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Tissue and Organ Donation

Contact Hours: 2

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Contact Hours: 2

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Course Purpose   

To provide healthcare professionals with knowledge on misconceptions regarding tissue and organ donation and provide an overview of the procurement and transplantation process.

Overview

The number of people who are waiting for an organ transplant far exceeds the number of donor organs available. While there are multiple ways to consent to organ donation, it is estimated that less than 40% of potential donors become actual organ donors, likely resulting from misconceptions regarding tissue and organ donation. Healthcare professionals must have the knowledge to address these misconceptions, and better educate the public on organ and tissue donation. 

Objectives

Upon completion of the independent study, the healthcare professional will be able to: 

  • Describe the various tissues and organs used in donation and transplantation
  • Summarize brain death and various ways brain death is determined
  • Understand the functions of the organ procurement coordinator
  • Outline the steps for tissue and organ donation

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Fast Facts: Tissue and Organ Donation

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Tissue and Organ Donation Pretest

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Definitions
Brain Death Occurs when an individual is in an irreversible coma with a known cause (ex. anoxia, brain tumors, cerebrovascular accidents, or traumatic brain injuries) and is completely unresponsive to stimuli.
Circulatory Death  The irreversible loss of cardiopulmonary function. 
Controlled Donation After Cardiovascular Death Happens when an anticipated cardiac arrest occurs.
Donation After Cardiac Death (DCD) A type of organ donation that allows donation by patients who are near death and are ventilator dependent but will not progress to brain death.
Living Donor An individual who donates an organ while they are still living.
Local Organ Procurement Organizations Assist with the coordination of organ and tissue donation, including the evaluation of potential donors, obtaining consent for organ and tissue donation, organ and tissue allocation, and the procurement process.
Medical Ethics A set of values is used to navigate complicated situations.
Organ Transplantation The removal of an organ from one person (the donor), and placement into another (the recipient).
The “Dead Donor Rule” (DDR)  An ethical norm that reflects the widely held belief that it is wrong to kill one person to save the life of another.
The Uniform Declaration Of Death Act (UDDA) Assures patients, families, and healthcare professionals that a patient who is brain dead is in fact dead.
Uncontrolled Donation After Cardiovascular Death Is most frequently seen in the Emergency Department and involves individuals who are dead on arrival to the hospital, or who die unexpectedly while admitted to the hospital.
Introduction

In the United States, it is estimated that a new person is added to the transplant list every ten minutes, and every day, twenty people on the transplant list will die while waiting for a transplant. An organ transplant is performed in people with end-stage organ failure and can increase life expectancy while also improving quality of life. ⁸ The number of people who are waiting for an organ transplant far exceeds the number of donor organs available. While there are multiple ways to consent to organ donation; signing a donor designation, designating donation on a driver’s license, or obtaining a signed consent from the deceased’s next-of-kin, it is estimated that less than 40% of potential donors become actual organ donors, even though approximately 80% of people support organ donation. ⁹ This disconnect is mainly caused by misconceptions of organ donation. Misconceptions include believing that there is an age limit to donation, the health history of the deceased would prevent donation, that it may go against one’s religion whereas few religions prohibit tissue and organ donation, that organ donation is costly when in actuality, often no cost is involved, and that healthcare professionals will be less likely to save someone in an emergency because they have designated themselves as a donor, when in fact saving their life is the top priority and tissue and organ donation is not considered. Healthcare professionals must have the knowledge to address these misconceptions, and better educate the public on organ and tissue donation. ²

Organ Transplantation

Organ transplantation is the removal of an organ from one person (the donor), and placement into another (the recipient). ⁸˒⁹ Organs that may be recovered from the donor and transplanted into the recipient include the heart, intestine, kidney, liver, lung, heart, and pancreas. Tissues that may be recovered from the donor and transplanted into the recipient include blood vessels, bone, cartilage, corneas, valves, skin, and tendons.

Tissues and organs are procurable and transplanted from both living and deceased donors. ⁴ Deceased donors are the major contributors to organ donation, and the most common causes of death of deceased donors are cerebrovascular accidents, traumatic brain injuries, and drug overdoses. Living donations are less common but still occur. The most frequently donated organ is the kidney, but portions of the liver or lung are transplanted as well. There are three types of living donations ⁴:

  • Directed donation – The donor designates to whom their organ will be given.
  • Non-directed donation (altruistic donation) – The donor does not specify a recipient, and the organ is matched to a person in need. 
  • Paired donation – Involves two or more people with a willing donor who is not a match for them. The people in need of a transplant are grouped, and the organs are ‘traded’ to ensure that everyone receives a compatible transplant.
Living Donors

A living donor is someone who donates an organ while they are still living. The most common organs (or partial organs) donated by a living donor are the kidney and liver. Relatives, loved ones, and friends are most likely to donate. To become a living donor, one must be 18 or older, healthy, and antigenically matched to the recipient. Considerations should be given to cost and potential complications of living donation. ⁴ While insurance may cover the surgery and follow-up care, any long-term complications associated with donation may not necessarily be covered. Uncovered costs include lost wages, particularly if there are long-term complications of surgery. 

Possible complications may include ⁴:

General

Abdominal internal bleedingAllergic reactions to anesthesiaBlood clots
Blood lossDeathDepression
InfectionOrgan dysfunctionPain
PneumoniaWound infection

Kidney 

Bowel obstructionDamaged kidney function that requires dialysis or transplantationHernia
Hypertension

Liver

Bile leakageBowel obstructionDamaged liver function requiring medical therapy or transplantation
Hernia
Dead Donor Rule

The “Dead Donor Rule” (DDR) lies at the heart of the current organ procurement policy. It is not a legal statute; rather, it is an ethical norm that reflects the widely held belief that it is wrong to kill one person to save the life of another. ⁵ Because of this ideology, an organ donor must already be dead before organs can be removed. The Uniform Declaration of Death Act (UDDA) assures patients, families, and healthcare professionals that a patient who is brain dead is in fact dead, and in combination with the dead donor rule, makes the removal of organs for life-saving transplantation legally and ethically acceptable.

Brain death under the UDDA increased the donor supply of organs for transplantation, but the demand for donor organs continues to grow faster than the supply. As a result of longer waiting lists and the number of deaths while on the list, there has been increasing emphasis on donation after cardiac death (DCD). This type of organ donation allows donation by patients who are near death and are ventilator-dependent but will not progress to brain death. After a valid decision is made to discontinue life support, the option of organ donation may be offered. If the patient expressed a wish to be a donor or if the family agrees to donation, donation after cardiac death may be conducted. ⁵The process includes taking the patient to the operating room where the ventilator is removed so ventilation stops, circulation stops within 60 minutes of ventilator removal, and when there has been no spontaneous circulation for 5 minutes after circulation stops, the patient is pronounced dead and organs are rapidly removed. The kidneys and liver can often be used for transplantation, but because of the ischemic time (decreased circulation over the total 65-minute period), the heart is seldom transplanted. If circulation does not stop within 60 minutes, the organs are deemed to be too damaged for transplant because of the ischemia that develops during diminished circulation, and the patient dies without donating organs.

Brain Dead

To make a diagnosis of brain death, an individual must be in an irreversible coma with a known cause (ex. anoxia, brain tumors, cerebrovascular accidents, or traumatic brain injuries) and completely unresponsive to stimuli. ¹ All reversible causes of a coma must be excluded, and all central nervous system depressant medications and neuromuscular-blocking agents must be weaned off. The individual should also not be hypothermic or hypotensive, and severe acid-base and electrolyte imbalances should be ruled out. The brainstem reflexes: corneal, cough and gag, pupillary, oculocephalic, and vestibular should be assessed, however spinal reflexes can remain in up to 75% of people and therefore, their presence should not stop a diagnosis of brain death. ¹

An apnea test can also assess respiratory drive. The apnea test is performed by disconnecting an individual from the ventilator for 10 minutes and observing for no respiratory effort and an increasing PaCO2. If cardiac arrhythmia hypoxemia or hypotension occurs during the test, the ventilator must be reconnected. A false-positive apnea test can occur when sedation is administered or if a high cervical injury impairing diaphragmatic function is present.

Although brain death is a clinical diagnosis, additional testing can support the diagnosis, especially when confounding factors are present. For instance, assessing the cerebral blood flow through cerebral angiography, transcranial doppler ultrasound, and cerebral scintigraphy are useful tests to confirm brain death because they are not influenced by central nervous system depression, hypothermia, or metabolic disorders. The electroencephalography (EEG) is also a common method to assess for brain activity, however it can be heavily influenced by sedation, hypothermia, and metabolic disorders limiting its usefulness. ¹

Circulatory Death

Circulatory death is defined as the irreversible loss of cardiopulmonary function. The typical donation after cardiovascular death (DCD) donor is one who has suffered a neurologic injury but does not fit the criteria for brain death. ³ There are two defined forms of DCD, controlled circulatory death, and uncontrolled circulatory death. ³˒⁷

  • Controlled DCD happens when an anticipated cardiac arrest occurs. In these cases, the decision to withdraw care is made before the decision to donate. Most often, the declaration of death occurs in the operating room. Life-sustaining measures are withdrawn, and the donor is monitored until there is a loss of cardiopulmonary function. After cardiopulmonary function ceases, an additional waiting period of 5 minutes commences to ensure no spontaneous resumption of cardiac function occurs before death is determined. Members of the organ procurement and transplant teams should not be involved in the process of care withdrawal or the declaration of death and should not enter the operating room until death is declared. Once death is determined, organ procurement can begin. 
  • Uncontrolled DCD is most frequently seen in the Emergency Department. These cases are often individuals who are dead on arrival to the hospital. Unexpected cardiac arrests in patients admitted to the hospital are also described as uncontrolled. Because these deaths are unexpected, organ donation in this group is less common because end-organ ischemia has likely already begun. Steps must be taken to stop the progression of ischemia while consenting and preparation for organ procurement occurs. 
Preparing for Procurement

Local organ procurement organizations assist with the coordination of organ and tissue donation, including the evaluation of potential donors, obtaining consent for organ and tissue donation, organ and tissue allocation, and the procurement process. ⁶ The organ procurement coordinator (who is often a nurse) collaborates with patients, families, and hospitals to make organ donation happen. When a patient in the hospital is near death or has died, the organ procurement coordinator should be notified. The organ procurement coordinator will speak with the nurse assigned to the patient and gather information including the patient’s name, age, medical identification number, past medical history, cause or anticipated cause of death, family contact information, and any other pertinent information to determine any potential for organ donation. The organ procurement coordinator will determine if the patient is a potential donor and should arrive at the hospital within 90 minutes if the patient is a suitable candidate. All deceased patients may be considered for organ donation. If the patient is an acceptable potential donor, the organ procurement coordinator will speak with the patient’s family to gain further information and permission to donate. If the family wishes to donate, the procurement coordinator will work to maximize the potential for a successful transplant by stabilizing the patient hemodynamically and adding certain medications that are used by transplant surgeons to promote a successful graft for the recipient. While being cautious, from procurement to placement, every step must be done quickly and efficiently to assure the best outcomes.

The steps for organ and tissue procurement include the following ⁶:

  • Arrange for additional tests.
  • Arrange for social work and clergy support for the patient and family.
  • Search the state registry to determine if prior consent for organ donation has been given on the patient’s driver’s license.
  • If possible, the living will of the patient will be located and evaluated. If there is no predetermined consent, the coordinator will contact the spouse, certified domestic partner, adult child, parent, adult sibling, legal guardian, or any other person authorized to make decisions.
  • Until a determination of donation is finalized, the coordinator will ensure the patient is maintained on artificial life support.
  • The procurement coordinator will also contact the medical examiner and Organ Procurement and Transplantation Network (OPTN) to initiate a search for potential matching recipients.
  • The donor is matched with the recipient based on tissue type, blood type, weight, height, length of time on the transplant list, severity of illness, and distance. The system generates a matching recipient list by tissue or organ type for the organ procurement coordinator, who then will contact recipients.
  • The first match for each tissue or organ becomes the main transplant candidate for contact.
  • The transplant surgeon makes the final decision based on the recipient’s health, suitability of the tissue or organ, and the availability of the recipient with local patients receiving preference.
  • The receiving coordinator obtains consents and conducts matching in a manner like the procurement coordinator.
  • The organ recovery surgical team is quickly scheduled by the organ procurement coordinator.
  • An ice-cold preservation solution that will be used to flush each organ that is removed is prepared.
  • The surgical team removes the donated organs using standard surgical incisions in a sterile operative environment.
  • The donor is then exsanguinated, followed by the rapid replacement of a hypothermic preservation solution that will lower the temperature of the intended organ, thereby decreasing metabolism and ischemia.
  • The intended organs are removed and placed in sterile containers where they are cooled.
  • Tissues (corneas, bones, skin, and tendons) are then removed after the organs.
  • All surgical incisions are closed.
  • Due to the rapid loss of viability of organs and tissues, rapid ground or air transport is arranged by the organ procurement coordinator. The procured organs are then transported for implantation into the recipient. 
  • The organ procurement coordinator then contacts the funeral director for removal of the body.
  • The recipient surgical transplant team as well as the recipient of the donor organ or tissue are coordinated to be ready to receive and complete the transplant.

Following successful transplantation into a recipient, the mainstay of long-term care is a combination of lifelong close monitoring and appropriate immunosuppression. An organ recipient must understand that close-monitoring after an organ or tissue transplant is essential, and life-long. Additionally, clinicians must understand current practice standards in caring for these patients. 

Medical Ethics

Medical ethics, a set of values used to navigate complicated situations, are founded in the concepts of patient autonomy, beneficence, non-maleficence, and justice. These concepts are relevant in organ donation and transplantation. Much of the ethical framework surrounding organ and tissue donation and transplantation has its basis in the dead donor rule. The dead donor rule is particularly relevant in donations after circulatory death, where the patient’s circulatory function must irreversibly stop for 5 minutes before beginning organ procurement. While most organ donations after circulatory death occur because of neurologic injuries, it has also been used for end-stage pulmonary and neuromuscular disorders. ⁶˒⁸ Some healthcare professionals have questioned the utility of donation after circulatory death. Patients electing to withdraw care and desire to donate their organs may not actually be able to do so, because waiting for death can lead to ischemia thereby reducing the quality of donor organs, which can lead to the organs not being donated.

Patients may also ask to voluntarily be euthanized, which differs from the traditional withdrawal of care in two key aspects; euthanasia requires the person being euthanized to provide consent, and the primary intent is to end life. Withdrawal of care intends to provide comfort to the patient, with death as a side effect. Rethinking the dead donor rule could allow people requesting to be euthanized to donate their organs prior to death, fulfilling their wishes. Advocates of this approach argue that withdrawal of care with a do-not-resuscitate order in place is equivalent to death and awaiting ‘irreversibility’ does more harm than good. Opponents to this approach argue that it violates the principle of non-maleficence and public trust, and a loss of public trust will lead to a decrease in organ availability. 

Although some patients with chronic, debilitating diseases or terminal illnesses may be in favor of euthanasia, some healthcare professionals may have cultural, ethical, or religious beliefs that preclude their willingness to participate in the donation or transfer of tissues or organs. It is important to respect each person’s belief systems; however, a healthcare professional’s beliefs should not interfere with the patient’s right to self-determination. A healthcare professional’s primary commitment is always to the patient. A healthcare professional can preclude themselves from the donation and transfer of tissue and organs, but they cannot prevent such acts from occurring because the patient’s desires should be respected as a personal choice.

Working within the Team

The healthcare professional’s responsibilities in tissue and organ donation varies with their role. Some providers work with the families of donors, while others work with the families of recipients. Some may be responsible for performing procurement, while others are responsible for managing the patient up to the point of organ retrieval. In addition, there is often an administrative team that works with organ procurement organizations. While health professionals should help educate patients and families on the benefits of organ donation, specific responsibilities of team members include:

  • Administration management and interaction with organ procurement organizations
  • Community and provider education on organ donation
  • Coordination of tissue and organ donation
  • Organ donor identification 
  • Support of donor and recipient families which includes understanding cultural, psychological, and religious issues

Healthcare professionals who would like to become more involved with organ tissue and organ donation should consider getting better informed by becoming familiar and involved with organ procurement programs such as the United Network for Organ Sharing (UNOS), or organizations located where the healthcare professional is licensed. The healthcare provider should also complete continuing education in organ donation and transplantation and seek opportunities to develop the skills needed to work with the organ procurement coordinator.

Conclusion

Tissue and organ donation is of tremendous benefit to people in need of a transplant. One donor’s tissue and organ donation can improve several lives. While most of the public is in favor of organ donation, people often fail to include this decision in their living wills or discuss their desires regarding organ donation with family members. Organ donation is vital to patients, yet there is a negative correlation between those willing to donate and those waiting on the transplant list. To improve donation awareness, healthcare professionals should have a clear understanding of the misconceptions of tissue and organ donation, and if interested, seek opportunities for learning by contacting their local organ procurement coordinator.

Successful organ or tissue procurement and transplantation require extensive teamwork and coordination. Early detection protocols should be in place to notify the appropriate organ procurement organization, who should notify the organ procurement coordinator. The coordinator has a big responsibility in the donation process, including reviewing factors such as blood matching, donor and recipient location, illness severity, and coordinating the donations with recipients. Once an organ or tissue is successfully transplanted, the healthcare professional must stress regular communication and close monitoring, which involves close screening for infections, organ rejection, and malignancies, for the best patient outcomes from transplantation. 

References
  1. Bernat, J. L. (2017). Brain death and the definition of death. Oxford Scholarship Online
  2. Childress, J. F. (2017). The failure to give: Reducing barriers to organ donation. Organ and Tissue Transplantation, 203-218. 
  3. Donation after cardiac death. (2015). Encyclopedia of Trauma Care, 490-490. 
  4. Friedman, L., & Thistlethwaite, Jr, J. R. (2021). Expanding living donor liver transplantation. The Living Organ Donor as Patient, 214-240. 
  5. McKenna, B. (n.d.). The ‘dead donor rule’ and organ donation. Foundations of Healthcare Ethics, 246-262. 
  6. Price, D. (n.d.). Consent to donation. Human Tissue in Transplantation and Research, 99-121. 
  7. Price, D. (n.d.). Living donation. Human Tissue in Transplantation and Research, 196-229. 
  8. Roh, Y. (2018). Organ donation. Organ Donation and Transplantation – Current Status and Future Challenges
  9. Roh, Y. (2018). Organ donation. Organ Donation and Transplantation – Current Status and Future Challenges
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