Organ donation.

Transplantation is now an established form of treatment for organ failure in childhood. Much has been published on the outcome and management of children with organ transplants, the ethical issues have been widely discussed, and the criteria for the diagnosis of brain death have been established. Most transplanted organs are taken from donors who are brain dead but have a circulation and are being mechanically ventilated, and recent publicity has drawn attention to a lack of such donors. Staff working on intensive care units, particularly doctors, have been repeatedly criticised for their lukewarm attitude towards organ donation and their failure to ask relatives of patients for permission to remove organs for transplantation. This criticism is primarily directed at those caring for sick adults but the shortage of organs for donation applies equally to children. The current debate is centred on ways of increasing the number of organs donated; by publicity, by obliging staff to ask relatives about organ donation (required request), or by an opting out scheme to replace the present system of organ donor cards. Surprisingly, there is no information to guide doctors caring for a child who is a potential organ donor. It is assumed that organ donation is a straight forward procedure once brain death has been diagnosed and parental consent has been obtained, but this is not so. An unhappy experience in our own unit recently led to a series of discussions on the subject of organ donation that involved medical and nursing staff and the local transplant team. It became clear that many interests need to be considered, particularly if multiple organ donation is being contemplated: the child and his family, the nurses and doctors responsible for the child's care, the transplant team and its coordinator, the various transplant centres (national and international), the coroner, the pathologist, and the local hospital services such as blood transfusion, theatre, and the mortuary. It was also clear that our unhappiness and unease that had resulted from previous attempts at organ donation arose from divided loyalties and blurring of responsibilities. A series of guidelines were agreed upon and drawn up for future occasions and have since been put into practice successfully. They are presented here in the hope that other paediatricians might find them useful. A few parochial details have been omitted but otherwise the guidelines are applicable to any children's department with intensive care facilities.