| Abstract|| |
To evaluate the utilization of critical care unit beds occupied by brain-dead patients during the period falling between confirmation of the diagnosis till, either, organ harvesting or patient's expiration. We studied all the consecutive patients who had been documented brain-dead from January 2001 to December 2009. Death by brain criteria was documented in 232 patients with a median age of 39 ± 18.2 years; 181 (78%) were Saudis and 175 (75.5%) were males. Only 37 deceased patients diagnosed by brain criteria were consented by their next-of-kin for organ donation; 26 (70.1%) of them were non-Saudis. The time from confirming death by brain criteria in the study patients until they were moved to a morgue or to the operating room for retrieval of organs were 93 ± 89.9 vs. 73 ± 48 h, respectively (P = 0.07). In conclusion, I believe a better utilization of the intensive care units' beds by other than brain-dead patients would not produce great cost savings, but may provide care for more patients with better quality of care.
|How to cite this article:|
Alsultan MA. Utilization of intensive care units' beds occupied by brain-dead patients. Saudi J Kidney Dis Transpl 2011;22:444-7
|How to cite this URL:|
Alsultan MA. Utilization of intensive care units' beds occupied by brain-dead patients. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2020 Jul 6];22:444-7. Available from: http://www.sjkdt.org/text.asp?2011/22/3/444/80478
| Introduction|| |
Brain death is defined as "irreversible cessation of all brain function." Establishing brain death gives relief from unjustifiable hope, prolonged anxiety and financial burdens on families and society. It also allows more efficient utilization of medical resources and potentiality allows retrieval of organs for transplantation. 
Healthcare resource allocation refers to "the distribution of healthcare resources among individuals and populations, and encompasses rationing and triage."  Bedside rationing by a physician is "withholding of medically beneficial service because of that service's cost to someone other than the patient." 
Even nowadays, the concept of organ donation is still alien to the Saudi society. Aldawood et al found that only 17% of the patients announced brain-dead in the intensive care unit (ICU) had their organs harvested. In fact, of this low percentage, only 13% was Saudi nationals, which emphasizes the unfavorable view toward organ donation among Saudis.  However, such negative view of organ harvesting post-diagnosis of brain death is not limited to the Saudi society. 
On the other hand, increasing demand to provide treatments with marginal benefits at best threatens the ability of others to access treatments that may offer them very real benefit.  When the availability of critical care beds is low, several factors, including age, illness severity and medical diagnosis, determine patient triage; however, their relative importance is uncertain. 
The cost of health and ICUs are usually elevated. ,, Accordingly, can the health care cost be reduced by limiting intensive care provision at the end of life? And, can we utilize beds in a critical care unit by rationing? Both are rational questions considering that ICU resources would be wasted on patients with poor outcome. However, there is evidence that this may not be the case.
The purpose of our study is to evaluate the utilization of critical care unit beds occupied by brain-dead patients during the period from the confirmation of the diagnosis to either organ harvesting or patients' expiration.
| Methods and Patients|| |
This prospective study was conducted in a 21-bed medical and surgical ICU in an 800-bed tertiary care teaching hospital in Riyadh, Saudi Arabia. This ICU is a closed unit, run by in-house, full-time, board-certified intensivists, with more than a thousand admissions per year.
All consecutive patients who had documented death by brain criteria from January 2001 to December 2009 were included. The patients were subjected to two separate clinical examinations at least 6 h apart. Additional confirmatory tests performed consisted of one of the following: brain perfusion study by nuclear scanning, electroencephalogram or cerebral angiography. After these two steps were performed, the apnea test was conducted. Then, if all these three steps revealed a negative brain stem function, the patient would be declared dead by brain criteria.
Data were collected on patients' age, gender, nationality, cause(s) of death, time of confirmation of death by brain criteria and the time of the harvesting or pronouncing the death.
| Results|| |
During the study period, 8,107 patients were admitted to the ICU, and death by brain criteria was documented in 232 (2.8%) patients, most of whom were young (median age, 39 ± 18.2 years); 181 (78%) were Saudis and 175 (75.5%) were male. Consents for organ donation by the next-of-kin were obtained in 37 deceased patients diagnosed by the brain, 26 (70.1%) of whom were non-Saudi.
The time from confirming death by brain criteria in the study patients until they were moved to the morgue or to the operating room for retrieval of organs was 93 ± 89.9 vs. 73 ± 48 h, respectively (P = 0.07) [Figure 1].
|Figure1: Time from confirmation of brain death by perfusion of brain scan until officially pronounced dead.|
Click here to view
| Discussion|| |
In this study, the overall percentage of relatives that consented for organ donation was higher in non-Saudis compared with the Saudi deceased patients. This is similar to an earlier report by Aldawood et al,  which emphasizes the unfavorable view toward organ donation among Saudis who may have misconceptions about death by brain criteria as the likely cause behind this modest figure.
However, Dr. Albar  in his review demonstrated the rapid acceptance of organ transplantation as a new modality of treatment that saves many lives. Furthermore, Saudi Arabia, the most conservative Islamic country, is ahead of the rest of the Islamic world in deceased organ transplantation. Until facilities for resuscitation improve and ICUs proliferate, organ transplantation from the deceased donors will be limited. Islamic teachings and Fatwas permit all types of organs transplantation if the required conditions are fulfilled. However, it seems that there has been a decline in the rate of organ donations in Saudi Arabia in early 2000 compared with the 1990s. One of the reasons for this decline could be a local Fatwa from few scholars in Saudi Arabia that discouraged organ donation, or at least did not favor it. 
The most striking finding in our data is the time from confirming brain death to expiration that was not significantly different whether donation was completed or not. This is against the usual belief by ICU staff that if organ donation is consented early, it will shorten the length of stay in the ICU. In contrast, this issue opens another ethical dilemma " Occupying the ICU bed with brain dead for how long and what about switch off the ventilator." It is well established that it is permissible to switch off the life support system with total and irreversible loss of function of the whole brain in a patient if three attending specialist physicians render their opinion unequivocal that irreversible cessation of brain functions has occurred. Legal death is not usually pronounced unless the vital functions have ceased after the external support system has been switched off, which is debatable in law, medicine and moral philosophy about appropriate and inappropriate ways of death. 
Arabi et al  believe that a better utilization for the ICU beds will have a clear impact in the following ways: (i) a larger number of patients can be admitted in the ICU with the available resources, (ii) the lead-time for admission in the ICU will be reduced and (iii) more elective surgeries (requiring ICU bed availability for follow-up care) can be performed. In addition, better utilization of ICU beds allows higher quality care to critically ill patients really in need of it, and minimizes the cost per patient in the ICU. However, Luce and Rubenfeld  pointed out that a similar approach would not produce great cost savings because most hospital costs are fixed and would not be influenced by decreases in ICU length of stay, and only a minimum number of patients have dismal prognosis that would not substantially reduce costs due to withholding ICU care from them. On the other hand, ventilating more patients who are hopelessly brain damaged to secure more donors raises ethical and economic issues. 
In conclusion, I believe that a better utilization of the ICU beds by other than brain-dead patients would not produce great cost savings but may provide care for more patients with better quality of care.
| References|| |
|1.||G. Edward Morgan, Maged S. Mikhail, Michael J.Murray. Clinical Anesthesiology, 4 th Edition. 2006 McGraw-Hill Companies, INC. |
|2.||American Thoracic Society Statement. Fair allocation of intensive care unit resources. Am J Respir Crit Care Med 1997;156:1282-301. |
|3.||Ubel PA, Goold S. Recognizing bedside rationing: Clear cases and tough calls. Ann Intern Med 1997;126:74-80. |
|4.||Aldawood A, Al-Qahtani S, Dabbagh O. Organ donation after brain death: Experience over five-years in a tertiary hospital. Saudi J Kidney Dis Transplant 2007;18(1):60-4. |
|5.||Daniels DE, Smith K, Parks-Thomas T, et al. Organ and tissue donation: are minorities willing to donate? Ann Transplant 1998;3(2):22-4. |
|6.||Hawryluck L. Ethics review: Position papers and policies-are they really helpful to front-line teams? Crit Care 2006;10:242. |
|7.||Sinuff T, Kahnamoui K, Cook DJ, et al. Rationing critical care bed: A systematic review. Crit Care Med 2004;32:1588-97. |
|8.||Adhikari N, Sibbald W. The large cost of critical care: realities and challenges. Anesth & Analg 2003;96(2):311-4,. |
|9.||Marsden C. An ethical assessment of intensive care. Int J Technol Assess Health Care 1992; 8(3):408-18. |
|10.||Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: The contribution of mechanical ventilation. Crit Care Med 2005;33(6):1266-71. |
|11.||Albar MA. Islamic Ethics of Organ Transplantation and Brain Death. Saudi J Kidney Dis Transpl 1996;7:109-14. |
|12.||Al Shehri S, Shaheen FA, Al Khader AA. Organ donations from deceased persons in the Saudi Arabian population. Exp Clin Transplant 2005;3(1):301-5. |
|13.||Beauchamp TL, Childress JF. Principles of biomedical ethics, 5th ed, New York: Oxford University Press; 2001 |
|14.||Arabi Y, Venkatesh S, Haddad S, Al Shimemeri A, Al Malik S. A prospective study of prolonged stay in the intensive care unit: predictors and impact on resource utilization. Int J Qual Health Care 2002;14(5):403-10. |
|15.||Luce JM, Rubenfeld GD. Can health care costs be reduced by limiting intensive care at the end of life? Am J Respirat Crit Care Med 2002; 165(6):750-4. |
|16.||Gentleman D, Easton J, Jennett B. Brain death and organ donation in a neurosurgical unit: Audit of recent practice. BMJ 1990;301(6762): 1203-6. |
Mohammed Abdullah Alsultan
Assistant Professor, College of Medicine, Dean of Admission and Registration, Director of Scholarship Department, Consultant, Emergency Medicine and Intensive Care Unit, King Saud bin Abdulaziz University for Health Sciences, Riyadh