Do "silent" brain deaths affect potential organ donation?

Brain death (BD) is not a stable, objective condition; in fact, it strongly depends on early intensive treatment before death, brain stem reflex testing, and intensive care unit (ICU) physician attitudes. Consequently, unpredictable "silent" BDs due to inadequate treatment or omitted declaration may affect potential organ donations. Several lines of evidence suggest that 55% to 65% of all deaths among patients with acute cerebral lesions (DACL) in the ICU may become brain deaths. Since DACL are easily measurable, deviations from the expected ratio of declarations will disclose "silent" BDs. Results from the National Registry of DACL in ICU settings have confirmed that BD declarations are consistently fewer than the number expected in Italy, particularly in regions where organ donation rates are low. Only 43% of the 10,304 referred DACL were potential donors in a 2-year period. Thus, around 1000 BDs per year are missing in Italy. Significant clinical factors for lost BDs may be older age and timing of death. As DACL represent the global donation potentiality (possible donors), we suggest the use of a new indicator-DACL in ICU per million population-and careful analyses of differences in DACL per million people among regions. In conclusion, since striking deviations from the expected ratio between BD declarations and deaths with an acute cerebral lesion exist in some regions, targeted training and support to ICUs should be planned. As adequate neurointensive treatment can improve outcomes and reduce "silent" BDs, more organ donors may exist where patients with acute cerebral lesion are better treated.