Recent Initiatives and Activities
Death Determination in Intensive Care Practices (DDePICt) www.ddepict.com
Sonny Dhanani, Laura Hornby, Roxanne Ward, Sam Shemie, Loeb Research Consortium & Canadian Critical Care Trials Group.
As a result of persistent shortages in organs for transplantation, the practice of donation after cardiac death (DCD) has been given reconsideration and wide endorsement. In Canada, DCD remains uncommon, as the criteria used to establish irreversibility of cardiocirculatory function are controversial and not evidence based. Some in the medical community have questioned whether those who become organ donors after cardiac arrest are really dead. There has been no rigorous attempt to resolve the uncertainty of how long one should wait to determine death following a cardiac arrest to ensure irreversibility and yet be able to maintain organ viability.
- To describe the current understanding and practice of the determination of death after cardiac arrest.
- To describe the current understanding of the resuscitation limits of the heart and brain
- To evaluate the determinants of death after cardiac arrest using non-invasive and invasive monitoring technology.
- To develop and implement standards for the determination of cardiac death for DCD in Canada
Implications of this Study
A larger study will be used in the establishment of clearly defined Canadian practice guidelines regarding the detemination of death after cardiac arrest. The impact of this information and the data collected will have significant impact on the future of donation after cardiac death ( DCD) which in turn will increase the rates of organ donation .
ii. “Survey of Determination of Death after Cardiac Arrest by Intensive Care Physicians” Sonny Dhanani, MD FRCPC 1,4, Roxanne Ward RN, BA (Psy) , Laura Hornby, MSc , Nicholas J. Barrowman, PhD , Karen Hornby, BScN, MSc, PhD(c) , Sam D. Shemie, MD. Submitted for publication March 2011 to Critical Care Medicine Journal- in revision. (CCMED-D-11-00631)
iii. “A systematic review of autoresuscitation after cardiac arrest.” Hornby K, Hornby L,Shemie SD.; Crit Care Med. 2010 May; 38 (5):1246-53.
Health Policy Analysis- Organ Donation Consent Rates: Actuarial Analysis and Intent to Donate Study
Sam Shemie, Jacquelyn Burkell, Jennifer Chandler, Laura Hornby
In Canada, as in many other jurisdictions, the demand for transplantable organs far outstrips the supply of donated organs. There are still perplexing gaps between the high support for donation in principle, and the low rates of expressed willingness to donate and actual donation. Canadians demonstrate exactly this gap, expressing a high degree of support for organ donation (>95%) while having one of the lowest donation rates among industrialized countries.
Improving consent rates is one of the most quantitatively effective mechanisms to increase the number of organ donors and the availability of transplantable organs. Previous research examining the impact of knowledge about organ donation and transplantation (ODT) on donation intent indicates that individuals who do not confirm intention to donate often lack ODT knowledge or hold factually incorrect beliefs. Interventions designed to improve ODT knowledge have been demonstrated to increase donation consent rates. This research, however, typically characterizes ODT knowledge as an understanding of issues such as; who can give permission for donation; whether people who need transplants receive them, etc. Missing from this assessment is an examination of whether people have an accurate understanding of their chances of either donating or requiring an organ in their lifetime.
The consent regime in Canada remains an opt-in system, focused on the theme of generosity and gift giving, based on altruism and benevolence. In this publicly funded health care system based on the principle of universality, access to the transplant waiting list (in the absence of contraindications) is a right without any responsibility to contribute to the supply of transplantable organs. Lifetime probabilities that appeal to individual self interest as part of inducing or facilitating consent have not been tested in the Canadian context. Providing this information would encourage a dual focus on the act of giving and the act of receiving an organ.
One strategy to induce consent is to develop organ donation policies and practices based on voluntary reciprocal altruism. With this approach, an individual is given priority on the waiting list for organs, if they agree to donate their organs upon death. The basis of this approach is that if their self interest is engaged, a prospective donor is more likely to overcome the natural reluctance to donate their organs. Organ donation becomes an altruistic decision that is reinforced by a personal benefit. In order for such a strategy to be viable, the likelihood of benefiting (i.e. the probability of needing a organ transplant) should significantly outweigh the likelihood of the altruistic action (i.e. the probability of donating one’s organs) and this information must be known by the decision maker (i.e. prospective organ donor).
Appealing to self interest in donation consent decisions in Canada requires evaluation. For example, prefacing a question regarding intention to become a donor with a question regarding the desire to receive an organ should one be required could well serve to increase expressed intentions to donate. This may be particularly true if actuarial data suggest that the likelihood of requiring an organ is higher than the likelihood of becoming a donor.
The value and effectiveness of providing relative probability information to donation consent discussions, consent registries, public education and social marketing should be evaluated. To our knowledge, this is the first study to generate information regarding the lifetime probabilities of requiring an organ transplant, receiving an organ transplant and donating an organ and to test the impact of providing this information within the context of consent to organ donation.
In addition, actuarial analysis of living donation rates, international comparison of deceased donation rates between Canada and the US and a 25 year supply-demand analysis were performed. These data contribute important and informative elements to potential targets in social marketing and public education strategies.
The results of this study as applied to organ donation intent decisions; reciprocity systems, public education and social marketing will inform government agencies, policy makers, educators and clinicians.
The Do!nation Project www.donationproject.ca
Loeb Chair and Research Consortium, University of Ottawa; Canadian Blood Services; Montreal University Health Centre; David Lehberg; Lili Shawn Shalev
The Do!nation Project is designed to increase the commitment of Canadians to organ and tissue donation
- A high-profile, national public awareness campaign.
- A widely targeted program that will reach a broad range of demographic groups and ethnic backgrounds.
- A social initiative to increase commitment to donation, building a sense of community and creativity that will effect change and help save lives.
The Do!nation Project involves a national short film competition with a celebrity judging panel, national media support, viral marketing, internet advertising culminating in a high profile gala event. The competition will be driven by a comprehensive website that will offer information about organ and tissue donation, educate people on how to commit to becoming donors and motivate them to become involved.
To achieve this goal of launching a successful short film competition overall project objectives are:
- To provide a viral media vehicle that brings profile, credibility and awareness to organ and tissue donation.
- To provide access to information and education about organ and tissue to diverse and previously unidentified and/or unengaged demographic.
- To provide the national and provincial organ donation agencies with significant data specifically regarding intention and commitment to organ and tissue donation.
- To secure sponsorship to support execution of the film competition and ongoing awareness activities.
The project provides an opportunity for sustainable, ongoing national awareness activities, for example, the film competition, which may occur annually, will provide a pool of promotional materials that can be using to build ongoing awareness.
Implications of this Project:
Developing and Integrated System to Improve Organ and Tissue Donation and Transplantation Performance in Canada An Ethics Consultation - Canadian Blood Services:
Sam Shemie, Karine Morin, Linda Wright
In August 2008 Canadian Blood services was given a mandate by the conference of Deputy Ministers of Health to lead the development of a national strategy for organ and tissue donation and transplantation in Canada. The Loeb Chair and Research Consortium along with other key experts is providing active consultative input regarding ethical principles and related system design requirements to support the implementation and development of Canada’s proposed OTDT system.
Ongoing work will include:
Review ethical principles that guide provincial, national and international OTDT systems and professional organizations that provide OTDT services.
Review the proposed national system design and advise on the ethical principles that should guide this system.
Identify any ethical deficits, future challenges and make recommendations to improve system design.
- Advise on mechanisms to ensure future ethical review and discussion of current and evolving OTDT issues.
The outcome of this work has situated the Loeb Chair and Research Consortium as an academic research arm within a national program for OTDT in Canada.
CIHR Knowledge Synthesis Grant -Organ Donor Registries: A Global Scoping Review”
Principal Investigator: Garg Amit Co-Investigators: Rosenblum A, Horvat L, Shemie SD
Implications of this Study:
The results of the Health Policy Analysis, particularly the results of the focus group work, is and will be used by both OPO’s and CBS in strategic planning, structure, design, development and assessment of organ donor registry projects within Canada. Results of this study were presented to OPO’s and Stakeholders June 2011.
Johnson Lecture Series
Bridges to Life - Technology and Organ Donation.
In an effort to support innovative research, education and leadership, Johnson Insurance Inc has partnered with the University of Ottawa and the Loeb Chair in Organ and Tissue Donation to develop a lecture series based on investigations into the complex multidisciplinary issues surrounding organ and tissue donation in Canada
The first lecture in the series was presented April 29, 2011 at the University of Ottawa Alumni event in Toronto in April 2010. The lecture entitled “Bridges to Life- Technology and Organ Donation” to an enthusiastic audience of alumni and invited guests.
The guest speakers for the evening were Dr. Sam Shemie Bertram Loeb Chair in Organ and Tissue Donation, Director of Extracorporeal Life Support at Montreal Children’s Hospital, Professor of Pediatrics, McGill University and Medical Director of Organs and Tissues, Canadian Blood Services, and Ian Kerr PhD, Canada Research Chair in Law and Technology. Dr Kerr is in the unique position of having a cross appointments in three faculties, Law, Medicine and Arts at the University of Ottawa. Dr Kerr is a member of the Loeb Research Consortium.
Dr. Shemie began by discussing the troubling statistics we face in Canada and worldwide as the gap, between the number of organs needed for transplantation and the number available to be transplanted, widens. He emphasized that organ donation is not simply a medical and biomedical issue, it is a societal issue.
Professor Kerr discussed the merging of technology and the human body Technology has allowed the development, manufacture and production of devices that provide advances and a positive impact .Most of us are aware of the positive impact of technology ; however, generally we are unaware of the legal, social moral and ethical impact that surround these advances.
Following the presentations the diverse audience asked many both informed and provocative questions. The evening concluded with a reception at which the debates continued.
Who Owns your Body Parts?
In November 2010 the Loeb Chair and Research Consortium held the second lecture in the Johnson Series at the University of Ottawa, Student Centre. The format of this evening was a panel discussion. Our panel of experts renowned in their fields presented views that revolved around the medical, biomedical societal, cultural and anthropological issues related to Transplant Tourism”.
The panellists included; Amy L. Friedman, M.D. is the Medical Director of SUNY Upstate Medical University’s Division of Transplantation, Syracuse New York and a professor of surgery in the College of Medicine. University Hospital of SUNY Upstate Dr. Jeff Zaltzman MD, MSc, FRCP(C) Associate Professor of Medicine, University of Toronto Division of Nephrology, Director of Renal Transplant at St. Michael’s Hospital. Professor Monir Moniruzzaman PhD is currently an Assistant Professor in the Department of Anthropology and Centre for Ethics and Humanities in Life Sciences at Michigan State University. Professor Vanessa Gruben, Common Law section of the University of Ottawa, Faculty of Law where she teaches property law and family law. The evening was hosted by Adrian Harewood, co-host of CBC News Ottawa Evening and Late Night News.
Following the panel discussion session members of the audience engaged in a lively and informative ‘open –mike’ that both challenged and informed all.
The third lecture in the series will be held in the spring of 2012.