ICU and You · Mind Map Series · Number 29
Donation nearly always needs major input from the ICU team. Every deceased-donor transplant in this country begins in a unit like ours — with a grieving family, and a clinician who recognised the possibility in time. This map lays out the work that follows: recognition, diagnosis, referral, donor management, and follow-up and review.
Do not read it like a chapter. Scan it. Let your eye go where it wants, read three boxes that catch it, and stop. You are not trying to finish it and you are certainly not trying to memorise it.
Then come back. Before a shift on which the subject might come up, or after a case that went a particular way, or in a quiet ten minutes. Thirty seconds at a time, often, beats an hour once.
It works the way a painting in a corridor works. Nobody sits down and studies the painting they walk past every morning, and yet after a year they could tell you what is in it, where the light falls, and exactly what is on the left-hand side — and they would notice at once if something had changed. That noticing is the point. These maps are not built to be recalled on demand; they are built so that when the thing in front of you does not fit, something quietly objects.
The framing worth holding onto: donation is not an afterthought bolted onto death. It is a discipline — identification, diagnosis, and physiological stewardship — that sits squarely inside our skill set. The map below is the whole territory on one page; the notes beneath walk each branch.
The Australian numbers are quietly damning. Four in five of us support donation in principle; only about one in three are registered. The gap is not attitude — it is a one-minute administrative act that nobody quite gets around to. And that gap surfaces at exactly the wrong moment: the family conversation in the hospital.
Roughly 2,000 Australians wait on the transplant list, with another 14,000 on dialysis — many of whom a single kidney would release. The lever that moves consent is not persuasion at the bedside; it is a decision made calmly, in advance, and spoken aloud to family. Friction, not conviction, is the enemy.
This is where the intensivist holds the lever. The single most important idea for trainees: identification is a systems task, not a judgement call. Missed donors are rarely lost to bad medicine; they are lost to a well-meaning clinician who decided in advance that the patient was too old, too complicated, or that the family would surely refuse. None of those are our call to make.
Any patient with a devastating, non-survivable brain injury where either brain death is anticipated, or withdrawal of life-sustaining treatment is being considered — for any reason. Refer all patients on an end-of-life pathway: the Organ and Tissue Donation Service wants to know about every one of these, and suitability is theirs to determine, not ours. The two pathways:
The rule that matters most in practice: contact the donation service before donation is ever raised with the family, and before withdrawal. This preserves the option, and it allows decoupling — separating the conversation about death from the conversation about donation, with the latter led by a trained requester alongside you. Decoupling and trained requesters are among the most robust findings in the field: consent rates rise when the ask is made well, by someone prepared for it, rather than bolted onto a futility discussion by a tired registrar at 3am.
Not your call to exclude
Age. Past medical history. A drinker, a smoker, a diabetic. Presumed family refusal. Presumed patient wishes. Suitability is determined downstream, with far more information than the bedside has. The absolute contraindications are narrow and specified — and even they belong to the donation service, not the night registrar.
The governing authority in this country is the ANZICS Statement on Death and Organ Donation — cite it, and know it. Brain death determination follows a fixed architecture, and skipping a step invalidates everything above it.
Brain death is a physiological storm followed by a collapse: vasomotor tone is lost, diabetes insipidus pours out, the myocardium falters, temperature falls, coagulation frays. Management is no longer about the person — it is about protecting the organs for the people waiting. The paradox is this: the ceiling of care hasn't lowered here. It has risen. You are resuscitating for two.
The bedside shorthand for the perfusion targets is the rule of 100s — four numbers that keep the organs viable, sitting on top of the real work: desmopressin for the DI, hormonal resuscitation in the unstable donor, lung-protective ventilation and recruitment, active rewarming, glycaemic control. As for the four numbers themselves — see the challenge below.
Challenge of the week
An easy one. One question: what is the "rule of 100s" in the management of the organ donor? I'll share the sharpest replies in a future newsletter.
And if you take one thing from this issue into your own life rather than the unit — spend the minute. Register your decision on the Australian Organ Donor Register, and tell your family what you chose. Eight in ten, versus four in ten. That is the whole argument.
Everything on this map begins with a decision somebody made long before they became a patient. Scan to join the Australian Organ Donor Register.
Anyone in Australia aged 16 or over can register, and it takes about a minute with a Medicare card. Or go to donatelife.gov.au.