Organ Donation and Transplantation

Jamie D. Blazek, Christine Hartley, Mary E. Lough, Mary Martel, Teresa J. Shafer and Schawnté Williams-Taylor

Organ transplantation provides the only opportunity for patients with end-stage organ disease to have an enhanced quality of life and an extended survival. Organ transplantation is accepted as the preferred and often only treatment option for end-stage organ disease. Success rates in patients treated—as well as increases in organ donation from the general public—have improved as the field of organ donation and transplantation has evolved. Such evolution came as a result of increased cultural acceptance of brain death, donation, and transplantation; legal and political efforts to facilitate organ donation; improved procurement and allocation processes; advances in organ preservation, organ recovery, and surgical techniques in transplantation, immunology, immunosuppression; and management of infectious diseases.¹

Nationwide, more than 114,241 people are waiting for a lifesaving or life-enhancing organ transplant. In 2011, the Organ Procurement Transplant Network (OPTN) reported 14,147 donors, of which 8128 were deceased donors and 6019 were living donors (Fig. 37-1). The categories of organ donors are described in Table 37-1. Total transplants performed in 2011 numbered 28,535. This is encouraging although insufficient, as one patient is added to a transplant waiting list every 10 minutes.²

TABLE 37-1

CATEGORIES OF ORGAN DONORS

DONOR	DEFINITION
Brain-Dead Donor	Donor declared dead by neurologic criteria for brain death
Donation After Cardiac Death (DCD)	Donor declared dead by circulatory criteria for death
Living Related Donor	Living family member related by blood who donates a kidney, portion of the liver, pancreas, intestine, or lung to another family member
Living, Unrelated Donor (Directed/Nondirected)	Living individual not related to a patient requiring a transplant who donates a kidney, portion of the liver, pancreas, intestine or lung to another individual. The donor may be anonymous or altruistic

From United Network for Organ Sharing website. http://www.unos.org/donation. Accessed May 7, 2012.

FIGURE 37-1 Growth in U.S. organ transplant waiting list outpaces growth in deceased organ donors. (From *Department of Health and Human Services*. *Organ Procurement Transplantation Network*. Collaborative scorecard. Data for period: September 2009-August 2010. https://www.healthcarecommunities.org.)

Ongoing collaboration between organ procurement organizations, transplant centers, and critical care nurses, physicians, and other health care workers is necessary to have a significant impact in saving lives through organ and tissue donation and transplantation.

Organ Donation

Role of the Critical Care Nurse in Organ Donation

The critical care nurse is an essential member of the team in the donation process, linking the hospital to the organ procurement organization (OPO), physicians, and families of potential donors. The Centers for Medicare & Medicaid Services (CMS) guidelines, The Joint Commission standards, and hospital policies require that patients meeting criteria for imminent death and cardiac death be referred to an OPO in a timely manner.³ Once the notification has been made, nurses must follow the established donation policies for their hospital in accordance with federal guidelines and state laws. Hospitals will already have worked with their federally designated OPO to develop their hospital policy to ensure that it meets these regulations and laws.

Continued hemodynamic support is necessary during the process of brain death declaration. Patients progressing to brain death undergo many physiologic changes that can compromise the viability of organs for transplantation. Ensuring that oxygenation and perfusion of the organs is maintained, as well as electrolyte and acid–base balance, preserves the opportunity for donation.

Collaboration between the nurse and the OPO staff is necessary to protect the right of the patient, who may already have made the decision to donate by indicating his or her wishes on a state registry. Failing that, the family can make the decision about donation. After declaration of death, the family is informed about the opportunity for donation. The goal of medical management of the patient shifts toward optimal preservation of organ function so that the organs are suitable for transplant. It is at this point that the OPO assumes the care of the donor, providing direction for medical management.

After death of the patient, nurses advocates for their patient by ensuring the patient’s donation decision is honored or—if the patient had not made such a decision during his or her lifetime—upholding the family’s right to be offered the opportunity to donate organs and tissues.⁴ Once authorization (formerly known as “consent”) is obtained, the OPO coordinator and nurse collaborate on management of the donor according to established donor management protocols. Such protocols include managing fluid and electrolyte imbalances secondary to brain death. It is not uncommon for patients to have a low circulating volume or high serum sodium levels, since hypertonic sodium may have been administered to prevent brain herniation. The donor management phase corrects deficits in the patient’s physiologic status in order to provide optimal organ function prior to surgical recovery and preservation. Nursing care shifts from cerebral protective strategies to aggressive donor management along with continued support of the family.⁵

The critical care nurse monitors and records vital signs, intake and output, and oxygenation status; draws labs; and assists with line insertions and multiple diagnostic assessments, such as chest radiographs, bronchoscopies, electrocardiograms, or echocardiograms, to evaluate organ function. This donor management phase of the donation process starts following brain death and continues until the patient is taken to the operating room and organs are recovered.

A recent study of hospital donation practices and their impact on organ donation outcomes revealed gaps in knowledge of organ donation, brain death, referral criteria, and at times, a poor relationship between the hospital and OPO.⁶ It is important that nurses are knowledgeable about the organ donation process. Nurses must assess their own beliefs that pertain to organ donation since the attitude of the nurse and care given to the family can impact the outcome of the donation.

Organ Procurement Organization as Part of the Health Care Team

Nurses, physicians, nurses, respiratory therapists, social workers, and other health care disciplines practice in the hospital because that is where the patients are. OPO staff practice in hospitals because that is where the potential donors are. The 2003 Organ Donation Breakthrough Collaborative helped break down many of the silos that exist in providing care to patients by various health care professionals.7–9

Gone are the days when hospitals and hospitals staff considered donation a “nice-to-do,” and “add-on” in terms of care. The federal government has made clear the responsibility placed on hospitals to actively engage and work through the donation process with OPOs, caring for the donor while the OPO is leading and managing the donor assessment, obtaining authorization, and facilitating the recovery process.

Because only OPO staff or trained designated requestors can make the request for donation, they are part of the health care team. In one of the largest donor family studies in the nation, a primary finding was that speaking to an OPO staff member was one of the few variables highly associated with authorization (versus nonauthorization) for donation.¹⁰ A successful donation environment is dependent on a deep, close, and open relationship with a hospital’s designated OPO. The OPO should be called before the patient has died when death is imminent. This requirement is established by federal regulation, by state law, and is practiced by the vast majority of hospitals and critical care units as policy and best practice.³

National Donation and Transplantation Laws

Organ transplantation is the only medical and surgical therapy that is regulated entirely by law. From donation to transplantation, the federal government—and to some extent the state governments—monitor the administrative and financial aspects of this process. These regulations ensure that organs are shared on a fair and equitable basis. In addition, the responsibilities and functions of health care professionals are sanctioned and safeguarded by these laws so that their responsibilities may be discharged with assurance and protection medically, legally, and ethically. The major laws are listed in Table 37-2.

TABLE 37-2

NATIONAL DONATION AND TRANSPLANTATION LAWS

LAWS	TYPE	FIRST ENACTED
Uniform Anatomical Gift Act (UAGA)	State law	1968; Revised in 1987 and 2006
National Organ Transplant Act (NOTA)	Federal law	1984
Uniform Determination of Death Act (UDDA)	State laws	1980
Hospital Conditions of Participation—Organ Donation; Centers for Medicare and Medicaid Services (CMS)	Federal regulation	1998
Medical Examiner Laws Restricting Ability of Medical Examiner or Coroner to deny organ donation	State laws	Various years by state
Omnibus Budget Reconciliation Act (OBRA)	Federal law	1986

From Organ Procurement and Transplantation Network (OPTN). http://www.organdonor.gov/legislation/timeline.html. Accessed May 7, 2012.

Overview of the Donation Process

CMS requires hospitals to notify their respective OPOs of all deaths, including patients meeting imminent death criteria and cardiac death to increase the potential for organ, tissue, and eye donation. Table 37-3 lists the types of organ donor referrals made to the OPO. All patients meeting imminent death criteria must be referred within the agreed-upon time (usually within 1 hour) of meeting criteria. All cardiac deaths must be referred, irrespective of age, medical condition, or cause of death.³ The nurse or hospital designee makes the initial call to the OPO to provide demographic information, admitting diagnosis, and current neurologic status of the patient. Most OPOs have either in-house staff or on-call coordinators who will respond to the initial referral call from the hospital. Once onsite the OPO coordinator will communicate with the bedside nurse and physicians involved in the care of the patient to obtain information about the patient’s present hospital course, past medical history, and the plan of care.

TABLE 37-3

ORGAN AND TISSUE DONOR REFERRALS TO THE ORGAN PROCUREMENT ORGANIZATION

ORGAN REFERRAL		TISSUE REFERRAL
BRAIN DEATH	DONATION AFTER CARDIAC DEATH (DCD)	CARDIAC ARREST
Irreversible, nonsurvivable brain injury	Irreversible, nonsurvivable brain injury	Patient may or may not have sustained a brain injury
Patient currently maintained on a ventilator	Patient currently maintained on a ventilator	Patient is not currently on a ventilator
Tests performed to confirm brain death (e.g., clinical exam, apnea test)	Any ventilator-dependent patient whose plans are to forgo life-sustaining treatment	No cardiac or respiratory activity
First person authorization/authorizing agent gives authorization for donation	Patient has not progressed to brain death	First person authorization/Authorizing agent gives authorization for donation
Patient maintained in critical care unit while donation evaluation and work-up is completed	Family decides to withdraw life-sustaining therapies	May donate tissue and corneas (bone, heart valves, skin, etc.)
To operating room for organ recovery	Family authorizes donation
Organ donors may also donate tissue and corneas	Patient is extubated, circulator arrest within 60-90 minutes, rapid recovery of organs in operating room
	Organ donors may also donate tissue and corneas

Developed by staff at LifeGift. Corporate headquarters Houston, TX.

Determining medical suitability is solely the responsibility of the OPO. Speaking to the family about donation is also the responsibility of the OPO, unless designated requestors at the hospital have been trained to do so.³

Types of Referrals

Imminent death referrals include patients with severe acute brain injury who 1) require mechanical ventilation; 2) are in a critical care unit or emergency department; and 3) have clinical findings consistent with a low Glasgow Coma Score (GCS) typically 5 or less; patients for whom physicians are evaluating the diagnosis of brain death or have ordered that life-sustaining therapies be withdrawn, pursuant to the family’s decision.⁹

Donation After Brain Death

Patients meeting the imminent death referral criteria may be or become brain dead (discussed later in chapter), resulting in donation after brain death (DBD) donation. Patients not meeting all necessary criteria for brain death but having an unsurvivable injury resulting in withdrawal of life support and subsequent cardiac arrest can be donation after cardiac death organ donors.

Donation After Cardiac Death

Donation after cardiac death (DCD), also known as donation after circulatory death determination (DCDD), donors are those patients who are not brain dead but who have suffered an irreversible neurologic brain injury, are ventilator dependent, and the family has made a decision to withdraw life-sustaining support. Patients with high spinal cord injuries as well as others dependent on mechanical ventilation may be candidates for DCDD. Organs are recovered after cardiac asystole and a 3- to 5-minute wait period. Cardiac asystole must occur within 60 to 90 minutes for organ donation to occur.

Cardiac death referrals provide the opportunity for patients to be tissue and eye donors after cardiac asystole. Because of the relatively rare occurrence of brain death or withdrawal of treatment, many more deceased patients have the opportunity to donate tissue and eyes. Other transplantable tissues include bone, skin, fascia, cartilage, tendons, ligaments, saphenous veins, heart valves, eyes and/or corneas.

Donor Evaluation

Once the initial call is made to the OPO an organ coordinator will contact the critical care nurse and request specific information regarding the patient’s age; sex; race; neurologic, ventilatory, and hemodynamic status; as well as the hospital’s plan of care. Once on site, the OPO coordinator will assess the patient and review the medical records, history of the current hospitalization, and major procedures—surgeries, therapies, current medications, past medical history, laboratory values specific to each organ, pulmonary status, systemic infection, diagnostic reports, and the hemodynamic status of the patient.¹² The time between brain death declaration and organ procurement is often marked by significant instability. During this time, optimal medical management is crucial to ensure post-transplant graft survival.

If the patient is not brain dead or there are no plans to withdraw support/decelerate care, the OPO coordinator will collaborate with the critical care nurse on a follow-up plan for ongoing evaluation. The OPO will continue to follow the patient until the patient meets neurologic criteria for brain death, death is declared, or there is a plan to withdraw life-sustaining support. Many patients referred to the OPO do not become donors because they do not meet brain death criteria or there are no plans to withdraw support as the patient’s status may improve. Patients declared dead by neurologic criteria constitute only 1% of total deaths in the United States.¹³

Brain Death

Brain death is the irreversible cessation of all brain functions including the brainstem. The clinical diagnosis of brain death is based on guidelines established by the American Academy of Neurology. The practice of brain death declaration varies based on hospital policy and state legislation. Neurologists, neurosurgeons, intensivists, and anesthesiologists usually perform the brain death evaluation. Prior to establishing brain death certain conditions must be confirmed, including the cause and the irreversibility of coma and confounding factors such as:

• Absence of severe hypothermia, defined as a core temperature of 32° C or less

• Absence of hypotension, defined as a systolic blood pressure of 90 mm Hg or less

• Absence of evidence of drug intoxication or poisoning, defined by a careful history, calculation of clearance, and if needed, a normal drug screen

• Absence of recent or current administration of neuromuscular-blocking medications, defined by the presence of four twitches with maximal ulnar nerve stimulation by a train of four peripheral nerve stimulation as shown in Figure 21-17 in Chapter 21

• Absence of electrolyte, acid–base or endocrine dysfunction, as defined by severe acidosis and marked deviation from normal values

Confirmatory Tests

Additional confirmatory testing for the determination of brain death may include cerebral angiography, electroencephalography, transcranial Doppler, and cerebral scintigraphy although these diagnostic procedures are not required (Box 37-1). The bedside clinical examination has three components: 1) absence of cerebral motor reflexes; 2) absence of brainstem reflexes; and 3) absence of respiratory drive.

Box 37-1

Confirmatory Tests in Brain Death

Cerebral Angiography

• Contrast medium under high pressure in both anterior and posterior circulation injections

• No intracerebral filling at the level of the carotid or vertebral artery entry to the skull

• Patent external carotid circulation

• Possible delayed filling of the superior longitudinal sinus

Electroencephalography

• Minimum of eight scalp electrodes

• Electrode dependencies should be between 100 and 10,000

• Integrity of the entire recording system should be tested

• Electrode distances should be at least 10 cm

• Sensitivity should be increased to at least 2 microV for 30 minutes with inclusion of appropriate calibrations

• High-frequency filter setting should be at 30 Hz, and low-frequency setting should not be below 1 Hz

• There should be no electroencephalographic reactivity to intense somatosensory or audiovisual stimuli

Transcranial Doppler Ultrasonography

• Bilateral insonation

• The probe is placed at the temporal bone above the zygomatic arch or the vertebrobasilar arteries through the suboccipital transcranial window

• The abnormalities should include a lack of diastolic or reverberating flow, small systolic peaks in early systole, and a lack of flow found by the investigator who previously demonstrated normal velocities

Cerebral Scintigraphy (Technetium Tc 99m Hexametazime)

• Injection of isotope within 30 minutes of reconstitution

• Static image of 500,000 counts at several time intervals: immediately, between 30 and 60 minutes, and at 2 hours

• Correct intravenous injection needs to be confirmed with additional liver images demonstrating uptake (optional)

This information is based on the American Academy of Neurology Guidelines. From Wijdicks EFM. The clinical diagnosis of brain death. In: The Comatose Patient. New York: Oxford University Press; 2008.

Cerebral Motor Responses.

Cerebral motor responses to pain in all extremities are absent in brain death. These motor responses can be stimulated by the application of pressure to the nail beds or supraorbital ridge. Some motor responses may occur spontaneously during the apnea testing because of the presence of hypoxia or hypotension and are considered spinal cord reflexes. These may also be elicited in the presence of respiratory acidosis and can include spontaneous flexion and muscle stretch reflexes in the arms and legs that can resemble grasping movements. It is important to determine whether the patient has been given any neuromuscular blocking medications that may induce pharmacologic motor weakness.

Brainstem Reflexes.

Brainstem reflexes that will be tested include pupillary signs, ocular movements, facial sensory and motor responses, and pharyngeal and tracheal reflexes.

Pupillary Reflexes.

Pupillary signs are evaluated by absence of the light reflex, which is consistent with brain death. Most often the pupils are round, oval, or irregularly shaped, although dilated pupils may remain even after brain death has occurred. This dilation may exist if the sympathetic cervical pathways to the pupillary dilator muscle are intact. Medications do not normally alter pupil response, although the application of topical medications or severe trauma to the eye may affect pupil reactivity.¹⁴

Oculocephalic Reflex.

Ocular movements are lost with brain death. The oculocephalic reflex also described as doll’s eyes involves fast turning of the head to both sides. In brain death this should not generate any eye movements. Neck movements should be avoided in patients with a traumatic brain injury.

Oculovestibular Reflex.

Because the oculovestibular reflex is tested using iced water or normal saline, it is sometimes called cold calorics. The head of the bed is elevated 30 degrees and approximately 50 mL of ice water or normal saline is injected into the ear, and no movement of the eye toward the side of the stimulus should be present. It is recommended that the patient be observed for up to 1 minute following each ear irrigation and 5 minutes should be allowed before testing the opposite ear. Medications that can influence the vestibulo-ocular reflex include sedatives, aminoglycosides, tricyclic antidepressants, anticholinergics, and anti-seizure agents.

Corneal and Jaw Reflexes.

Facial sensory and motor responses are elicited by testing for corneal and jaw reflexes. Stroking a cotton-tipped swab gently across the cornea tests the corneal reflexes. Grimacing in response to pain can be elicited by applying deep pressure to the nail beds, to the supraorbital ridge, or the temporomandibular joint. Severe trauma within these areas could inhibit interpretation of facial brainstem reflexes.¹⁴

Gag and Cough Reflexes.

Pharyngeal and tracheal reflexes are absent in patients with brain death. The gag reflex can be evaluated by stimulating the posterior part of the pharynx with a tongue blade. The cough reflex can be tested with bronchial suctioning.¹⁴

Apnea Testing.

The loss of brainstem function results in the loss of centrally controlled breathing with resultant apnea. The respiratory neurons are controlled by cerebral chemoreceptors that sense changes in the partial pressure of carbon dioxide (Paco₂) and pH of the cerebrospinal fluid that accurately reflect changes in plasma Paco₂.

Guidelines for determination of death recommend achieving Paco₂ levels greater than 60 mm Hg for maximal stimulation of brainstem respiratory centers. Prerequisites and the procedure for apnea testing are outlined in Box 37-2. The prerequisites that should be addressed prior to the apnea test are to prevent cardiac dysrhythmias, hypotension, and decreased oxygen saturation. If any of these conditions occur during the apnea test, the test should be aborted and confirmatory testing should be performed (see Box 37-1). In cases where a patient is a CO₂ retainer or the clinical examination is not reliable due to head trauma, confirmatory testing is necessary. Confirmatory testing is mandatory in children.

Box 37-2

Apnea Test

Prerequisites

1. Normothermia

2. Systolic blood pressure ≥90 mm Hg

• A pulse oximeter is connected to the patient to monitor the O₂ saturation

• Preoxygenation for 10 minutes with Fio₂ of 100%

• Reduce ventilation frequency to 10 breaths per minute and reduce PEEP to 5 cm H₂O

• If pulse oximetry oxygen saturation remains more than 90%, obtain baseline arterial blood gas, including Paco_2, pH, bicarbonate and base excess

• Disconnect the ventilator

• Place a cannula at the level of the carina and deliver 100% O_2, 6 liters/min

• Observe closely for respiratory movements for 8-10 minutes. Respiration is defined as abdominal or chest excursions that produce adequate tidal volumes

• Abort if blood pressure remains less than 90 mm Hg systolic or declining despite increasing vasopressors

• Abort if oxygen saturation is less than 80% for 2 minutes or drops steadily (consider retry with T-piece and CPAP)

• If no breathing drive is observed, measure arterial Pao₂, Paco₂, and pH after approximately 8 minutes

• If respiratory movements are absent and Paco₂ is ≥60 mm Hg (or 20 mm Hg increase in Paco₂ over a baseline normal Paco₂) the apnea test result is positive (i.e., it supports the clinical diagnosis of brain death)

• If the patient breathes, repeat test a few hours later

From Wijdicks EFM. The clinical diagnosis of brain death. In: The Comatose Patient. New York: Oxford University Press; 2008.

Donation After Cardiac Death

As stated above, donation after cardiac death (DCD) is also known as donation after circulatory death determination (DCDD). DCDD is based on the cessation of circulatory and respiratory functions.¹⁵ Previously, DCD donors were known as non–heart-beating donors or asystolic donors. Patients who do not meet brain death criteria, but have an unsurvivable condition, such as a catastrophic neurologic injury, high spinal cord injury, or a medical condition requiring mechanical ventilation, are candidates for DCD. Before the enactment of brain death laws in the 1970s, all organ donors were DCD donors. Interest in DCD has increased due to 1) family interest in organ donation when neurologic criteria for brain death have not been met, and 2) the continued national demand for organs.^16,17

Controlled Donation After Cardiac Death

DCD donors are classified as controlled and uncontrolled DCD donors. Controlled DCD occurs when the family has made a decision to withdraw life-sustaining support and death is declared at the time of circulatory arrest. In controlled DCD, families, health care providers, and OPO staff are involved in the timing and planning of the time when support will be withdrawn.¹⁴

Uncontrolled Donation After Cardiac Death

Uncontrolled DCD describes a situation in which cardiac arrest has occurred and resuscitation efforts are determined to be futile. The uncontrolled DCD process is rapid as the patient is undergoing cardiopulmonary resuscitation. After authorization from the family, the patient is taken to the operating room for immediate recovery of organs, primarily kidneys.¹⁸

DCD is an opportunity to increase the number of organs available for transplantation. Five-year organ survival rates in kidney and pancreas recipients from DCD donors and brain-dead donors are similar.¹⁹ Liver transplant grafts from DCD donors can encounter complications secondary to ischemic cholangiopathy (damage to the bile ducts from an impaired blood supply); consequently many transplant centers have changed their criteria for acceptance of DCD donors based on the age of the donor.²⁰ DCD lung donor outcomes are favorable to those of brain-dead lung donors.²¹

Authorization for Donation

“Presumed Consent” is the donation law existing in many European countries. This is a system in which one is deemed a donor unless the person has taken action not to be a donor. That is not the law in the United States. The United States retains a voluntary system, often referred to as “opting-in.” The architecture of U.S. organ donation law, also termed “Gift Law,” is the Uniform Anatomical Gift Act (UAGA), which is enacted in all 50 states.

The OPO coordinator is an advocate for the donor/donor family and potential recipients. Many factors are important in working with potential donor families. The nurse and OPO coordinator are important in providing a safe, comfortable environment for families in a position to make decisions about donation.²² Assessing the needs of the family is crucial to the outcome of the donation conversation. Timing of the conversation is also important. Donation does not consist of simply asking the family if they wish to donate.¹⁵ The critical care nurse should inform the family that an expert member of the health care team is available to provide information and answer their questions about donation.²⁶

Many myths and misconceptions surround organ donation. Common misconceptions from families surround religious beliefs, cultural milieus, and concerns about possible body disfigurement, concern about the ability to have an open casket funeral, and costs to family.²³ Another common misperception is that hospital staff will not attempt to save the life of their loved one if they believe the patient could be a donor.²³ These misperceptions must be debunked with the family. Finally, research has shown the manner in which the donation request is made is the main factor in a family’s ultimate decision regardless of pre-existing attitudes.²⁴ Many families report that donation has helped their healing in the grieving process and say that donation represents something positive in their loss.²⁴