While it is common to believe that it is primarily intra-cerebral catastrophes that lead to patients being candidates for organ donation, in this study we found that the patients who later entered into organ donation processes presented themselves prehospitally with many different diagnoses. Thus, 30% of patients who later became organ donors were diagnosed prehospitally with diagnoses other than intracranial haemorrhage, traumatic brain injury, or stroke.
In Denmark, the increased levels of treatment offered prehospitally may be likened to what happens in the initial phase at the emergency department or the intensive care unit. The treatment may thus include tracheal intubation and mechanical ventilation, inotropic support, medical treatment of elevated intracranial pressure, antibiotic therapy, or other supportive measures . The level of treatment offered may be influenced by the perceived prognosis of the patient and the decision to treat the patient or refrain from treatment prehospitally lies solely at the discretion of the attending prehospital physician. In Denmark, it is fully accepted that the physician may terminate or refrain from treatment in cases considered futile already in the prehospital phase. This decision, however, is not only based on medical factors, such as age, comorbidity, or clinical findings. The decision to treat a patient or not has also been shown to depend on many other factors, including non-medical, or intangible factors .
The decision to refrain from treatment or withhold treatment may appear ethically sound on the individual level. The possibility that the prehospital physician may terminate the treatment prehospitally implies, however, that the prehospital physician in effect can be considered a gatekeeper for organ donation. A patient in which the treatment may well be considered futile could nonetheless later be considered eligible to enter into an organ donation process.
Previous Danish literature has discussed the potential for increasing the donor pool by increasing the level of the treatment . Considering patients with lethal brain lesions only, one study reported that there is a huge, unrecognised in-hospital donor potential. One of the major points in that particular study was that in patients with lethal brain lesions, withholding tracheal intubation, artificial ventilation, and admission to an intensive care unit will lead to many patients dying without having been considered for the possibility of inclusion in a donation process . The provision of artificial ventilation and admission to an intensive care unit for these patients would undoubtedly increase the number of potential organ donors. This change of focus from the care of a potentially salvageable patient to the care of a patient whose recovery is unlikely with the aim of caring for another patient may, however, be ethically challenging .
It has, however, been underscored that actions necessary to facilitate donation in patients who have reached end-of-life care are justified when organ donation is recognised to be consistent with the wishes and interests of a dying patient . These decision processes are not restricted to the intensive care units as potential organ donors may also be identified in the emergency departments. Up to 51% of the time, the decision to initiate end-of-life care starts in the emergency department .
Prehospital presentation of patients that later became organ donors
In our study, the prehospital diagnoses of patients that later underwent organ donation were not restricted to brain injury. Twenty-two patients, who later underwent organ donation, had out-of-hospital cardiac arrest (OHCA). This is a significant finding since patients with cardiac arrest prehospitally otherwise might not routinely be recognised as potential donors. Our findings are in line with other studies that suggest that there is an unrecognised donor potential in out-of-hospital cardiac arrests [15,16,17,18,19,20,21]. We concur with these suggestions. In The Region of Southern Denmark, during our study period of five years, approximately 5000 patients suffered from OHCA . In patients without reliable signs of death, prehospital withholding of therapy in OHCA has previously been reported in up to 50% of patients. Of the other 50% who received cardiopulmonary resuscitation, 52% of patients had their treatment terminated at the scene . The termination of treatment in almost 25% of all patients with OHCA without reliable signs of death may point towards a conflict between the ethics surrounding the individual patient and the potential for procuring more organ donors. Although it is unlikely that all of these patients that did not attain a return of spontaneous circulation could have been eligible as organ donors, it seems unlikely that only 22 patients fulfilled the criteria for organ donation. Furthermore, among these 22 patients with OHCA who later became organ donors, seven patients had intracranial haemorrhage which is usually associated with a potential for organ donation. We thus believe that patients with OHCA do represent a potential for increasing the donor pool and it is possible that a higher level of treatment offered to these patients could indeed increase this donor pool. This has been specifically addressed in other countries. A Dutch study investigated the decision-making related to the resuscitation of patients with OHCA. This study found that besides specific medically patient-oriented information (electrocardiographic findings, trauma mechanism), potential organ donation was one of eight themes that influenced the decision-making regarding the level of treatment of prehospital cardiac arrest .
In our study, forty-nine patients with a prehospital diagnosis of stroke and 21 patients with SAH became organ donors in the five years. One-third of the patients with stroke and two-thirds of the patients with SAH were intubated at the scene. This left one-third of the patients with SAH unintubated prehospitally. Given the potentially rapid descent in the level of consciousness often seen in patients with SAH, one could speculate if the threshold for intubation and ventilation of these patients should be reconsidered.
In our material, 15 patients were assigned various diagnoses not intuitively associated with the potential for organ donation. This probably reflects the limited diagnostic modalities available prehospitally.
Strengths of the study
One major strength of the study was that because of the unique Danish Civil Registry , which includes all Danish citizens, all patients who underwent organ donation in the Region of Southern Denmark in our study period from 1st of January 2016 to 31st of December 2020 who received emergency prehospital care were screened for inclusion in our study.
Another strength is that all the prehospital medical journals were manually scrutinized and data was manually extracted. This opens up the possibility that any inaccuracies in the medical records could be corrected and clarified.
A major limitation in this study was that the information in the prehospital medical records to some extent was sparse. This may be caused by the very nature of the medical records, where entries in the medical records in effect are supposed to be entered into the record system during treatment or in conjunction with the transfer of the patients to the emergency departments. Most of the patients were, indeed, seriously ill, and the focus from the prehospital physician may in some instances have been primarily on the medical treatment of the patients, not the documentation.
Another limitation in this study is the external validity. The study is also only a single-region study including only patients from the Region of Southern Denmark. Although the emergency medical system in the five Danish health regions principle does not deviate from one another, the density of anaesthesiologist-manned ground-based rapid response units differs somewhat and our results might not reflect the patterns found in the other four health Regions of Denmark to the letter.