Background/Objective: Organ donations in Japan remains markedly less common than in other developed countries, partly due to limited recognition of potential brain death (PBD) or legal constraints affecting the critically ill. In particular, pediatric end-of-life (EOL) and donor process remain poorly characterized. This study aimed to review intensive care unit (ICU) deaths at a leading institution with the highest number of organ donations in Japan, to identify challenges unique to the Japanese pediatric donor process.
Methods: A single-center retrospective observational study was conducted at Okayama University Hospital, including pediatric patients (<18 years) who died more than 24hours after emergency ICU admission between April 1, 2018, and March 31, 2024.
Results: Seventeen children (47.1% male) with a median age of 7.2 years (interquartile range [IQR] 3.0-11) met inclusion criteria. Cardiac arrest occurred in 15 cases (88.2%), and external causes were identified in 11 cases (64.7%). All patients underwent brainstem function assessment, including continuous electroencephalography monitoring, and auditory brainstem response testing. These findings led to clinical diagnosis of PBD and EOL. Organ donation was discussed in 13 cases (excluding those with suspected abuse or developmental disabilities), with 5 families ultimately consenting to donation. Withdrawal of life-sustaining therapy was implemented in 12 cases (withdrawal of medications: 11; mechanical ventilator: 1). Median durations from admission to PBD diagnosis, family decision-making, and ICU stay were 6.7 days (5-9), 17.9 days (14-20), and 24.3 days (20-28), respectively. During this period, additional interdisciplinary team meetings were held a median of 3.6 times (3–5), and family conferences 6.5 times (5–8).
Conclusion: Pediatric organ donation in Japan was found to be a complex and prolonged process requiring clinical decisions based on PBD and ongoing communication with families. Only a limited number of cases resulted in actual donation, indicating the need for further examination of social, ethical, and institutional factors.