To the Editor: We are writing in response to the pejorative, unhelpful and somewhat misleading editorial “The shortage of kidneys for transplantation in Australia”.1

There are many possible reasons for lower organ donation rates in Australia. Several Australian initiatives have led the way in reducing the incidence of severe, traumatic brain injuries. These include the compulsory wearing of seat belts and helmets, random breath testing, and a zero blood alcohol limit for inexperienced drivers. Intensive care medicine is better structured and organised in Australia and New Zealand than in most of the countries cited by Mathew et al, with higher organ donation rates. Intensive care outcomes in Australia are world-leading. So the donor rate may be lower because patient outcomes are better. A comprehensive chart audit of donor potential in New South Wales carried out under the supervision of the Organ Donation Network NSW/ACT, identified very few missed donors (T Wills, Manager, Organ Donation Network NSW/ACT, personal communication), and a Victorian audit has suggested that the donor pool may be much lower in Australia than previously estimated.2

Similarly, organ donation rates will appropriately vary considerably among hospitals. To improve outcomes, critically ill patients are transported to centres with specific experience and expertise, resulting in a preponderance of potential donors in hospitals with trauma and neurosurgical services compared with hospitals lacking these. The intensive care community supports these life-saving initiatives, notwithstanding the effect they may have on organ donation potential.

In fact, the principal “barrier” to organ donation in Australia appears to be the consent rate. From 2000 to 2004, 44% of families declined organ donation when faced with an actual rather than a hypothetical request.3

The intensive care community represents the interests of critically ill patients and their families. We will continue our best endeavours to improve both the survival and quality of life of patients suffering devastating brain injuries (our performance standard). When all brain function ceases, despite our best efforts, we will continue to facilitate organ donation, in discussion with the family, and in consideration of the patient’s known or projected wish. The intensive care community has led the way in developing organ donation-related practice guidelines4 and in related education. Australian Donor Awareness Program — Training (ADAPT) workshops are now a compulsory component of Fellowship of the Joint Faculty of Intensive Care Medicine training. The editorial implication of poor performance and lack of commitment is inaccurate and offensive.

In reply: We regret that Raper et al have misinterpreted our editorial on the shortage of donor kidneys in Australia.1 We are particularly concerned and indeed mystified by their last statement, where they state that we implied that “poor performance and . . . lack of commitment” were to blame. This was in no manner our message. Rather, we sought to emphasise that all possibilities to optimise local donation rates should be explored, so desperate patients seeking grafts from potentially dangerous overseas sources need not expose themselves to serious potential morbidity and mortality.

We consider that our intensive care colleagues perform superbly under the most difficult of circumstances when managing potential organ donation. We understand they are often unsupported with managing potential donations while they must at the same time deal with the grieving family, and the immediate demands of treating other seriously ill patients. We simply suggest that problems within the system (for example, differences between states in the number of intensive care beds per head of population or in the provision of specifically funded donor coordinators) that might hinder increasing organ donation should be carefully examined.

We believe it is unhelpful to suggest that the South Australian experience should simply remain unexplained. In the article by Opdam and Silvester (cited by Raper et al), of 112 potential donors, 46 were considered medically suitable unrealised potential donors, and their estimated maximal potential donor rate was 30 per million,2 remarkably similar to the rates seen in Spain (the country with the highest organ donor procurement rate) and South Australia. We agree with the conclusions of Opdam et al that “an increase in the organ donation rate may be possible through increasing consent and the identification and support of potential donors”. As they also state, this would require substantial changes in clinical practice, with resource and ethical complications

We did not mean to offend our intensivist colleagues. We merely suggest that we all need to assess the systems in which donation occurs and attempt to improve donation rates, for the sake of the many desperate people awaiting organ transplants in this country.