1. ISODP20111 Reasons for not formally diagnosing potential donors brain dead: Donor Action ® MRR data from 7 countries Leo Roels 1, Jacqueline Smits 2, Bernard Cohen 1 1 Donor Action Foundation, 2 Eurotransplant International Foundation

2. ISODP2011 2. Background Formal brain death (BD) diagnosis is a crucial step in the process of converting a potential heart-beating donor (HBD) into an actual donor

3. ISODP2011 3. Study aims to investigate reasons for not declaring potential donors - who met all criteria for brain death (BD) diagnosis according to national and international BD criteria - formally brain dead in 7 countries that have implemented the Donor Action ® (DA) methodology* since at least 3 years as a quality assurance tool to optimize their donation rates *Donor Action ® (www.donoraction.org) is an international initiative to alleviate organ shortage. Its DA Program: - identifies how many, where and why potential donors are missed along the donation pathway - highlights staff attitudes, confidence levels and needs re donation related activities, provides corrective measures for identified weaknesses as well as defining roles and responsibilities of health professionals involved in the donation process.

4. Materials & methods Medical Record Review (MRR) data from 59,064 patients who died between January 2007 and June 2010 in 620 critical care units in 228 hospitals in Belgium, Croatia, Finland, France, Israel, Poland & Switzerland ‘potential HB donor’: any ventilated patient ≤75 years without contra- indications to donation and meeting criteria for brain death (BD) diagnosis (8.8% of all cases) MRR data entered into DA System Database for analysis ISODP2011 4.

5. ISODP2011 5. Results (1) % potential donors diagnosed brain dead 34% NOT diagnosed on a total of 5,195 patients who met all criteria for formal BD diagnosis (=potential donors), only 3,708 cases were formally diagnosed BD (= 66% of potential ) highest: Israel (90.7%) lowest: Poland (38.4%) P<.0001

6. cardiac arrest, failed resuscitation ISODP2011 6. Reasons for not diagnosing BD non-identification average: 22.5%average: 25.8%

7. treatment de-escalationbecoming medically unsuitable ISODP2011 7. Reasons for not diagnosing BD average: 10,6%average: 11.8%

8. objections to donate (family approach, registry) ISODP2011 8. Reasons for not diagnosing BD average: 15,6% family approach before BD diagnosis: good practice? non-donor registrations (BE, FR, PL): BD diagnosis futile

9. consent to donate (family approach, registry) ISODP2011 9. Consent to donate after BD diagnosis average: 73% Opting-out legislation: -Belgium -Croatia -Finland -France -Poland Opting-in legislation: -Israel -Switzerland P<.0001

10. Average conversion rates ISODP2011 10. Average conversion rates of potential into actual donors, vs. not BD diagnosed potential and other donor losses, per country 41.7% 33.9% 24.4%

11. ISODP2011 11. Conclusions Markedly different BD diagnosis practices demonstrate a significant room for improvement in donation processes in the 7 countries surveyed. On average, nearly 34% of deceased potential donors meeting all criteria for BD diagnosed were missed along the donation pathway, due to: –non-identification –cardiac arrest, failed resuscitation –treatment de-escalation, withdrawal –objections to donate DA’s Medical Record Review methodology enables individual hospitals, regions and countries to assess their conversion rates of potential into actual donors and compare their donation performances with other area’s.

12. ISODP201112