The number of adult heart transplants in the UK has fallen by more than 50% over the last 15 years, what may be a result of inadequate donor assessment and/or poor donor organ function. Previous studies have demonstrated that early aggressive donor management could lead to increased utilisation of some donor hearts. A UK pilot programme was initialised on 1 April 2013 which involves sending a member of the cardiothoracic retrieval team, the ‘scout’, to the donor intensive care unit as soon as consent for organ donation is obtained.

Background The UK has implemented a national strategy for organ donation that includes a centrally coordinated network of specialist nurses in organ donation embedded in all intensive care units and a national organ retrieval service for deceased organ donors. We aimed to determine whether despite the national approach to donation there is significant regional variation in deceased donor kidney donation rates. Methods The UK prospective audit of deaths in critical care was analysed for a cohort of patients who died in critical care between April 2010 and December 2011. Multivariate logistic regression was used to identify the factors associated with kidney donation. The logistic regression model was then used to produce risk-adjusted funnel plots describing the regional variation in donation rates. Results Of the 27 482 patients who died in a critical care setting, 1528 (5.5%) became kidney donors. Factors found to influence donation rates significantly were: type of critical care [e.g. neurointensive vs general intensive care: OR 1.53, 95% confidence interval (CI) 1.34–1.75, P<0.0001], patient ethnicity (e.g. ‘Asian’ vs ‘white’: OR 0.17, 95% CI 0.11–0.26, P<0.0001), age (e.g. age >69 vs age 18–39 yr: OR 0.2, 0.15–0.25, P<0.0001), and cause of death [e.g. ‘other’ (excluding ‘stroke’ and ‘trauma’) vs ‘trauma’: OR 0.04, 95% CI 0.03–0.05, P<0.0001]. Despite correction for these variables, kidney donation rates for the 20 UK kidney donor regions showed marked variation. The overall standardized donation rate ranged from 3.2 to 7.5%. Four regions had donation rates of >2 standard deviations (sd) from the mean (two below and two above). Regional variation was most marked for donation after circulatory death (DCD) kidney donors with 9 of the 20 regions demonstrating donation rates of >2 sd from the mean (5 below and 4 above). Conclusions The marked regional variation in kidney donation rates observed in this cohort after adjustment for factors strongly associated with donation rates suggests that there is considerable scope for further increasing kidney donation rates in the UK, particularly DCD.

Affiliated to the Association of Surgeons in Training and the British Transplantation Society, the Carrel Club is the transplant trainee surgical society. The Carrel Club held a joint meeting with the Chapter of Transplant Surgeons, a subsidiary organisation of the British Transplantation Society, at the Manchester Hilton Hotel on 31 January and 1 February 2013. As part of the meeting, ten abstracts were presented. A selection is printed below. The winner of the Best Presentation award was Mr Mownah.

BioethicsVolume 27, Issue 7 p. 409-409 LETTER TO THE EDITORS A Brief Response to Religious and Secular Death: A Parting of the Ways Dale Gardiner, Dale GardinerSearch for more papers by this authorPaul Murphy, Paul MurphySearch for more papers by this authorAlex Manara, Alex ManaraSearch for more papers by this authorNoam Stadlan, Noam StadlanSearch for more papers by this authorPaul Shore, Paul ShoreSearch for more papers by this authorAsim Shah, Asim ShahSearch for more papers by this author Dale Gardiner, Dale GardinerSearch for more papers by this authorPaul Murphy, Paul MurphySearch for more papers by this authorAlex Manara, Alex ManaraSearch for more papers by this authorNoam Stadlan, Noam StadlanSearch for more papers by this authorPaul Shore, Paul ShoreSearch for more papers by this authorAsim Shah, Asim ShahSearch for more papers by this author First published: 01 July 2013 https://doi.org/10.1111/bioe.12024 Address for correspondence: Dr Dale Gardiner, Intensive Care Medicine, Nottingham, United Kingdom. Email: [email protected] Conflict of interest statement: No conflicts declared Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume27, Issue7September 2013Pages 409-409 RelatedInformation