Dr. Ruairí Dwyer:

I am Ruairí Dwyer and I am a consultant in the ICU in Beaumont Hospital. I have been involved with identifying and obtaining consent for transplantation there. In that context, I work in close collaboration with the organ procurement service run by Ms Phyllis Cunningham, who came before the committee last week. I am chairman of the committee on organ donation of the Intensive Care Society of Ireland, ICSI. The ICSI represents doctors who work in intensive care medicine. Our committee and organisation include representatives of nurses who work in ICUs and organ donor co-ordinators. We emphasise the importance of links with ICU nursing in respect of this issue. As intensive care consultants, we are the clinicians who are directly responsible for the care of all patients with serious brain injuries and the diagnosis of death in those patients who unfortunately progress to brain death. We are involved in explaining organ donation and in requesting permission from families for such donations. We are also involved in the care of organ donors in order to optimise the number of organs suitable for transplantation.

Promotion of organ donation is seen as being an integral part of our job if our efforts to preserve life have failed. There is strong enthusiasm in ICUs on the part of both medical and nursing staff. Education in organ donation issues is an integral part of the training relating to our specialty. This education remains ongoing throughout our careers. The ICSI held a day-long conference devoted to organ donation in 2012. This attracted a large attendance of both medical and nursing staff who work in intensive care. The ICSI has published guidelines on the diagnosis of brain death and on organ donor management in order to help increase the number of organs available for transplantation. With support from the HSE, intensive care clinicians are establishing an audit programme which will encompass a comprehensive audit of organ donation within ICU and which will identify any potential for improvements in this area.

We believe that our specialty has made a significant contribution to the relatively high rate of organ donation in Ireland. However, we see major challenges in increasing the rates of organ donation and even in maintaining current rates of organ donation. I work in the neurosurgical centre in Beaumont Hospital. When I started 20 years ago we had a brain death diagnosed probably once a week but now we have such a diagnosis once or twice a month. That is the pool we are recruiting from for organ donors.

We strongly support the proposals from Professor Egan, which have been mentioned by the two previous speakers, for promoting public awareness, for increased numbers of organ donor co-ordinators and for the appointment of staff in each hospital network with responsibility for promoting organ donation. There are differing opinions within our specialty on presumed consent. Many are concerned that presumed consent could lead to a decrease in organ donation if the concept of organ donation as a voluntary gift is replaced by a perception of compulsion. Others, however, feel that presumed consent would have a positive effect on organ donation numbers. On balance, that is my position. I will return to that at the end of the statement.

Our society was unanimous that whatever legislation is introduced, the practical details of its implementation will be vital in ensuring that current levels of consent to organ donation are maintained. We are the group who will be asked to implement any new legislation and we hope it will be drafted to ensure there are no accidental obstacles to organ donation in it. Issues of concern to us include how the issue of consent to organ donation will be addressed in practical terms. We must examine what will happen if no relatives are available to provide consent and whether presumed consent would apply to donors after cardiac death, which are a different group to donors after brain death. There is need to have a secure register for those who wish to opt out of organ donation before death, if presumed consent was introduced. We suggest it would be vital to have close collaboration with the clinicians on the ground who work in ICU in drafting any legislation or regulations for its implementation.

We are delighted with the amount of attention being given to organ donation and with the level of commitment of this committee in addressing the issue. Organ transplantation transforms the lives of patients and it will be a very positive achievement for society as a whole if we can maximise the number of patients who benefit from it.

To return to the issue of presumed consent, we canvassed opinion within intensive care medicine. A fairly significant majority was opposed on the basis that it could have the opposite effect to what is intended. That is something on which my colleagues will elaborate. On balance, I feel it would have a positive effect in terms of changing the terms on which we approach patients for organ donation, in making organ donation the norm rather than the opt-in position. Most importantly, when one looks at the evidence that is available from countries that have introduced presumed consent, it seems to be associated with a small but significant increase in organ donation, provided it is linked with improvements in resources, in particular improvements in staff who are aligned with organ donor co-ordination services.