Dr. Colman O'Loughlin:

What I will do is drill down a little deeper into what we do as intensivists and why the views of the Intensive Care Society of Ireland on organ donation should carry a lot of weight. The majority of organs donated in this country are donated from brain-dead donors. The care of those patients occurs in intensive care units. Brain death occurs in intensive care after a significant brain injury where a person is on a life-support machine. The staff involved include the intensive care specialist, the nursing team and our trainees. It is our job to care for those patients. Our primary duty of care is to the patients and, by extension, to their families. Sometimes a brain injury progresses onto brain death. That is a clinical diagnosis that we must make at the bedside. We do two sets of brain stem tests. They are identical tests done by two separate groups of people separated by a brief period of time. Our job is to do the tests, the first, to determine brain death, and the second to confirm that at a later stage.

It is between the two sets of brain stem tests that we approach the family of the patient and bring up the issue of organ donation. How we do that is very important. It will be obvious to everyone that this is a period of extreme trauma for the family. There will be overwhelming grief, a lot of confusion, anger and a huge amount of tension among family members because these types of events happen, by and large, to young people and they happen very suddenly. One has to imagine what it is like to deal with these scenarios, the patients and their families. When we engage with them on the issue of organ donation it is very important that we do it delicately with a lot of compassion and empathy. How we say it and how we bring it up is extremely important. We are advocates for the patients and, thereby, their families. We do not have any say in who is on a waiting list for organ transplantation. We have no idea of what is happening on that end. We are on one end only. In these circumstances, we do not ask them to be organ donors or we do not ask them not to be organ donors, we give them the opportunity to consider organ donation. We do not necessarily ask for an answer straight away.

What we normally do is go back and do the second set of brain stem tests to confirm brain death. Time of death will be at the conclusion of the second set of brain stem tests. At this stage we will go back to the family and re-engage with them and ask for their opinion on the topic of organ donation. We will have families come back to us and say “Yes”, that for many years they have talked about it and it is something that they as a family and their deceased relative really supported for many years, and that they would like to consent to the process of organ donation. To that family I say, “Thank you for considering this. You have done the right thing for you, your family and your deceased relative.” Alternatively, the family might come and say they are not sure, that they have talked about it and they have never been easy with the concept, that they are not comfortable with it and not really keen to consent to organ donation. To that family I say, “Thank you for considering it. You have done the right thing for you, your family, and the deceased relative.”

What I am trying to say is that there is no right answer, there is no wrong answer. There is only the answer that is given to me by the family. I have to accept it. I have to remain and continue to remain neutral in the process. My duty of care is to the patient in the bed and his or her family and to no one else. I have to be really neutral. One might ask why I do not lobby for transplantation. I do not for the same reason that I cannot lobby against it. I have to be neutral. I can raise the question. Dr. Hickey explained the matter eloquently. My job is to ensure that in every single incident that brain death occurs in this country, the question is asked to the family to give them the option. Not to give the option is a dereliction of care from a societal point of view. I cannot sway their opinion either way but I have to give people the option. The role of the Intensive Care Society of Ireland in that is to make sure that this happens; to educate our colleagues and to provide resources and training for them so that they are aware of how brain death occurs, that they test for it properly and that they are given the proper skills to deal with the families, help them to come to terms with what is happening and to phrase the issue of organ donation in a neutral, empathic manner.

That is really what I want to say and I want to set the scene as to why and how this happens every single day, separate from the transplantation issue. I have reservations about presumed consent, largely because, as echoed by our transplant colleagues, I do not think it will make a huge difference. I go back to what I said about how we interact with a family and where I could bring presumed consent into the conversation. I am not going to change my style of conversation with the family, regardless of what comes out of this process because that is what is practised throughout the world and that is the recognised way of trying to deal with this delicate scenario with traumatised families.

Consequently, I do not see it as a huge issue but as being way down the list.

I will not go through all of the resource allocations required as that issue has been eloquently discussed this morning. However, from the perspective of consent, it is not the big issue. It is not the big ticket and I do not think changing this will make any difference. What really will make a difference is increasing resources and infrastructure.