Solid organ transplantation has been a therapeutic option for patients with end-stage organ failure for more than 50 years; however, transplantation is associated with many challenges. A scarcity of organs reduces the likelihood of transplantation for many individuals. Currently more than 78,000 people in the United States are active on organ transplant waiting lists. In January 2015 there were 1,257 organ donations and 2,797 organ transplants. Of these transplants, 772 were from deceased donors and 485 were from living donors.
Critical care nurses work collaboratively with procurement agencies and transplant teams throughout the continuum of care from identification of a possible organ donor, optimal care for families, brain death testing, clinical donor management, organ procurement, and mutual care/support for multidisciplinary team members.
Organ donation has developed into a separate entity from organ transplantation. Critical care nurses are usually the first to identify a potential organ donor and must understand clinical triggers to initiate referral of possible organ donors to the OPO, clinical findings associated with brain death, and organ-specific care considerations to expect in managing the potential organ donor.
Defining Brain Death
Throughout history, death was defined as the cessation of blood flow when the heart permanently stopped beating in response to non-recoverable catastrophic illness or injury. The advent of intensive care availability which facilitated physiologic support for patients following previously uniformly fatal brain injuries let to exploration of the concept of brain death. The concept of brain death dates to 1959 with the introduction of “coma d‚pass‚,” a state beyond coma indicating loss of life functions such as reflexes, consciousness, and mobility. In 1968 the Harvard committee on brain death described “irreversible coma” (what is now considered brain death), incorporating most current clinical testing. What are known as the “Harvard criteria” became the basis for much of current brain death testing.
SEE ALSO: Earn CE: Organ and Tissue Donation
Generally criteria for brain death are defined as lack of cerebral and brainstem function associated with a non-survivable head injury. Non-survivable head injury may be structural such as catastrophic brain trauma or intracerebral hemorrhage. Such injuries may also be metabolic such as profound/prolonged hypoxemia or prolonged cardiopulmonary arrest. An individual was determined to be dead based on neurologic criteria (brain death) when these clinical requirements were met, and not when the heart stopped beating (circulatory death). This formerly controversial concept still requires education, review and reinforcement with healthcare professionals and the public. The concept of brain death also requires careful, sensitive communication with patients’ families when brain death testing is a consideration as well as consistent messages from multidisciplinary team members.
In 1968 the Uniform Anatomical Gift Act (UAGA) was passed in the United States. This law established a legal framework for individuals to authorize an anatomical gift of one’s organs, tissues, and eyes following death. It also prohibited the trafficking of human organs. Individual states have adopted UAGA, which has since been revised in 1987 and 2009.
The National Organ Transplant Act (NOTA) of 1984 called for an Organ Procurement and Transplantation Network (OPTN) to be created and run by a private, nonprofit organization under federal contract, providing oversight for transplantation and organ donation, as well as to develop and maintain a national registry for organ sharing and matching. The United Network for Organ Sharing (UNOS) was first awarded the national OPTN contract in 1986 by the U.S. Department of Health and Human Services. UNOS is the only organization ever to operate the OPTN. UNOS has available multiple resources for healthcare providers, transplant professionals, and members of the public seeking information regarding organ transplantation. This information is also accessible to patients on a transplant wait-list as well as their families. Information available includes promoting organ donation, organ donation/transplant statistics, and professional resources. This information and access is taxpayer-funded and available at http://www.unos.org/.
Despite these national efforts, donor organs remain scarce, limiting the availability of transplantation. In 1998 the Centers for Medicare and Medicaid Services (CMS) implemented Conditions of Participation for transplantation that impose requirements a hospital must meet to increase organ donation. Any hospital that receives Medicare or Medicaid reimbursement must notify the local OPO in all cases of impending death. It is the responsibility of the OPO coordinator to obtain consent for organ or tissue donation from the family of the deceased patient.
Hospitals have clinical criteria to ensure appropriate referral of potential organ donors. These criteria may also be known as clinical triggers for OPO referral. Such clinical triggers may include a Glasgow Coma Scale score less than 5, severe stroke or brain trauma with a declining neurological examination including decrease in or loss of one or more brain stem reflexes. Impending withdrawal of mechanical ventilation in a palliative care setting for a dying patient are also appropriate clinical triggers for OPO referral.
Improving Quality of Life
Organ donation may be a life-saving intervention in most cases. Tissue donation, although not lifesaving, improves quality of life. Tissue donation includes skin, corneas, heart valves, bone, cartilage, and tendons. A corneal donation may give the gift of sight. Skin donation may make possible skin grafting to treat severe burns or extensive wounds. Hospitals are required to have a formal arrangement with a tissue bank for the referral of potential donors. Unlike organ donation, any deceased patient has the potential to be considered for tissue donation.
There are three ways in which organ donation may occur. A living donor who is otherwise healthy may donate an organ such as a kidney or, less frequently a liver segment, when clinical evaluation determines an appropriate match with the recipient and that the donor is healthy enough physically to tolerate surgery as well as has no psychosocial contraindications. A brain dead donor may donate following consent by their family or first-person consent such as donor designation on a driver’s license or a signed organ donor card. In any case, thoughtful, caring and compassionate communication must occur among the healthcare providers, OPO representative and the patient’s family. A patient may become an organ donor following circulatory death in which, after certain clinical criteria are met, organs are recovered following withdrawal of life-sustaining therapies and the patient becomes asystolic within a protocol-directed time frame. Organ donors can also be described as altruistic living donors, high-risk donors, and extended criteria donors.
To qualify as a living donor, whether as an altruistic living donor or family member donating an organ to a relative, an individual must be physically fit, in good general health, and free from high blood pressure, diabetes, cancer, and kidney and heart disease. The potential living donor must also be free from any transmissible diseases such as malignancy or infectious processes that may be passed to the recipient. Potential living donors are evaluated by a separate team from those caring for the potential recipient to avoid any conflict of interest. Evaluation for a living donor typically begins after the intended recipient is active on the transplant wait-list and includes clinical/medical, psychosocial evaluation as well as evaluation of motivation to donate. This is vital to determine if any coercion or financial incentives are present. The evaluation process is also vital in determining that the donor is healthy/low-risk enough for organ recovery surgery.
Individuals considered for living donation are usually between 18 and 60 years of age. Individual transplant centers may, when determining physiological versus chronological age, be flexible with upper age limits for living donors. Gender and race are not factors in determining a successful match, but donors must have a blood type compatible with the intended recipient. The potential donor is evaluated to determine the level of physical and mental health, and compatibility with the patient on the transplant waiting list. Living donor donation is coordinated by the transplant team.
For thousands of years, life has been the subject of deep thought as we reflect on our existence and what happens after we die. This may be challenging to think of, maybe even uncomfortable and sometimes death is hard to accept. Death, in time, comes to us all. Death of a beloved family member engenders grief and can be an opportunity to think of how just one life may make a difference for others. A peaceful dignified funeral and celebration of someone’s life creates an opportunity to work through pain, contemplate love and life that once was. Today, untold lives may be saved and pain at death of a beloved family member can be lessened by thinking about organ donation..from ourselves after our death or from a family member as a way they may live on and as a way the gift of a life-saving organ transplant may save another family from experiencing such pain upon the death of someone they deeply love.
All of us have this opportunity to give this gift of life to another patient and family. Anyone may have the opportunity to consider and reflect on this choice at some point in their life. One question to ask is, “Would I want someone to consider this and answer yes, to organ donation if I or a member of my family needed a life-saving organ transplant?” It can become a means to honor those who have died by having that gift save lives in the community by this generosity. Translation.organ donation saves lives and saves families from great pain.
This summer many of our blockbuster movies feature superheroes. But it strikes us that not all superheroes wear capes. Some carry a card. an organ donation card.
You can give the gift of life. We urge you to learn more at http://www.donors1.org/
Richard Arbour is neuroscience clinical nurse specialist at Lancaster General Hospital in Pennsylvania.