[Management of organ donation for patients with severe coma due to cerebrovascular stroke]

Organ procurement practices are tending towards the use of older or more borderline donors. In the current context of steadily decreasing availability of traumatic donors, stroke victims make up the majority of donors. In France, where organ procurement activity has stabilized following a period of growth, the possibility of organ donation after a cerebral stroke is variable and uncertain.

Among potential donors--severe coma patients beyond therapeutic possibilities--those who are stroke victims are also those for whom emergency units often initiate the support withdrawal process early, before brain death. Yet the time to the final diagnosis of brain death is also the time necessary for intensive care before organ procurement. Several teams with expert experience in dealing with relatives in these circumstances have demonstrated the steps of the process.

Potential donors can be admitted to intensive care units with the exclusive aim of organ removal. This strategy can be accepted only if the organ donation has a reasonable chance of success. The probability of brain death must therefore be likely and no contraindications found. The key element is open and frank communication with relatives about the severity of brain injury and the lack of therapeutic alternatives. With the relatives, it is recommended to separate the discussion of withdrawal from the question of possible opposition to organ donation.

This approach allows both support for end-of-life patients, and fulfillment of their wishes with regards to organ donation. It enables case-by-case decision-making, after relatives have agreed on transfer to the intensive care unit for organ removal. Thus, each hospital should institute a fully cooperative care procedure where all therapeutic possibilities are evaluated in order to enable the most appropriate therapeutic approach, and, if applicable, organ procurement.