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175
Correspondence: Claudia Helena Marck, Emergency Practice
Innovation Centre, St Vincent’s Hospital Melbourne, PO Box 2900
Fitzroy, 3065 VIC Australia; e-mail: claudia.marck@svha.org.au
COMPARING ORGAN DONATION PRACTICES
AND RATES BETWEEN AUSTRALIA AND THE
NETHERLANDS TO DETECT BEST PRACTICES
AND AREAS FOR IMPROVEMENT
Claudia H. Marck1,2, Nichon Jansen3, Sandra L. Neate4, Bernadine M. Dwyer5, Frank van Haren6,
Willem Weimar2, Jan N.M. IJzermans2
1 Emergency Practice Innovation Centre, St Vincent’s Hospital, Melbourne, Victoria, Australia
2 Department of Internal Medicine, Section Transplantation, Erasmus Medical Centre Rotterdam, The Netherlands
3 Dutch Transplant Foundation, Leiden, The Netherlands
4 Organ and Tissue Department, St Vincent’s Hospital, Melbourne, Victoria, Australia
5 Organ and Tissue Authority, Canberra, Australian Capital Territory, Australia
6 Australian National University Medical School; and Intensive Care Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia
Keywords - Organ transplantation, brain death, circulatory death, Cross-Cultural Comparison, humans
Received October 10th, 2014, revised November 28th 2014, accepted December 1st, 2014
Summary
- Improving deceased organ donation rates is a priority worldwide. Australia and the Netherlands are devel-
oped countries that have historically had similar donation outcomes, but varying attitudes and practices make comparison
of interest, as opportunities may exist to learn from each other. For example, Australia has successfully implemented a
reform to increase donation and transplantation rates in 2009, whereas Dutch rates have only slightly increased following
the implementation of a similar government plan in 2008. While 30-40% have registered their wish regarding donation
in both countries, more than 10% of the Dutch population registered unwilling to donate, compared to only 0.1% in
Australia. Differences exist in donation after circulatory death (DCD) practices and rates, with Australia implementing DCD
pathways in hospitals in recent years. Emergency department (ED) clinicians in Australia are increasingly involved in donor
recognition and referral, whereas the number of potential donors in Dutch EDs is unknown and Dutch ED clinicians have
minimal involvement in donor identification and referral. In both countries potential donors are still missed, but compari-
sons are made difficult as data collection and reporting methods differ. There are significant areas of lack of data, such as
potential DCD numbers in Australia and potential donors transiting the ED in the Netherlands. Assessing these potential
donor pools may help increase organ donation rates. Comparing practices and outcomes between countries can be a
useful method to detect effective practices in each country and identify areas for improvement, and this may be further
facilitated by applying international data collection and reporting standards.
ORGANS, TISSUES & CELLS, (17), 175-183, 2014
RESEARCH ARTICLE
176 C.H. Marck et al.
consent, pathways of donation and reporting on (poten-
tial) donation rates. Furthermore, it is hypothesized that
emergency departments (EDs) play an important role in
the identification and referral of potential donors. Dona-
tion after circulatory death (DCD) occurs with increasing
frequency in both countries and, due to the time pressures
involved in the DCD process, timely referral is of the es-
sence. Patients with a poor prognosis who may be eligible
to donate are often first seen by an ED clinician and end-
of-life decisions are frequently made in ED. Therefore, the
involvement of the emergency department (ED) in these
two industrialized Western countries will be explored and
compared in order to detect and learn from their practices.
Comparing donation rates and outcomes
Both the Netherlands and Australia have been steadily
increasing rates of donation and numbers of transplant
recipients although Australia’s relative increase has been
larger. In the Netherlands in the last 5 years the number
of donation after circulatory death (DCD) donors has
overtaken the number of donation after brain death (DBD)
donors, which impacts negatively on the number of trans-
plant recipients, as fewer organs can generally be retrieved
from DCD donors compared to DBD donors. In Australia
the proportion of DCD to DBD donors is increasing but
still equates to less than a quarter of all donors (Figure 2).
Although the re-implementation of DCD pathways and
protocols is still in the early stages in Australia, DCD has
provided Australia with an expansion of the donor pool
and this is expected to increase further as the process is
optimized, importantly without decreasing the number of
DBD donors (1, 2). As the two countries’ demographics
and geography differ, there may be an inherent difference
in the potential donor pool. Comparing outcomes between
countries is further challenged due to differences in prac-
tices and laws (3), population demographics, and variations
in data collection and reporting methods. The Netherlands
defines deceased organ donors as donors of which at least
one organ is transplanted; Australia defines organ donors as
those who underwent organ retrieval surgery regardless of
whether any organs were actually retrieved or transplanted.
Also, differences are found between data reported by the
websites of The International Registry on Organ Donation
and Transplantation (IRODaT), the European Directorate
for the Quality of Medicines and Healthcare (EDQM)’s
Transplant Newsletter, and the annual performance reports
from the Dutch Transplant Foundation (Nederlandse
Transplantatie Stichting, NTS) and the Australian Organ
and Tissue Authority (OTA) for donation rates per million
population (PMP) (Table 1). Although outside the scope
of this article, it should be taken into account that both
Background
The shortage of deceased organ donors leads to patients
dying on the waiting list for transplantation. This unac-
ceptable situation is the incentive for most countries to
continue searching for new ways to improve donor rates.
Both the Netherlands and Australia have had historically
comparable deceased donation rates which are significantly
lower than many other developed countries (Figure 1) and
major efforts have been made in both countries to increase
donation rates in the last five years. This article seeks to
compare and contrast policies and practices in these coun-
tries and to identify areas where there may be potential to
learn from the other countries’ practices which could assist
with improving donation rates. It comprises an overview
of deceased organ donation rates in the Netherlands and
Australia, and compares the practices related to obtaining
FIGURE 1 - IRODaT 2011 worldwide deceased donation rates per million
population (39).
Comparing organ donation practices and rates between Australia and the Netherlands to detect best practices… 177
organ and tissue transplantation. The OTA employs 93
staff in eight specialist “DonateLife” agencies and in addi-
tion employs 162 medical and nurse donation specialists
(DS) within 72 hospitals in Australia, who mostly work in
these roles part time while also employed by hospitals in a
clinical nursing or medical role (6). Given the geography
of Australia, there are smaller rural and remote hospitals
that do not have affiliations with the OTA, however most
hospitals with a significant potential donor pool have at
least one DS. Hospital based DSs provide education for
staff in various hospital departments on the use and imple-
mentation of the national “Clinical Trigger” tool (Figure 3)
(7) which assists staff to identify and refer potential donors
thereby ensuring that all potential donors are identified
and their next of kin, usually a family member or partner
(hereafter called family) is provided with an opportunity
to discuss organ donation. These DSs have been trained
in family donation conversations and are often the point
of contact for hospital staff to assist them with conversa-
tions with the family of a potential donor. The College of
Intensive Care Medicine has included Family Donation
Conversation training as part of the mandatory training
programme for intensive care trainees. In most states,
when a potential donor is identified and it seems likely
that consent for organ donation will be obtained, the DS
contacts a coordinator from the local DonateLife agency
who attends the donor hospital to organize the donation
and transplantation. More recently there has been a move
towards, and a trial of, a collaborative request model where
the coordinator will become involved earlier and play a
significant role in the planning of and participation in the
family donation conversation.
The NTS, the organisation responsible for coordinating or-
countries, but especially the Netherlands, is investing large
efforts into living donation, which affects waiting list data
considerably.
Organisation
In Australia the commonwealth government funded OTA
(also known as DonateLife), was established under the Aus-
tralian Organ and Tissue Donation and Transplantation Au-
thority Act 2008 (4) in 2009 and was allocated $AUD151
million to develop and implement a National Reform
Agenda over the following 4 years. The purpose of the
OTA is: “to establish - in partnership with states, territories,
clinicians, consumers and the community - a nationally
coordinated approach to organ and tissue donation for
transplantation” (5). Although there are national guidelines
and protocols regarding deceased organ and tissue dona-
tion, every state and territory has its own laws to regulate
the Netherlands Australia
2009 2010 2011 2012 2013 2009 2010 2011 2012 2013
Number of deceased organ donors~ 215 216 221 252 255 247 309 337 354 391
Number of transplant recipients 634 643 672 746 703 808 943 1009 1053 1122
Transplant recipients per donor 2.9 3.0 3.0 3.0 2.8 3.3 3.1 3.0 3.0 2.9
Donors per million population (IRODAT) 13.0 13.0 13.2 15.1 15.3 11.3 14.0 15.1 15.6 16.9
Donors per million population (NTS/OTA) 13.8 13.7 13.6 15.3 15.2 11.4 14.0 15.1 15.6 16.9
Donors per million population (EDQM) 13.8 13.7 13.6 15.3 15.9 11.3 13.5 14.9 15.5 16.8
People on waiting list^ 1288 1300 1311 1286 1149 1768 1663 1614 1536 1556
Dutch data from Nederlandse Transplantatie Stichting (NTS) (10, 40), The International Registry of Organ Donation and Transplantation (IRODaT) (41), and
Centraal Bureau voor de Statistiek (42).
Australian data from Australia and New Zealand Organ Donation Registry (ANZOD Registry) (44-46) and Organ and Tissue Authority (46, 47).
International data from the European Directorate for the Quality of Medicines and Healthcare (EDQM) Transplant Newsletters (48-52) and IRODaT (53).
~ The Netherlands defines deceased organ donors as donors of which at least one organ is transplanted; Australia defines organ donors as those who un-
derwent organ retrieval surgery regardless of whether any organs were actually retrieved or transplanted. Donors who did not have organs transplanted: six
in 2009 and 2010, five in 2011, 12 in 2012 and no data is available yet for 2013.
^ Waiting list data from December 2013 for both countries.
TABLE 1 - Deceased organ donation and transplantation data.
FIGURE 2 - Organ donation rates.
178 C.H. Marck et al.
hospital), uDCD category 2 (circulatory death inside the
hospital when resuscitation is not successful), controlled
DCD (cDCD) category 3 (anticipated circulatory death in
hospital) and 4 (circulatory arrest in a brain-dead donor)
(8). Australia does not perform uDCD and not all hospitals
offer controlled DCD pathways. Potential DCD donors in
hospitals without DCD pathways are either transferred to
other hospitals if feasible, or are unable to donate organs.
This applies also to potential organ donors if they are
located in a remote area where some hospitals or clinics
may not have an ICU. In addition to these geographic and
logistic challenges, Australia’s criteria for donor age, and
maximum time from withdrawal of respiratory support to
circulatory arrest to allow for transplantation are currently
stricter than the Dutch criteria and this can have a signifi-
cant impact on the number of potential and actual donors
and transplantation outcomes.
Reporting systems
In Australia, donation specialists retrospectively review
all deaths occurring in the 72 hospitals in the DonateLife
network and complete monthly reports on the number and
characteristics of potential donors identified, referred, and
missed, the so called “DonateLife audit”. This includes all
deaths in those aged between 28 days and 80 years occur-
ring in, or within 24 hours of leaving, the ED or ICU and
all other patients for whom organ donation was considered
(9). Within the hospital, and at jurisdictional DonateLife
meetings, these data are reviewed and discussed, with a
focus on ensuring minimization of missed donors and
improving potential donor identification and consent
procedures. These data are also collected by the OTA on
a national level. Although data on all potential donors is
collected in the audit, data published in the yearly per-
formance report of the OTA only includes approximate
figures as rates of consent to donation and conversion
(actual organ donors/all potential donors) are calculated
using only data from donors with confirmed or probable
brain death, and does not include those with imminent
brain death, or potential DCD donors due to OTA’s con-
cerns about accurately and objectively identifying potential
DCD or imminent brain death donors via the audit tool.
In the Netherlands a similar reporting system records all
hospital deaths through physician completed documenta-
tion including a donation form. Dutch donation coordina-
tors and transplant coordinators review these forms in all
95 hospitals (this includes all Dutch hospitals except pri-
vate clinics and cancer centres). Collected data are entered
in the ‘Dutch Deceased Registration Donors’ (Nederlandse
Overledenen Registratie Donoren, NORD), an application
developed by the NTS. These data provide information
gan donation and transplantation in the Netherlands, came
into existence one year before the Dutch organ and tissue do-
nation act was implemented in 1998. In 2008 a governmen-
tal program “Master Plan Organ Donation” was launched in
order to increase the number of organ donors and a number
of organisational changes were implemented. First, hospitals
were clustered; one large hospital together with a number
of smaller hospitals, and within the cluster local donation
coordinators were employed. Donation coordinators provide
education to medical professionals including training in
donation related communication with family and register all
hospital deaths in order to monitor the entire process from
donor identification to donor referral. All organ donation
procedures in Dutch hospitals are facilitated by transplant co-
ordinators, who attend the donor hospital as soon as the rela-
tives provide consent or authorization for donation. These
coordinators are also involved in providing education, data
collection and reporting. Secondly, in these clusters, dona-
tion intensive care physicians were appointed in the intensive
care units (ICUs) to facilitate organ donation. The donation
intensive care physicians evaluate all organ donation requests
within their cluster, by the use of a questionnaire, to find
out the strengths and weaknesses within the consent process.
Thirdly, regional self-supporting organ retrieval teams were
appointed to retrieve organs for transplantation, without
having to rely on the operating team of a local donor hospi-
tal. These organisational changes have now been rolled out
nationally and will be evaluated at the end of 2014.
Practices
The Netherlands currently carries out DBD and DCD
including uncontrolled DCD (uDCD) Maastricht cat-
egory 1 in a pilot setting (circulatory death outside the
FIGURE 3 - Clinical Trigger.
Comparing organ donation practices and rates between Australia and the Netherlands to detect best practices… 179
depending on whether the register was checked before or
after the request, that those who have consented have then
had the register checked following conversations with the
family. In the Netherlands, legislation mandates that the
donor register is checked for every potential donor and
documentation regarding organ or tissue donation is com-
pleted for every deceased patient.
In Australia as well as in the Netherlands, registration on
the ODR is legally recognised as consent or non-consent,
for people aged over 16 (in the Netherlands) or 18 (in
Australia), however confirmation that this wish has not
changed since registration is usually requested from fami-
lies. In most cases, families adhere to the legal consent or
non-consent as recorded on the ODR. However, the prac-
tice in both countries is not to proceed with donation if the
family has serious objections even after consultations with
specialists, as there is concern about the impact of proceed-
ing against the family’s wishes (15) (Table 3).
Family consent and donor conversion rates
In Australia, only data on potential donors who were
confirmed or suspected brain dead are included in reports.
In 2013, 4% of potential donors were missed, and there
was an approximate consent rate (rate at which families of
potential donors consent) of 61% and conversion rate (the
rate at which potential donors become actual donors) of
54% (16). These data are estimates and, due to concerns
regarding consistency in methods of data collection and
reporting between jurisdictions, it is not possible to obtain
data on other potential donors. In Australia the DonateLife
audit registers those registered on the AODR as ‘not willing
to donate’ as a non-consent, but this is a rare occurrence
and only minimally affects consent rates. Given imminent
brain death and DCD potential donors are not taken into
account in the reported consent and conversion rates, it is
likely that consent and conversion rates across the whole
donor pool may be lower (14).
about deceased patients and potential donation opportu-
nities. In addition, a more comprehensive assessment on
medical records of deceased patients in ICUs from 92 hos-
pitals is carried out to identify barriers to organ donation.
Reported data on potential donors includes all confirmed
and suspected brain dead potential donors and potential
DCD donors from hospitals with a DCD protocol, who
died while receiving cardiorespiratory support. It is esti-
mated that around 99% of potential donors are identified
in the ICUs of Dutch hospitals based on data from the
additional medical record review (10).
Organ Donation Register
Although a topic of discussion in both countries, presumed
consent (an opt-out system) has not been adopted in either
country. While the Dutch are able to register their wish
regarding donation from the age of 12 (11), Australians are
able to register intent at age 16 and consent at age 18 (12).
While both have the option to register their wish to donate
or to not donate, and specify organs and tissues they wish
to donate, the Dutch also have the additional option to de-
fer this decision to the family (which is the default in both
countries when someone is not registered) or another speci-
fied person. A striking difference between these countries
is that, while 30-40% of the population are registered on
the organ donor register in both countries, the proportion
of people registered as not willing to donate in the Neth-
erlands is 100 fold higher compared to Australia (Table 2).
Although it is encouraged, it is not yet routine practice in
all Australian states and territories to check the Australian
organ donor register (AODR) before a request is made to
the family for consent and there is no national data avail-
able regarding how frequently and when the AODR is
checked. Recent Victorian audits revealed that the register
was checked in 50%-85% of cases and that checking the
register was associated with a higher consent rate (13, 14).
It is possible, however, that this association may reflect,
The Netherlands Australia
NOf all
registered Of population N Of all
registered Of population
Registered 5.771.382 100% 39.6% 6.009.246 100% 32.5%
Wish to donate^ 3.485.914 60.4% 23.9% 5.986.276 99.6% 32.4%
Wish not to donate 1.581.359 27.4% 10.8% 22.970 0.4% 0.1%
Family to decide 704.109 12.2% 4.8% N/A N/A N/A
^ Registered wish to donate at least one organ or tissue.
Dutch donor registration data on 31-12-2013 (54), Population data on 1-1-2014 (14.589.608 people ≥ 12 years) (55).
Australian data from 31-4-2014 (12). Population data on 30-6-2013 (18.480.406 ≥ 16 years, best available data). In 2005 the Australian organ donation
register changed from registering “intentions to donate” to “valid consent to donate”. This table shows combined number of intent and valid consent.
TABLE 2 - Organ donor registration data.
180 C.H. Marck et al.
organ retrieval rate compared to other inpatient units in-
cluding the ICU (27). Two audits performed in 2004 and
2006 in Australia showed that there was a missed potential
donor pool in EDs (25, 26) and a recent audit showed that
13.8% of potential donors were identified in ED indicat-
ing that the ED plays a small but significant role in donor
identification in Australia.
Data from the NORD have the potential to provide
valuable information regarding the potential donor pool
identified in, and referred from, EDs in the Netherlands,
however no reports detailing this are currently available
(28). There are few missed donors from Dutch ICUs,
however, preliminary data indicates that not all potential
organ donors are identified in EDs in the Netherlands (29).
As it became clear in Australia that there was a missed
potential donor pool in EDs (25, 26), the Australian
government aimed resources at improving identification
of potential donors in EDs by implementing a Clinical
Trigger nationwide. This tool assists clinicians in EDs and
ICUs to identify and refer potential donors. The Trigger
(Figure 3), including the referral details for that specific
hospital is depicted on posters in the ICU and ED, and
many staff members carry a plasticised card. There are sev-
eral Australian hospitals where emergency physicians have
been trained by the OTA to communicate with families
and other health clinicians regarding organ donation, and
are appointed as a DS to raise awareness regarding organ
(and tissue) donation. Potential donors that were missed in
ED are identified retrospectively by the DonateLife audit
and this information is used to assist in giving feedback to
those clinicians involved. A recent study showed that 63%
of ED clinicians were familiar with the clinical trigger and
that 78% supported the use of this Trigger in the ED (30).
In the Netherlands, the numbers of organ donors going
from the ED directly to theatre for organ retrieval are
small, and are only uDCD donors (category 2, or category
1 in a pilot setting). It has only recently been nationally
recognised that perhaps not all potential DCD and DBD
donors, who are generally referred to ICU before organ
Dutch data from 2013 shows that only 10 of 863 (1%)
potential donors in ICUs were missed, the organ donation
register was checked in 87% of identified cases and when
registered objection was lacking, donation was discussed
with the family in 95% of cases (Table 3) (10). Although
consent is legally not required for those registered as will-
ing to donate in the Netherlands, in 6% of these cases the
family objected to organ donation and donation did not
proceed. The consent rate of 48% ultimately gave rise to
a conversion rate of 30% (10). Although it is difficult to
compare these rates due to the differences in definitions of
potential and actual donors (Table 1), the overall Dutch
family consent rate of 48% in 2013 seems lower than the
Australian consent rate of 53-61%, which is again lower
than the target set by OTA to obtain family consent in
75% of all potential donors. Equally, the conversion rates
seemed lower for the Netherlands (30%), compared to
Australia (34%-50%), again lower than the targets set by
the OTA (50% for DCD and 70% for DBD donors).
Potential donor pool and involvement of emergency
departments
Despite many initiatives, there may still be room for im-
provement regarding deceased donation rates. One of these
areas is donor recognition in the ED. Traditionally, organ
donation occurs from the ICU, however the ED can play
an important role in the early identification of potential
organ donors, for both potential DCD donors and DBD
donors. This was first mentioned in the literature in 1977
(17) but the ED has only in the last decade received more
serious recognition as a source of potential organ donors
around the world including the USA (18), UK (19-21),
Brazil (22), Turkey (23), Canada (24), and Australia (25,
26). Although some indicate the potential donor pool in
ED may be small, any increase in donor recognition would
make a significant difference to donation rates (21). In ad-
dition, referral from the ED may have a higher success to
Category N % Family approached Family consent rate
Register not checked 110 13%
542 94% 34%
Register checked but outcome unknown 7 1%
Not registered 394 46%
Registered that family is to decide 64 8%
Registered as not willing to donate 115 13% (family not approached)
Registered as willing to donate 163 19% 162 99% 94%
Total 853 100% 704 95% 48%
Adapted from NTS annual report 2013 (10) including all identified DBD and DCD (only from hospitals with a DCD protocol) potential donors on a ventilator.
TABLE 3 - Consultation of the Donor Register and family consent rate for recognized potential organ donors in 2013 in the Netherlands.
Comparing organ donation practices and rates between Australia and the Netherlands to detect best practices… 181
training to assist with communication with donor families
in both countries, and although it is available to ED staff,
their involvement in formal training has thus far been less
common and largely driven by advocates.
Discussion and conclusion
The comparison between Australia and the Netherlands
in deceased organ donation practices and rates show that
organisational structures are generally similar. However
significant differences between the two systems exist. While
Australia’s rates of DBD and DCD donation have both
increased in recent years and are expected to increase fur-
ther, the slight increase in the Netherlands seems due to an
increase in DCD donors, the number of DBD donors (the
preferred pathway) fluctuates. Best practices that have been
identified are 1) the recent efforts made in Australia to im-
prove donor recognition and referral from EDs, including
the Clinical Trigger tool that assists clinicians to recognize
donors, 2) the inclusion of the DCD pathway in all Dutch
hospitals, and 3) the inclusion of all potential donors in
audits and reports which currently does not occur in either
country; while the Netherlands doesn’t collect or report
data on potential donors in EDs, Australia doesn’t report
data on missed DCD or imminent brain dead donors.
In the Netherlands, assessing the potential donor pool
in EDs may elucidate whether it is worthwhile to invest
efforts to increase the involvement of EDs. Improving
donor recognition and referral from the ED may increase
donation rates as potential donors may arrive via the ED,
especially in the Netherlands where (controlled and un-
controlled) DCD is a common practice. As the number
of identified and referred potential donors increases and
potential donors are identified earlier, higher success rate
for donation and transplantation may result. Assessing
Dutch ED clinicians’ attitudes and knowledge regarding
the identification and referral of potential donors would be
warranted as significant barriers may exist and need to be
overcome to improve the involvement of ED staff.
In Australia, it is expected that a proportion of potential
DCD donors are currently missed as DCD pathways have
not yet been implemented in all Australian hospitals, how-
ever, these data are not reported currently. These data could
help to further assess if and where the implementation of
DCD pathways may be warranted to increase donation
rates.
Central to all these considerations is the need for applying a
more uniform international standard that defines categories
of potential donors, missed and actual donors, and criteria
for collecting, registering and publishing these data are nec-
essary to be able to compare between countries and identify
areas for improvement, or set targets (37, 38). Although
retrieval, are identified in the ED. Because there are no do-
nation specialists working in the ED, clinical staff have the
responsibility for potential donor identification and referral
to ICU. There are no Dutch equivalents to the Australian
Clinical Trigger for use in ED. Several projects and initia-
tives are currently being undertaken to analyse end of life
care decisions that may have an impact on the possibilities
for organ donation in the Netherlands. In the Netherlands
ICU and ED doctors are trained in ‘Communication about
Donation’, to facilitate medical professionals raising the
subject of donation and assisting the family in the decision-
making process.
The Netherland is a frontrunner in the area of controlled
DCD in the ICU, the southern region is particularly active
in this area as they have been practising both uncontrolled
and controlled DCD for over 25 years. As uDCD donors
are often identified in ED, they have had longstanding
connections with ED staff. This area of the Netherlands
also had the highest donation rate PMP in 2013, 30.2
compared to 15.2 nationally (10). This area is involved in
several pilot studies and projects involving the ED with the
aim of maximising the opportunities with regard to the
potential donor pool. Some of the hospitals involved have
now employed dedicated staff to educate and raise aware-
ness among ED clinicians regarding DCD, and assist if a
potential donor is identified in ED. The final results of this
pilot have not been yet published (31).
A national survey carried out in Australia in 2011 in over
800 Australian ED clinicians, showed that many had
been involved in organ donation related tasks and most
felt comfortable and competent doing so, however barri-
ers were identified regarding available resources as well as
knowledge about eligibility, brain death and DCD. Most
importantly, having received some education regarding
organ donation was related to having more knowledge and
more positive attitudes, and a large majority indicated a
need and desire for further education (30, 32-35). These
data have informed further education programs. While in
Australia emergency medicine was recognized in 1993 as a
formal specialty, in the Netherlands this is a relatively new
specialty only formally recognized in 2008 (36). Therefore
medical staff working in Dutch EDs were from a vari-
ety of medical specialties. Little data is currently available
about the Dutch ED clinicians’ involvement, attitudes,
knowledge and perceived barriers to organ and/or tissue
donation. The authors of a qualitative report with Dutch
medical specialists from several disciplines (other than the
ED) recommend further assessment of the role and the
number of potential donors in the ED and indicate that
ethical barriers are likely to play a role (28). Awareness and
willingness of staff to be involved in organ donation is cru-
cial for complex interactions where time is of the essence
(28, 31). Intensive care medical staff receive (mandatory)
182 C.H. Marck et al.
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these limitations currently impede the ability to directly
compare family consent and conversion rates, in this study
it seems that the Dutch family consent and conversion rates
may be lower. Furthermore, a significant proportion of
Dutch people are registered on the ODR as not willing to
donate, while this proportion is negligible in Australia. This
may reflect a difference in public attitudes towards deceased
donation that may affect consent and donation rates. This
remarkable difference in organ donor registrations between
Australia and the Netherlands deserves further study.
Author’ contributions
Claudia Helena Marck conceived the study and analysed
the literature with Nichon Jansen. Claudia Helena Marck
and Nichon Jansen drafted the manuscript and all authors
revised the manuscript and approved it before submission.
The authors declare that they have no conflict of interest.
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