After the Referral Call

Once the referred patient clears preliminary screening, an organ procurement coordinator (OPC) is assigned to the case to work through the final evaluation and donation process.

The procurement coordinator is not involved in direct patient care. Their role is to carry out all tasks necessary to preserve the opportunity for organ donation. This includes a conducting a detailed medical evaluation, offering support to the donor’s family, and directing the physiologic support for the potential donor. In addition, the procurement coordinator is responsible for approaching the family for authorization for donation. If the patient is a registered donor they will work with the family to facilitate donation. They will also coordinate with with the organ recovery team and manage the organ preservation and allocation process. 

Best Practices

Regular communication between the procurement coordinator and the hospital staff through the "huddle" is critical. The huddle is not just an activity or a one time event, rather it is an approach, an attitude towards donor and donor family support. The huddle represents the frequent and clear communication between the OPO staff and the hospital staff. All concerned personnel come together to deliver status updates, identify, discuss and solve issues, and delegate duties at every stage and for all aspects of the donation process. Generally organized and led by the procurement coordinator, the huddle enables all those involved in the donation process to coordinate and conform to the recognized best practices.

On one hand, the huddle enables the procurement coordinator to evaluate the patient for donation potential and institute physiologic support; on the other, it allows the critical care staff to continue providing end-of-life care to their patient. Above all, the huddle prevents errors in communication with the potential donor's family. When information is apparently contradictory, this can confuse the donor's family and make them less receptive to the idea of organ donation.

Hospital staff is expected to follow their hospital's order sets to continue to provide all relevant testing and physiologic support to the potential donor during this time. Good donor care is also good end-of-life care, and does not interfere with medical care. The OPC will review laboratory tests that are conducted by the hospital as part of regular patient care to help assess donor suitability. After a patient has been declared brain dead or the family has decided to withdraw care and agrees to donation after cardiac death (DCD; see below), the OPC will request certain tests be done to determine suitability.

After determination of death (see below), there are standardized order sets that CORE has developed for use at all hospitals in the DSA. These order sets are based on the best scientific knowledge about organ recovery and the best possible outcomes for transplant recipients. However, as research evolves, the guidelines in order sets can change. Structured donor management protocols improve adherence to quality care and significantly increase the number of organs transplanted without compromising the quality of the organ [36]. Donor management guidelines and critical care endpoints vary by the hospital and the specific organs being recovered [37].

For more information about critical care endpoints, see Appendix D.

A fundamental premise of organ donation is the dead-donor rule, which requires that donors must be dead before their vital organs can be recovered [20-22]. Thus, an affirmative determination of death is mandatory before proceeding with organ donation. The Uniform Determination of Death Act sets forth a broad physiologic definition of death: An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions (cardiorespiratory death), or (2) irreversible cessation of all functions of the entire brain, including the brain stem (brain death), is dead [23]. The procurement coordinator or other donation/transplant professionals are not involved in determination of death. Rather, it is the responsibility of the hospital to determine death. Determination of death must not be rushed, but it must be timely.

In the United States, the Uniform Determination of Death Act sets the general legal standard for neurologic determination of death, but the law does not establish the clinical criteria for this determination. Instead, the Quality Standards Subcommittee of the American Academy of Neurology developed the clinical criteria for neurologic determination of death, which are detailed in the 1995 American Academy of Neurology Practice Parameters [24]. Brain death is defined as the "irreversible loss of all brain functions including brain stem reflexes" [24]. Brain death is frequently a result of severe head injury or aneurysmal subarachnoid hemorrhage [24].

Physicians who have completed a neurologic examination of the patient and evaluated their medical history make the brain death diagnosis. Some states, including Pennsylvania and West Virginia, require a second comprehensive neurologic examination. Although the same physician may do both exams, hospitals often require different physicians to conduct the two exams. The importance of the second neurologic exam lies is to establish the irreversibility of the condition determined during the first exam. While the intervening period between the two exams is arbitrary, a period of 6 hours is considered reasonable [24]. In children (37 weeks to 18 years), the recommended observation period is longer (12 hours for 1 year or older to 48 hours for 7 days to 2 months old) [27]. You should be familiar with your hospital's protocol.

Donation after Cardiac Death (DCD) is an alternative to donation after brain death when the latter is not feasible, such as: a) when brain death is not imminent or the brain death criteria cannot be met in spite of the presence of catastrophic brain injury and there is a request for withdrawal of life support; and b) when brain death testing cannot be conducted due to severe hemodynamic instability [13, 28].

DCD is considered only after the patient's treating physician has determined that there is no expectation of meaningful survival and after the family has made the decision to withdraw the ventilator and oxygen perfusion support [29, 30]. At this time, the procurement coordinator talks to the family about the opportunity for organ donation. The OPC explains to the family that there is a possibility that the patient may not pass in the time frame to facilitate transplantable organs. Prior to withdrawing life-support, the patient is evaluated for the likelihood of passing away within 60 minutes. This may involve several different respiratory evaluations including a ‘T-piece trial.' The T-piece trial involves removing the patient from the ventilator and providing passive oxygen. The OPC explains to the family that the patient is at risk of decompensating and experiencing a respiratory arrest during T-piece trial. The patient is monitored closely to see if he/she experiences a decrease in oxygen saturations and either 1) a decrease in respiratory rate or effectiveness of the breaths, or 2) a decrease or increase in the blood pressure. If the patient's condition remains stable past the 30-minute mark, there is a high likelihood that the patient will not die within 60 minutes. Conversely, if the patient's peak inspiratory pressure (PIP) is greater than 30 mm Hg, the patient is highly likely to pass away within 60 minutes.

The specific set of procedures to be followed during the withdrawal of ventilator support is governed by individual hospital policies. CORE gets involved only if donation is anticipated. In CORE's DSA, patients are taken to the operating room and comfort measures are provided by the hospital's clinical team. The attending physician from the hospital is in charge of withdrawal of support. Once the physician deems that the patient is comfortable, ventilator and oxygen perfusion support is withdrawn. Death is pronounced two minutes after loss of pulse, apnea, and unresponsiveness to noxious stimuli.

Until the attending physician declares the patient dead, patient management continues to be under the control of the hospital. The recovery surgeon or team has no contact with the patient. OPTN policies prohibit the procurement coordinator, or those involved in organ recovery or transplantation from being involved in determination or declaration of death. In some cases, the patient does not pass away in the expected time period after removal of ventilator support. In such cases, the donation process is aborted and the patient is returned to the intensive care unit or the ward and made comfortable [29, 32].

Under Federal regulation, all activities to determine medical suitability of the donor are governed by OPTN policies [18]. Each OPO establishes acceptance criteria for deceased donors and organs, and evaluate potential donors for fulfillment of those criteria. Once the OPC is assigned the case, the process of evaluating the patient's medical suitability for donating organs is initiated. The goals of the medical suitability evaluation are: 1) to identify conditions that may make the potential donor ineligible; 2) to determine risk of infections and employ strategies to alleviate that risk by treating the donor for the infection; and 3) to implement preventive measures including vaccination in the potential recipient [19].

Hospital staff should assist CORE in reporting known medical and social history. The OPTN requires that the medical history includes each of the following: 1) laboratory tests and results used to identify transmissible disease, treated and untreated, that if transmitted will adversely impact the recipient; 2) factors that are associated with increased risk of infectious disease transmission including HIV, HBV and HCV; and 3) prior exposure to Human Pituitary Derived Growth Hormone to determine the risk of prion disease. In addition, obtaining information on vaccination status, residence or travel to disease endemic areas, drug use, risky sexual behavior and incarceration are also required [45]. Identified infections, if any, do not automatically preclude transplantation in all cases and in all infections. The urgency of the recipient's need and the recipient's infection status are also factored in while making a decision to accept or reject the organ. For instance, if the donor is HIV positive and the recipient is negative, the organ is rejected. However, if the donor and recipient are both HCV positive, the organ can be accepted for transplant. The medical and behavioral history is obtained from the patient's medical records and from interviewing close associates. The history of the potential donor and the mother is recorded for donors less than 18 months old.

The role of the OPC is to carry out all tasks necessary to preserve the opportunity for organ donation.