Guidelines

1. Organ & Tissue Donation in Australia Guidelines

2. Ethical and professional standards • Clinicians are guided by detailed ethical and professional standards and guidelines some of which include: • National Health and Medical Research Council (NHMRC) Guidelines, Organ and Tissue Donation After Death, for Transplantation: Guidelines for Ethical Practice for Health Professionals (2007) • Australian and New Zealand Intensive Care Society, Statement on Death and Organ Donation (1998 – currently under review) • The Transplantation Society of Australia and New Zealand Organ Allocation Protocols (2002, updated 2004) • Australasian Transplant Coordinators Association National Guidelines for Organ and Tissue Donation (2006)

3. Organ & Tissue donation in Australia In 2007 there were: • 198 donors = 9.4 donors per million population [dpmp] • 349 kidneys (342 recipients) • 133 livers (147 recipients) • 62 hearts (including six heart/lungs) • 150 lungs (65 double, six heart/lungs and eight single lungs) • 28 pancreas • 5 pancreas islets transplanted into recipients. • In addition there were: • 125 corneas • 42 heart valves • 11 bone donations from these donors

4. Organ & Tissue donation in Australia The mean age of donors was 43.4 years, median 45.2 years with a range of 0.7 - 80.4 years In 2007, the major cause of death in 53% of donors was (CVA) cerebrovascular accident, while road trauma caused 15% of all donor deaths The donation of more than one organ occurred in 82% of donors. The average number of organs transplanted per donor was 3.3

5. Cause of Donor Deaths in Australia2001 – 2006

6. General Organ Donor Medical Criteria Patients who have suffered irreversible loss of brain function (brain death) but still have an intact cardiovascular system, are potential donors of heart, lungs, liver, pancreas and kidneys Organ donation after brain death can only occur when the patient has died in the intensive care or emergency department setting and is still maintained by mechanical ventilation Organ donation cannot take place until death has been confirmed and authorisation has been obtained

7. General Organ Donor Medical Criteria All potential donors are considered individually but the patient must have: Suffered irreversible loss of brain function – brain death Been maintained on a ventilator with intact circulation No current malignancy except primary brain tumour or minor skin lesions

8. Exclusion Criteria for Organ Donation Human Immunodeficiency Virus (HIV) Current neoplastic disease other than primary brain tumour and non-malignant skin cancers Systemic viral infections/uncontrolled sepsis (eg: measles, rabies, adenovirus, enterovirus, parvovirus and herpes encephalitis)

9. Definition of Death In the States and Territories of Australia, with the exception of Western Australia, the two legal definitions of death are: Irreversible cessation of circulation of blood in the body of a person OR Irreversible cessation of all function of the brain of a person (In Western Australia organs and tissues may be removed for the purposes of transplantation if two medical practitioners certify that irreversible cessation of all function of the brain has occurred.)

10. Certification of Brain Death The confirmation of brain death must be certified by two medical practitioners, each of whom has carried out a clinical examination, to confirm cessation of function and demonstrate irreversibility Each State and Territory has legislation that prescribes the legal requirements necessary for the removal of organs or tissues for transplantation including the required status of the two medical practitioners who are to perform the certification of brain death

11. Clinical Certification of Brain Death Prior to clinical testing all preconditions must be satisfied: Diagnosis of severe brain injury – usually confirmed by neuroimaging Exclusion of coma caused by drugs or poisoning Exclusion of metabolic causes for coma (eg: severe electrolyte or endocrine disturbances) Exclusion of hypothermia- core temp >35˚C Confirmation of intact neuromuscular conduction Minimum of four hours mechanical ventilation and observation of GCS 3, non-reactive pupils, absent cough and gag reflexes and no spontaneous respiratory effort

12. Cerebral Angiogram Carotid siphon Normal Cerebral Bloodflow Absent Cerebral Bloodflow

13. Cerebral Perfusion Scan Normal Cerebral Bloodflow Absent Cerebral Bloodflow

14. Medical Management Of the Potential Donor In response to brain death a cascade of complex physiological changes occur, resulting in haemodynamic instability, which at times can be profound Medical management of the potential donor in the ICU is aimed at maintaining normal physiology and the usual spectrum of monitoring and interventions should be employed Management is designed at optimal organ perfusion

15. Allocation of Organs • Kidneys are allocated by: • Blood group compatibility, tissue typing and cross-matching • National Organ Matching System (NOMS) – computer system, best match • Multiple possible recipients • Allocated after retrieval surgery • No suitable recipient for an organ then the organ is NOT removed • Heart, lungs, liver & pancreas are allocated by: • Blood group compatibility, size match and cross-matching • Allocated to home state recipients first then offered on rotation interstate • Transplant units have 20 mins to respond to offer • Allocated prior to retrieval surgery

16. The Retrieval Surgery Always performed in the operating theatre at the donor hospital by specialist transplant surgeons There is a midline incision from the sternal notch to the pubic bone with a neat, meticulous closure of incision with no disfigurement to the donor Family always given opportunity to view loved one post retrieval surgery There is no delay for the family in making normal funeral arrangements

17. Care of the Donor and Donor Family CARE OF THE DONOR FAMILY STARTS WITH CARE AND RESPECT OF THE DONOR

18. Donor Family Follow Up Initial phone call within 24 hours 7 -10 days: follow up letter of donation outcomes, ‘In reflection’ and ‘Coping with Grief’ booklets sent 6 weeks: Information regarding donor family and recipient correspondence, thanksgiving services, counseling services, reflection rose bush 1 year anniversary card

19. Cost of Donation Over 1,800 Australians are waiting for an organ transplant at any given time. The wait for a transplant can extend to many years and comes at a significant cost to the health system. For example, hospital based kidney dialysis costs an average of $83,000 per person per annum. In contrast, a kidney transplant costs $65,000 per recipient for the first year, and $11,000 a year thereafter. There is no cost to the family for the donation of organs or tissues.

20. The Australian Organ Donor Register The Donor Register ensures that an individuals consent (or objection) to donating organs and/or tissue for transplantation can be verified 24 hours a day, seven days a week by authorised medical personnel, anywhere in Australia. In the event of an individuals death, information about their decision will be accessed from the Donor Register, and provided to their family.

21. The Australian Organ Donor Register Only persons who are aged 18 years or over can register consent (or objection) on the Donor Register. A signature is required to record legal consent (or objection) to organ and/or tissue donation for transplantation. If registration is done online, a form will be mailed to the registered address to obtain a signature.

22. The Australian Organ Donor Register To register: Call 1800 777 203 or Visit your local Medicare Office or Complete the self sealing pamphlet at your GP surgery and send to the pre paid address

23. Further Information State Based Agencies Other websites Australian Organ Donor Register Ph: 1800 777 203 Email: aodr@medicareaustralia.gov.au Website: www.medicareaustralia.gov.au/public/services/aodr Australasian Donor Awareness Programme – ADAPTPh: (02) 9229 4429Website: www.adapt.asn.au Australian Transplant Coordinators Association Email: Info@atca.org.au Website: www.atca.org.au The Australian and New Zealand Intensive Care Society (ANZICS) Ph: (03) 9340 3400 Email: anzics@anzics.com.au Website: www.anzics.com.au Transplantation Society of Australia and New Zealand Ph: (02) 9256 5461 Email: tsanz@racp.edu.au Website: www.tsanz.com.au The Australia and New Zealand Dialysis & Transplant Registry (ANZDATA) Website: www.anzdata.org.au/v1/index.html Kidney Health AustraliaPh: 1800 682 531Email: vic@kidney.org.auWebsite: www.kidney.org.au National Health and Medical Research Council (NHMRC) Website: www.nhmrc.gov.au/publications NSW/ACT : LifeGift NSW/ACTPh: (02) 9229 4003Website: www.organdonor.com.au ACT : ACT Organ and Tissue Donation ServicePh: (02) 6244 3071Email: organ.donation@act.gov.au Vic/Tas : Victorian Organ Donation Service LifeGift – Australian Red Cross Blood ServicePh: 1300 133 050 (number restricted to Vic / Tas callers) Email: lifegift@arcbs.redcross.org.auWebsite: www.organdonor.com.au Queensland : Queenslanders Donate Ph: (07) 3240 2350Email: queenslanders_donate@health.qld.gov.auWebsite: www.health.qld.gov.au/queenslandersdonate South Australia : South Australian Organ Donation AgencyPh: (08) 8207 7117Email: organ.donation@health.sa.gov.auWebsite: http://www.organdonation.sa.gov.au Northern Territory : LifeNet NTPh: (08) 8922 8786 Western Australia : Donate WestPh: (08) 9222 0222Email: donatewest@health.wa.gov.auWebsite: www.donatewest.health.wa.gov.au