End-stage organ failure is associated with high mortality, and organ transplantation is the current standard of care [1]. Organ transplantation would not be possible without the generosity of living and deceased organ donation [2]. Deceased donation is possible after brain death (donation after brain death [DBD]) or after circulatory death (DCD). The primary source of organ donation is DBD [3]. Organ donation has legislative and regulatory implications that vary across countries. Worldwide organ donation rates are measured in donors per million of population (PMP). Deceased donation rates vary among different countries, ranging from 0.2 PMP to 46.90 PMP [4].
In spite of the global efforts to improve organ donation rates, the number of organ donors remains low [5]. Patients with end-organ failure face long waiting times on the waitlist, which sometimes ends with mortality before receiving an organ. The situation is worse for the pediatric population; twice as many pediatric patients die while waiting for organ transplants when compared to adults [6]. The proportion of deceased organ donation in pediatrics is lower than in adults due to several reasons—including low mortality in the pediatric age group, medical unsuitability, contraindications, and missed opportunities with potential donors [7]. This has led to limiting organ transplant surgeries in pediatrics [8, 9].
Reasons for poor donation rates are multifactorial and include medical contraindication, failure to identify potential donors, failure of donor organ maintenance, failure to confirm brain death diagnosis, and refusal by relatives [10]. Brain death disclosure and DBD discussions occur mostly in the intensive care unit (ICU), rendering intensivists major stakeholders in this process [11]. Intensivists need to acquire essential competencies to achieve successful donations—such as identifying potential donors, guiding families through the process of brain death, and facilitating donor management [12, 13]. A lack of these competencies leads to missed donations. A retrospective study of all deaths in ICUs and emergency rooms in Alberta, Canada, identified 64 patients with a high probability of becoming brain death donors that were missed, which could have increased the organ donation rate by 7.5 PMP [14].
The important role intensivists play in the process of organ donation has been recognized by leading countries. Spain, for instance, has the world’s highest deceased organ donation rate (46.9 PMP), followed by Portugal at a distant second with 34 PMP (actual deceased donors) during the same period [15]. While Spain’s success in deceased organ donation is multifactorial, the role of trained intensivists forms a cornerstone of that success. Intensivists both lead and identify the disclosure process. All health professionals in Spain are trained in deceased organ donation [12, 16].
Pediatric intensivists play the same pivotal role in the identification and management of pediatrics organ donors [8]. The American Academy of Pediatrics recommends national strategies for the training of physicians involved in all aspects of organ transplantation—including psychological, social, and medical aspects [17]. Evidence suggests pediatric intensivists have less knowledge when compared to adult intensivists on matters of brain death, and only one-third (33%) of pediatric intensivists considered themselves with a high level of assurance in explaining brain death to family members [18].
Organ transplantation spans over four decades in Saudi Arabia [19, 20]. The country is the fourth-highest in living organ donations, with 27.7 PMP. However, deceased donation rates remain relatively low (3.3 PMP) in 2017 [15]. From 2010 to 2016, the annual number of reported potential DBD cases remained relatively unchanged between 570 and 710 [21].
The Saudi Center for Organ Transplantation (SCOT) has laid down clear policies for the diagnosis of death by brain function criteria and acquisition of the approval of religious scholars on DBD. While SCOT facilitates the process of organ donation through coordinators assigned for different hospitals, most intensivists are not aware of this role [20, 22]. Children who are potential donors comprise a significant proportion of all donors, with those under 10 years of age and those between 10–20 years of age comprising 11% and 28.4% of all donors, respectively [21].
Thus, organ donation in Saudi Arabia could greatly benefit from involving intensivists in the process. However, to formalize the organ donation process, intensivists’ competencies need to be identified and knowledge gaps and skill deficiencies assessed. This study, therefore, set to identify intensivists’ knowledge and skills relating to the brain death process and organ donation. Unlike previous studies, which were general in terms of assessing organ and tissue donation, the present study addresses physicians’ competencies with respect to several aspects, including the neurological determination of death and DBD, while exploring the medical, legal, and cultural/religious considerations of transplantation.