This involves attempting to determine the previously stated wishes of the deceased. If this is not possible, then permission for, or lack of objection to, organ retrieval is sought from the next of kin. In some instances there may be difficulty in deciding who this is, in which case the most senior, the closest, or at least the most concerned relative should be identified and asked to canvass views within the family and to act as spokesperson. In the event of disagreement amongst the relatives it might be considered reasonable to accede to the wishes of the nearest or most interested, or, in a situation where there are several close relatives, the majority view. If there is a serious unresolvable dispute, it may be wiser not to proceed to organ donation.
Difficulties may also occur when the next of kin attempt to override the clearly stated wish of the deceased to donate organs in the event of his or her death. This may arise, for example, when the patient was carrying a donor card or had registered his or her wishes on a computer database. Currently the generally accepted legal view in the United Kingdom is that the person lawfully in possession of the body is the hospital management, and therefore the relatives cannot veto the patient's wishes. In practice, however, once the issues have been fully discussed, it is almost always advisable to concur with the wishes of the relatives.
All potential donors must be tested for HIV, and it is recommended that permission for this should be obtained from the relatives. A positive test must be revealed to those at risk of contracting the disease from the deceased. This requires sensitivity and tact, combined with the provision of appropriate counseling and follow-up services.
It is important that discussions with the relatives should specifically address the issue of multiple rather than limited organ retrieval. Multiple organ donation
Retrieval of multiple organs, which can be performed without jeopardizing the function of individual organs, should now be the objective in all brain-dead potential donors. Assiduous supportive treatment is essential to prevent deterioration of initially suitable donors as this will both increase donation rates and improve graft survival and function. Complications related to the profound physiological disturbances consequent on brainstem death are common ( Table 1) and may jeopardize organ function. The incidence of complications increases progressively after brainstem death and, although adequate time must be allowed to confirm the diagnosis, unnecessary delays must be avoided. Meanwhile meticulous intensive care is required to sustain organ perfusion and to improve graft survival and function. In particular a high level of nursing case, with a bedside nurse-to-patient ratio of 1:1 or sometimes 2:1, is required. The introduction of a comprehensive standardized donor management regimen, including pulmonary artery catheterization and hormone replacement, has been shown to increase the proportion of hearts which are suitable for transplantation ( ^Wheeldon §L,§L 1995).
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Table 1 Consequences of brain death
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