hospital role for education and organ donation promotion (2). In Australia, the .... Famiréa Research Group, Saint-Louis University Hospital,. Medical Intensive ...
Online Letters to the Editor intubation in the intensive care unit: Development and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med 2013; 187:832–839 6. Jaber S, Monnin M, Girard M, et al: Apnoeic oxygenation via high-flow nasal cannula oxygen combined with non-invasive ventilation preoxygenation for intubation in hypoxaemic patients in the intensive care unit: The single-centre, blinded, randomised controlled OPTINIV trial. Intensive Care Med 2016; 42:1877–1887 DOI: 10.1097/CCM.0000000000003043
Experience and Perception in Organ Donation: A Matter of Team Work To the Editor:
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e read with great interest the informative survey of healthcare professional (HCP) perception of organ donation from brain-dead patients by KentishBarnes et al (1) in a recent issue of Critical Care Medicine. The authors conclude that there are significant differences among HCP and clinician’s perceptions of organ donation and hypothesized this may affect family experience and consent rates. We would like to present arguments in favor of structural changes, as one solution to resolve the raised issues. Despite national efforts to unify processes, the success and rate of organ procurement can vary greatly between as well as within countries. A difference in attitudes toward organ donation is frequently evoked but does not explain all the variation. According to the data presented here, one might think that it depends on the local culture of care (1). Our hypothesis is that the lack of available dedicated resources could be important. We were surprised that the authors did not consider questioning about availability and perception of supportive resources. Indeed, numerous countries have had success by implementing measures with high impact on organ donation performance. In Spain, for example, success holds in transplant organizations and coordinators, the latter having a major inhospital role for education and organ donation promotion (2). In Australia, the implementation of support to donor’s families, the education of HCP, and the creation of professional organ donation staff enhanced efficacy (2). One important barrier to organ donation in the ICU, mentioned by the authors, is the shift from curative care to organ donation, which is perceived as emotionally complex. The necessity to care for relatives during the whole process adds to the difficulty (1). In fact, the support of relatives facing the experience of unexpected death, as well as the consent process for organ donation, requires availability and comfort from the HCP. Many studies have reported that HCP suffer distress and feel a burden with such a process, in part due to lack of dedicated organizational structure (3). This is in agreement with the perceived stress reported in the survey, for HCP with little experience in caring for potential organ donors (1). The constitution of a dedicated team who is comfortable and committed to organ donation may facilitate the process for HCP facing situations with potential organ donor. This team can contribute to the better understanding or acceptance of brain death, encourage continuous education, debrief challenging cases as well as provide support to HCP and families,
Critical Care Medicine
while changing the local culture (4). One approach to change the culture and modify the attitude toward organ donation can certainly be achieved with a curriculum on national organ donation (5). However, we believe that the concentration of expertise with exposure to a higher number of donors, an inhospital professionalization, as well as an expert team available for support (even remotely for smaller hospital), could be a solution to strive a positive attitude toward organ donation. Ms. Lagacé disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest. Anne-Marie Lagacé, RN, MSc, Emmanuel Charbonney, MD, PhD, Pierre Marsolais, MD, Département des soins intensifs, Hôpital du Sacré-Cœur de Montréal, Montréal, QC, Canada
REFERENCES
1. Kentish-Barnes N, Duranteau J, Montlahuc C, et al: Clinicians’ perception and experience of organ donation from brain-dead patients. Critical Care Medicine 2017; 45:1489–1499 2. Rudge C, Matesanz R, Delmonico FL, et al: International practices of organ donation. Br J Anaesth 2012; 108(Suppl 1):i48–i55 3. Floden A: Thesis: Attitudes Towards Organ Donor Advocacy Among Swedish Intensive and Critical Care Nurses, 2011. Available at: https:// gupea.ub.gu.se/bitstream/2077/24632/1/gupea_2077_24632_1.pdf. Accessed January 30, 2018 4. Marsolais P, Durand P, Charbonney E, et al: The first 2 years of activity of a specialized organ procurement center: Report of an innovative approach to improve organ donation. Am J Transplant 2017; 17:1613–1619 5. Hancock J, Shemie SD, Lotherington K, et al: Development of a Canadian deceased donation education program for health professionals: A needs assessment survey. Can J Anaesth 2017; 64:1037–1047 DOI: 10.1097/CCM.0000000000003026
The authors reply:
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e thank Lagacé et al (1) for their comments regarding our survey of healthcare professional (HCP) perception of organ donation–related activities from brain-dead patients (2), which was recently published in Critical Care Medicine. Our study shows that HCPs working in the ICU have different perceptions and experiences of organ donation–related activities and that 20% perceive these activities as stressful and tiring. We agree with Lagacé et al (1) that structural changes are necessary. Death in the ICU, whether brain death or death occurring after a decision to withhold or withdraw treatment, is organized within a collective work context. One cannot hope to improve the experiences of persons involved in the process (family members, ICU HCPs, and transplant coordinators) by focusing on them separately. We believe that one should adopt a holistic approach that focuses on the way that the system’s constituent parts interrelate and how they work over time and even within the context of larger systems. This requires an understanding of the history, the organization, and the culture of the institution as well as how people work with the institution. End-of-life (EOL) in the ICU is subject to organizational constraints: not only is it dependent on a strong professional www.ccmjournal.org
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culture but also on highly variable local cultures (3). Taking all these elements into account can help identify meaningful improvement approaches. Stepping back and looking at the bigger picture, rather than focusing on individual parts, help one see differently and find new ideas or proposals. In France, transplant coordinators are dedicated nurses and doctors who play major roles, among which caring for the family members of potential organ donors in collaboration with the ICU team, developing other HCPs’ motivation as well as training HCPs and informing the general public. Transplant coordinators collaborate closely with ICU staff but do not systematically propose support for nurses and doctors who may experience emotional difficulties. Broadening and formalizing this role may be beneficial. We agree with Lagacé et al (1) that not specifically studying perception of supportive resources may be a limitation to our study (2). However, an expert multidisciplinary team available for support should not be specific to organ donation–related difficulties. Other EOL situations in the ICU can cause emotional suffering that must also be recognized by the institution. Improvement must be seen as a whole as organ donation activities rely on all ICU HCPs—everyday ICU activities are intertwined with organ donation–related activities. Many of these activities are complex (medically, ethically, and/or emotionally). Ensuring HCPs’ general well-being is a means to improve their experience of organ donation–related activities. This well-being includes education, support, recognition, implication—both concerning everyday ICU activities and organ donation–related activities. Regularly being active along with the transplant coordinators may permit stronger engagement, increased knowledge, as well as increased satisfaction. ICU HCPs must not be dispossessed of caring for relatives of organ donation patients (4). Encouraging a positive attitude toward organ donation cannot be separated from HCPs more general experience of care and team work in the ICU. To impact on perception and experience of organ donation–related activities, one must impact of local culture as well as institutional culture that promotes HCPs’ well-being. Taking care of HCPs by offering organ donation education, an agreeable work climate, a culture in which their role is recognized, and their involvement encouraged, as well as support by trained specialized teams when necessary, will help promote a more positive attitude to EOL in general and to organ donation more specifically. A more holistic and collaborative approach (ICU team/transplant coordinators) may help overcome certain barriers or apprehensions and improve experience of organ donation–related activities. Dr. Kentish-Barnes’ institution received funding from Agence de la BioMédecine. Dr. Azoulay’s institution received funding from Fisher and Peyckle, Astellas, Baxter, Pfizer, MSD, Jazz Pharma, and Alexion, and he received funding for lectures from Alexion, MSD, Gilead, and Baxter. Dr. Charpentier disclosed that he does not have any potential conflicts of interest. Nancy Kentish-Barnes, PhD, Assistance PubliqueHôpitaux de Paris, Famiréa Research Group, Saint-Louis University Hospital, Paris, France; Julien Charpentier, MD, Assistance Publique-Hôpitaux de Paris, Cochin University e622
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Hospital, Medical Intensive Care Unit, Paris, France; Elie Azoulay, MD, PhD, Assistance Publique-Hôpitaux de Paris, Famiréa Research Group, Saint-Louis University Hospital, Medical Intensive Care Unit, Paris, France, Biostatistics and Clinical Epidemiology research (ECSTRA) team, U1153, INSERM, Paris Diderot University, Paris, France, and Sorbonne University, Paris, France
REFERENCES
1. Lagacé A-M, Charbonney E, Marsolais P: Experience and Perception in Organ Donation: A Matter of Team Work. Crit Care Med 2018; 46:e621 2. Kentish-Barnes N, Duranteau J, Montlahuc C, et al: Clinicians’ perception and experience of organ donation from brain-dead patients. Crit Care Med 2017; 45:1489–1499 3. Mark NM, Rayner SG, Lee NJ, et al: Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: A systematic review. Intensive Care Med 2015; 41:1572–1585 4. Domínguez-Gil B, Coll E, Elizalde J, et al; ACCORD-Spain study group: Expanding the donor pool through intensive care to facilitate organ donation: Results of a Spanish multicenter study. Transplantation 2017; 101:e265–e272 DOI: 10.1097/CCM.0000000000003099
Timely Transthoracic Echocardiogram in Pulmonary Embolism—Is It Worth the Trouble? To the Editor:
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e read with great interest the article published in a recent issue of Critical Care Medicine by Filopei et al (1) and accompanying editorial (2) describing the use of fellow-performed goal-directed echocardiography (GDE) in patients with confirmed pulmonary embolism (PE). Ostensibly, the purpose of GDE is to identify true right ventricular dysfunction (RVD) that is not otherwise clinically manifest (i.e., sensitive test) while reliably excluding RVD (i.e., specific test). Both articles suggest that GDE is feasible, timely, and reasonably sensitive and specific—and therefore an accurate strategy to rapidly diagnose RVD in acute PE (1, 2). Incorporating the results of this study by Filopei et al (1) into clinical practice, however, anchors on two fundamental questions: Are the results of the study valid, and will the results inform patient care (3)? This study by Filopei et al (1) has two major threats to its validity: the internal consistency of the results and patient sample bias. First, the authors’ reported test performance characteristics are incongruent. For example, fellow-identified right ventricular systolic dysfunction had a sensitivity of 71% and a “false-negative rate” of 10%. By definition, “false-negative rate” is 1—sensitivity, which should equal 29%. We identified multiple inconsistencies in Table 2 (1) and seek clarification on these computations. Second, test performance properties of GDE may be distorted if GDE is selectively performed and/or if GDE’s results influence whether subsequent confirmation on transthoracic echocardiogram (TTE) is undertaken (3). A total of 283 patients had confirmed PE, but only 154 patients had GDE performed, a practice suggesting selection bias (3). Furthermore, if formal TTE studies were often performed to verify GDE findings, then verification bias is also introduced (3). Both sources of June 2018 • Volume 46 • Number 6
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