Unit 3: Summary and Quiz
After a member of the hospital staff makes a referral to the OPO that a patient has died or meets the criteria imminent death as described on the CORE trigger card, and that the patient has been deemed preliminarily suitable to be a donor, the OPO will dispatch an organ procurement coordinator (OPC) to the hospital in order to determine final suitability and to provide support and information to the donor family.
Hospital staff who participate in donor care after arrival of the OPC can maximize donation potential by following these best practices:
Communicate through huddles. Proactively coordinating patient and donor care activities (1) enables the organ procurement coordinator to evaluate the patient for donation potential, (2) allows the critical care staff to focus on providing quality end-of-life care, and (3) prevents errors in communication with the donor’s family.
Follow order sets. Maintaining proper physiologic support for the patient maximizes potential for donation and has a direct impact on the health of the transplant recipient. CORE has developed DSA-wide order sets based on the best scientific knowledge about organ recovery.
Assist in brain death testing. A donor must be dead before organs or tissue are recovered. The organ procurement coordinator is not involved in determination of death—only the hospital is responsible for determination of death. In the United States, the Uniform Determination of Death Act sets the general legal standard for death determination. The clinical standard for brain death, detailed in the 1995 American Academy of Neurology Practice Parameters, is defined as the “irreversible loss of all brain functions including brain stem reflexes.” A considered but timely determination of death by hospital staff improves prospects of successful organ transplantation and expedites the substitution of mechanical ventilation.
Discuss Donation After Cardiac Death. Donation After Cardiac Death (DCD) is an alternative to donation after brain death that is considered when a declaration of brain death is not feasible — such as when a) 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/or b) when brain death testing cannot be conducted due to severe hemodynamic instability. Donation After Cardiac Death 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 ventilator and oxygen perfusion support.
Recognize the OPC’s role in evaluating medical suitability. The medical suitability of the donor is determined by the OPC and transplant surgeon in accordance with OPTN policies and, in the case of tissue, FDA regulations. The goals of medical suitability evaluation are 1) to identify conditions that may make the potential donor ineligible, 2) to determine risk of infection and employ strategies to alleviate that risk, and 3) to determine whether it is necessary to implement preventive measures, including vaccination, in the potential recipient. In addition, CORE reports the known medical and social history of the donor, which includes 1) laboratory tests and results used to identify transmissible disease that could adversely affect the recipient, 2) factors associated with increased risk of infectious disease, and 3) prior exposure to Human Pituitary Derived Growth Hormone to determine the risk of prion disease. The presence of infection does not necessarily preclude a donor from eligibility. Final decisions are made on a case-by-case basis depending on the condition of the recipient and the urgency.
The Uniform Anatomical Gift Act of 1968 (revised 1987, 2006) states that organs can be donated either through first-person authorization or next-of-kin authorization.
First-Person Authorization proclaims an individual’s desire to make an anatomical gift and requires no further authorization from the next-of-kin. When an imminent death patient is referred to the OPO, the donor referral coordinator queries a state-operated database to determine the donor’s registration status. The OPO is legally obligated to honor the donor’s wish if the donor is registered and medically suitable for donation.
Next-of-Kin authorization is considered if the potential donor is medically suitable to donate and there is no evidence of first-person authorization. There are two important considerations for this type of authorization:
- Individual to be approached for authorization. The Uniform Anatomical Gift Act (UAGA) requires OPOs to make reasonable efforts to approach the highest order next-of-kin and, if not available, to move down the order of the next available next-of-kin.
- Timing of the authorization request. The request for authorization should be “decoupled” from the news that the family’s loved one has died. The request for organ donation should be made only after the family has had sufficient time after being informed of the death of their loved one.