Organ and Tissue donation - wsh.nhs.uk€¦ · Organ and Tissue Donation Policy For use in: Critical Care Services, Accident and Emergency, wards, theatres, mortuary For us e by:

Source: Critical Care Issue date: August 2019 Page 1 of 30 Status: Approved Review date: August 2022

Trust Policy and Procedure Document Ref. No: PP(19)326

Organ and Tissue Donation Policy

For use in: Critical Care Services, Accident and Emergency, wards, theatres, mortuary

For use by: All Trust staff

For use for: The Dying and deceased

Document owner: Wasim Huda, Clinical Lead Organ Donation

Status: Approved

Contents Page Nos

1 Purpose of policy 2

2 Background 2 – 4

3 Definitions 4

4 Staff roles and responsibilities 5 - 7

5 Protocol for organ donor identification and referral in critical care areas 7 - 16

6 Training requirements 16

7 Monitoring and Audit 17

8 Approval and Implementation 17

9 References 17 - 18

10 Appendices 19 - 30


1. Purpose of the policy

The purpose of this document is to maximise the organ donor potential of the Trust, and to ensure that donation is offered to all families where appropriate.

2. Background

The Organ Donation Taskforce was charged with identifying how the UK should improve its organ donation performance, which was lagging behind many other Western nations. The Taskforce

reported in January 2008 and made 14 recommendations.

It suggested that full implementation of the recommendations might lead to a 50% increase in the number of deceased organ donors. Since then, all the recommendations have been implemented and deceased donor numbers have risen in line with expectations. This is a great tribute to all the donors, their families and the doctors and nurses who made this possible. There are people alive today following a transplant who would otherwise have died.

Organ donation in the NHS has been transformed: there are more Specialist Nurses in Organ Donation to support families, every hospital has access to a dedicated Clinical Lead and is supported by a Donation Committee and there are dedicated organ retrieval teams serving the entire UK, 24 hours a day. Clinicians now have access to ethical and legal advice to help them facilitate donation, the National Institute for Clinical Evidence has published best practice guidelines and training and development programmes have improved knowledge and skills. Regional Collaboratives bring together leaders in organ donation, to promote the need for donors and provide support for service improvement. Clinicians increasingly view organ donation as a normal part of end-of-life care.

Currently there are over 7,000 people on the UK national transplant waiting list and, during the last financial year, over 1,300 people either died whilst on the waiting list or became too sick to receive a transplant. It is therefore vital that we continue to build on the current success and continue to make more progress.

Taking Organ Transplantation to 2020 (TOT2020) is a UK-wide strategy which provides a series of calls to action to enable the UK to match world-class performance in organ donation and transplantation.

What will organ donation and transplantation look like in 2020 and how it will be achieved?

Action by society and individuals will mean that the UK’s organ donation record is amongst the best in the world and people donate when and if they can.

o Develop national strategies to promote a shift in behaviour and increase consent

o Ensure that it is easy to pledge support for organ donation and once a pledge has been given, to honour the individual’s wish.

o Increase black, Asian and minority ethnic communities’ awareness of the need for donation to benefit their own communities and provide better support for people in these communities to donate.

o Learn from the experience of legislative change in Wales.

Action by NHS hospitals and staff will mean that the NHS routinely provides excellent care in support of organ donation and every effort is made to ensure that each donor can give as many organs as possible.


o Increase adherence to national standards and guidance.

o Increase the number of people who are able to donate following circulatory death and learn from the Scottish pilot on donation after failed resuscitation.

o Provide hospital staff with the support, training, resources and information they need to provide an excellent organ donation service.

o Ensure every donor’s care, prior to retrieval, optimises organ quality.

Action by NHS hospitals and staff means that more organs are usable and surgeons are better supported to transplant organs safely into the most appropriate recipient.

o Increase the number of organs that are retrieved from both DBD and DCD donors.

o Increase the number of organs that can be transplanted safely, and provide surgeons with the information and guidance to make decisions about organ suitability.

o Improve transplant recipient survival by improving understanding of the donor organ/recipient compatibility.

Action by NHSBT and Commissioners means that better support systems and processes will be in place to enable more donations and transplant operations to happen.

o Support regional collaboratives to lead local improvement in organ donation, retrieval and transplant practice and promote organ donation.

o Review and improve the workforce, IT, systems and processes which operate throughout the donation and transplant pathway.

o Build a sustainable training and development programme which can be tailored to meet local needs, so as to support organ donation and retrieval.

Measuring success

Aim for consent/authorisation rate above 80% (currently 57%)

Aim for 26 deceased donors per million population (pmp) (currently 19.1 pmp)

Aim to transplant 5% more of the organs offered from consented, actual donors

o 85% of abdominal organs from DBD donors to be transplanted (currently 80%).

o 35% of hearts and lungs from DBD donors to be transplanted (currently 30%).

o 65% of abdominal organs from DCD donors to be transplanted (currently 60%),

o 12% of lungs from DCD donors to be transplanted (currently 7%).

Aim for a deceased donor transplant rate of 74 pmp (currently 49 pmp)

A mid-point review of the above published later showed some progress in all areas of the ‘call to action’ with more people joining the NHS Organ Donor Register (ODR), increasing rates of referral to the organ donation service, presence of a Specialist Nurse – Organ Donation (SNOD) and consent for organ donation. The report showed consent broken down by whether or not the patient had opted-in on the ODR and whether or not a SNOD was present. The report also showed the progress that has been made in the number of deceased solid organ donors and the resulting


transplants, and the number of patients still actively waiting for a transplant. Supporting improvements in key systems and processes have been made.

In 2020, the law around organ donation will be changing in both England and Scotland. Both

countries will be introducing an opt out system for organ donation, just as Wales did in

December 2015 and Jersey from 1st July 2019.

Purpose

This policy is designed to ensure that every patient who dies in the care of the West Suffolk NHS Foundation Trust is considered for organ and tissue donation where appropriate. Where a patient and their next-of-kin wish to consent to donation, this policy will enable all Trust staff involved to facilitate those wishes. This will be done by:

Ensuring identification and referral of all potential organ and/or tissues donors to the Specialist Nurse-Organ Donation or tissue coordinator.

Ensuring that the families of all potential donors are given the option for organ and/or tissue donation.

Ensuring that the wishes of the potential donor have been determined (through Organ Donor Register check and discussion with the family).

Ensuring that assessment of potential is made before approaching families unnecessarily or giving false hope.

Ensuring that in instances where families have requested donation and this is not a possibility, communicating this information is done with sensitivity.

Ensuring that clinical management of the potential donor results in optimal function of the donated organs/tissues at transplantation.

Ensuring that communication and documentation through all parts of the donation pathway meet Trust and National standards.

Scope

Organ donation: All Accident and Emergency, Critical Care, Theatre and Recovery staff plus associated staff involved in the care of a donor / potential donor working in collaboration with the Specialist Nurse – Organ Donation.

Tissue donation: All staff working in areas caring for patients on end of life care pathways, with recently deceased patients or working with recently bereaved families.

3. DEFINITIONS

Clinical Lead for Organ Donation (CLOD): A clinician with responsibilities for developing and championing donation within the Trust.

Specialist Nurse – Organ Donation (SN-OD): A senior nurse employed by NHS Blood and Transplant who is a specialist in working with donor families, co-ordinating the donation process and is responsible for working with the CLOD to develop and champion donation within their hospital Trust.


Donation after Brain Stem Death (DBD): Donation of an organ or organs following the diagnosis of death using tests to confirm the absence of brain stem function.

Donation after Circulatory Death (DCD): Donation of an organ or organs after death has been confirmed on the basis of permanent cardio-respiratory arrest.

BAME: Black and minority ethnic

Human Tissue Act 2004: Act governing removal, storage and use of organs from the deceased for transplantation in England, Wales and Northern Ireland. Came into force September 2006.

Human Tissue Authority: Oversees the implementation of the requirements of the Human Tissue Act. Covers licensing of premises for retrieval, storage and consent. The licence covering organ and tissue donations for transplant is held by NHS Blood and Transplant – this does not cover tissue taken purely for research.

Organ donation: For the purposes of this policy this will refer to the donation of solid organs after death has been diagnosed following brain stem testing or permanent cardio-respiratory arrest.

Tissue donation: The donation of tissues after death has been diagnosed following brain stem death testing or permanent cardio-respiratory arrest.

Potential organ donor: Any patient in the A & E or Critical Care departments who meets the criteria laid down for potential solid organ donation as set out in the Trust referral protocol.

Potential tissue donor: Any patient in West Suffolk NHS Foundation Trust who dies during their stay in hospital.

Human Tissue Authority: Oversees the implementation of the requirements of the Human Tissue Act. Covers licensing of premises for retrieval, storage and consent.

4. STAFF ROLES AND RESPONSIBILITIES

Chief Executive

Will ensure the Trust has a policy for Organ and Tissue donation

Executive Chief Nurse

Will ensure that this policy is implemented operationally and monitored as part of the Clinical Governance Strategy

Clinical Directors/Associate Directors/General Managers

Will ensure this policy is disseminated and implemented within their areas of responsibility

Those managers and directors who have a specific remit for services involved with organ and /or tissue donation will ensure communication regarding changes within their service.

Matrons and Service Managers

Will ensure all staff in their areas are aware of and understand the policy and that it’s implemented into practice locally.

Will investigate failures to comply with the policy and ensure corrective action is taken to prevent a recurrence.

Ward managers

Will ensure all staff are aware of and comply with the policy.


All staff

Will adhere to Trust policy

Will use this policy in conjunction with all other Trust policies that relate to bereavement.

The clinical lead for organ donation

Each Trust has a clinical lead for organ donation to undertake the role on behalf of NHSBT. The role includes:

Championing organ donation within the Trust and the local population

Setting up and assisting with the running of the Trust Organ Donation Committee

Leading on the implementation of policies and guidelines

Reporting to NHSBT and the Trust Board on all aspects of donation activity

Tackling issues relating to donation activities

Keeping the Trust updated on current practice in donation and transplantation

Education

The CLOD will receive support and training on all aspects of donation from NHSBT.

The Specialist Nurse for organ donation

Each Trust has a Specialist Nurse – Organ Donation, employed by NHSBT and possessing an honorary contract with the Trust. The SN-OD will be part of the Critical Care team. The role includes:

Working in-house to help encourage staff to see donation as part of all end-of-life decision-making

Speaking to families/next of kin regarding the possibility of organ donation

Coordinating the donor process

Supporting staff throughout the donation process and follow up post donation

Education/training for all staff involved in donation

Audit (national/local)

Reporting to the Trust / NHSBT / departments on all aspects of donation activity

Contributing to the end of life and palliative care teams

Working with the CLOD to:

o Promote donation across the Trust and local population o Keep the Trust updated with current practice o Tackle issues around donation activity

Maintaining a regional on-call commitment


Teaching / presenting externally for the regional team (eg universities, schools, public events)

Undertaking specific projects relating to organ donation for the regional team

Debriefing staff within two weeks of donation The SN-OD will be given resource support and Trust-based mandatory training by the Trust and will receive all other support by NHSBT.

5. PROTOCOL FOR ORGAN DONOR IDENTIFICATION AND REFERRAL IN CRITICAL CARE

AREAS

Organ donation must be considered as part of all end of life decision for all patients.

When a clinical decision has been made to brain stem test or when no further treatment options are available and a plan of withdrawal of life sustaining treatment has been made on a ventilated patient of any age the doctor or nurse must page:

UK Organ Donation referral line (24-hour on-call service) on 03000203040 will explore the

potential for organ donation.

This notification should take place even if the attending clinical staff believes that donation might be contra-indicated or inappropriate. The only absolute contra-indication to donation is suspicion of CJD. All other potential donors will be assessed on an individual basis and the SN-OD will seek advice, where necessary, from transplant surgeons.

Potential solid organ donors

Potential solid organ donors will be identified from the A & E and Critical Care Departments. The patient may, on rare occasions, be cared for in Theatre Recovery but will be under the care of an A & E or Critical Care Consultant. Timely referral will enable early assessment of the suitability of the patient for donation. It is considered appropriate to verify a patient’s pathophysiological suitability for donation before the issue is broached with the next of kin / person in a qualifying relationship / legal representative, in order to ensure that:

Families are not asked for consent unnecessarily

Where donation is a possibility, there are no unnecessary delays for both the donor’s family and the condition of any organs that may be donated.

On referral to the SN-OD

Most doctors have not received formal training in approaching the families of potential

donors, whereas this is a key and core component of training and development that SN-ODs

now receive.

It is hard to escape the conclusion that there is some link between this and the higher rates

of consent/authorisation seen when SN-ODs are involved in a family approach. However, SN-

ODs are not currently involved in all family approaches, even though there are professional

recommendations that this should be the case.


The pathway in Appendix describes three key stages in approaching a family for consent/

authorisation for organ donation

Planning the approach

Confirming understanding and acceptance of loss

Discussing donation

The SN-OD will either attend the department immediately (if the embedded SN-OD is in the hospital) or will phone the referrer and gather some information to enable:

Checking of the Organ Donor Register (ODR)

Assessment of the clinical suitability of the patient for solid organ donation

The referrer will be asked for the patient’s details (including: name, address, current condition including treatment, past medical history, current and admission blood results and plan). The SN-OD will then check the ODR and may make some calls to Transplant Centres to discuss the patient’s suitability. The SN-OD will then contact the referrer to either inform them of the SN-OD’s planned time of arrival in the department or to inform them that the patient is not suitable to donate solid organs (+/- suggest referral to Tissue Services).

HM Coroner

All potential organ donors will be referred to HM Coroner. This will be done by the SN-OD and may require input from the clinician. The timing of the discussion with HM Coroner may vary depending on the case. The Coroner has the ultimate decision in these cases and may place restrictions on what can be donated. The SN-OD will arrange this. The Coroner has a legal duty and must be informed in every case if death is caused, contributed to or accelerated by violence, an accident (however far in the past), neglect by self or others, industrial disease, poisons, errors in medical management, or occurred before recovery from an anaesthetic, within twenty four hours of admission or in a detained person (prison, police or under provisions of the Mental Health Act). Unless the death is due to entirely natural causes the matter should be referred to the Coroner’s office. If there is any doubt it is the Coroner’s not the doctor’s decision and the case should be referred. The Coroner must establish who the dead person was, when and where that person died and how that person came by their death. In all cases, even in suspicious cases where the police are involved, the coroner is responsible for the final decision as to whether a donation goes ahead. Organ or tissue donation cannot proceed without the agreement of the Coroner who must be satisfied that the donation will not interfere with their duty to investigate the death. It is important to realize that in such cases, although the Coroner must agree to donation, the Coroner has no power to authorise donation. The Coroner must conduct a full investigation of the death and, where necessary, ensure that any evidence relevant to the investigation is preserved. A principal concern of Coroners is to ensure that any forensic examination or criminal proceedings arising from the death are not compromised by the retrieval of organs or other interference with the body. Before giving permission in a particular case, where criminal proceedings are likely, it is important that the Coroner discusses the case with the pathologist (forensic or otherwise) who will be carrying out the post mortem examination and the senior police investigating officer. The Coroner may also ask for a forensic pathologist to be present at the retrieval or that photographs


are taken or witness statements are obtained from the retrieving surgeons. This may mean that donation can proceed where otherwise it may not have been possible. Provided such procedures are followed and there is appropriate consent either from the donor or from an individual in a qualifying relationship, the Coroner should have no reason to object or organ or tissue donation in most circumstances. Even in deaths entailing a police investigation, if full information is provided, the Coroner, in consultation with the police, may be able to agree to donation of some organs and / or tissues. However, in such cases, the SN-OD will contact the pathologist and senior police investigating officer, in addition to the coroner as soon as possible (DH 2010a).

The SN-OD will liaise with the Coroner as required and the Department of Health have produced separate guidance for SN-OD’s working with Coroners and an aide memoire for Coroners regarding organ and tissue donation (DH 2010a & b). All conversations with the Coroner or their Officer must be recorded in the deceased’s medical records.

Consent

The Human Tissue Act 2004 became law in April 2006. This legislation means the ‘wishes’ of the deceased will take precedence. It is lawful to take organs for transplantation where the deceased consented before death. However it remains good practice to ensure relatives are consulted. Each case should be considered individually. If an individual has not expressed a wish to donate their organs or tissues after death, The Human Tissue Act 2004 requires ‘appropriate consent’ which means consent from an appropriate person needs to be obtained. See appendix 1 for a list of those who can give consent. Further detail regarding consent can be found in the Human Tissue Authority (2009) Code of practice 2 (Donation of solid organs for transplantation) www.hta.gov.uk/guidance/codesofpractice.cfm

Anaesthetic support

All potential solid organ donors will be under the care of an A&E / Intensive care / Anaesthetic Consultant covering A&E and Critical Care, who will ensure that an Anaesthetist is available to support the donation process. Out of hours the anaesthesia over shall be provided by the Intensive care consultant on call. In cases of DBD an Anaesthetist will be required to:

Transfer the patient to theatre

Maintain the patient until cross-clamp

Where the cardio-thoracic team has brought its own Anaesthetist/Donor Physiologist, be available to give support if required.

In cases of DCD an Anaesthetist will be required to:

Transfer the patient to the anaesthetic room (If withdrawal takes place there)

Assist with withdrawal of support (extubation)

Pronounce death

http://www.hta.gov.uk/guidance/codesofpractice.cfm


Re-intubate for lung re-intubtaion prior to lung retrieval (if required).

Theatre Support

A suitable time will be negotiated between the Theatre Coordinator, Anaesthetist and SN-OD. Theatre staff will ensure that:

The anaesthetic room is prepared for DCD withdrawal

The theatre is set up with suction (2X4 chamber), diathermy and trolleys

The retrieval team(s) are greeted and shown where to change and where to put equipment (designated theatre)

A member of staff (runner) is available to support the retrieval team

Members of staff are available to undertake last offices along with the SN-OD

Protocol for donation after brain stem death (DBD)

If it is suspected that the patient is brain stem dead or is likely to become brain stem dead the patient will be referred to the Critical Care Consultant. The Critical Care Consultant will be responsible for their management. (See Appendix). Unless the family / next of kin initiate discussion about organ donation the option should not be discussed until such time as brain stem death testing has been carried out and the family / next of kin fully understand that death has occurred. The family / next of kin will be fully informed of the plan to brain stem death test and the nature of the tests. Testing will be carried out in line with national guidance: A Code of Practice for the Diagnosis and Confirmation of Death (The Academy of Medical Royal Colleges 2008). Date and time of death is pronounced and documented following completion of the first set of tests. Understanding that death has occurred in a warm, heart-beating, ventilated patient is sometimes very difficult for family members to understand. In these cases it may be useful for some family members to witness the tests being done. If this is the case, unless they insist on witnessing both sets of tests, it could be suggested that they watch the second set of tests (confirmatory set) or just the apnoea test. The SN-OD will consult with the Nurse in Charge and Consultants undertaking the tests before approaching the family about witnessing the testing. A member of staff must be able to support the family and explain what is being done throughout. The SN-OD will be present during the pre-testing and post testing discussions with the family. Research has shown that the earlier the SN-OD is involved with the family the higher the consent rate.

Once the clinical staff and SN-OD have established that the time is right to approach the family for donation the SN-OD will be available to answer any questions and explain the process. If the family decline donation, withdrawal of life sustaining treatment will take place as decided by the doctor. The SN-OD will stay to support the family and staff. If the family wish to proceed with donation the SN-OD will:


Obtain verbal consent from the next of kin

Contact the Coroner to ensure no restrictions to donation

Instigate a donor management protocol with the attending doctor

Ensure patient’s blood group is known, arrange for group and save to be sent if not

Take written consent

Take a medical / social history from the family/next of kin

Prepare the family / next of kin for what will happen during the process and answer all questions

Arrange for bloods to be taken for tissue typing and virology

Arrange for couriers to take bloods to specialist labs

Arrange for the Scout Team to attend if cardio-thoracic organs being donated

Undertake a complete physical assessment of the patient

Contact the patients GP for information on the patient

Arrange for clinical tests to be carried out as necessary (ECG, chest x-ray, ECHO)

Place all information on the Electronic Offering System (EOS)

Ensure organs are offered appropriately

If necessary arrange for some units of blood to be ready for theatres

Liaise with theatres to book an appropriate time for retrieval

Liaise with the doctors, nurse in charge and bedside nurse to keep them informed of progress

Arrange for retrieval teams to arrive at the specified time

Liaise with Anaesthetist to be available for transfer and theatres

Assist with transfer to theatre

Coordinate teams in theatre

Ensure all organs despatched to transplant centres

Ensure all family wishes regarding last offices are carried out (including handprints and hair locks if requested)

Assist with last offices / viewing by family

Ensure all documentation is complete

If necessary ensure that mortuary staff are informed that tissue donation will be occurring

Support the family throughout

Contact the family if requested with the outcome of the donation

The SN-OD and CLOD will offer debrief sessions for all staff involved within two weeks of donation. A follow-up letter will also be sent to those involved with the donation.

Protocol for donation after circulatory death (DCD)

Death is based upon cardiac criteria instead of brain criteria and, following the confirmation of death, the organs needs to be cooled as quickly as possible by an in situ perfusion technique and retrieved promptly by the transplant surgeons. It is possible to retrieve kidneys, liver, pancreas, heart and lungs from DCD donors.


Decision to withdraw life sustaining treatment / support

The decision to withdraw life sustaining treatment should:

Be based on a multidisciplinary consensus on the futility of continued organ support and should involve the patient’s consultant, medical and surgical staff, nursing staff and next of kin / person in qualifying relationship / legal representative.

Be clearly documented in the patient’s healthcare records

Be made in accordance with the national guidelines published by the GMC and Intensive Care Society and be sufficiently robust to bear objective scrutiny.

Be made in conjunction with a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order

Be transparently independent from any subsequent discussion regarding organ donation

Not involve members of staff involved in the transplant programme

The UK Donation Ethics Committee (Dec 2011) state ‘Where donation is likely to be a possibility, full consideration should be given to the matter when caring for the dying patient.’ Following the decision to withdraw treatment, all care should be in the best interest of the patient. Measures to maintain organ function where it has been deemed to be in the patient’s best interest i.e. where a patient has stated, through legal means, (ODR, card, verbally), that they want to be an organ donor are acceptable. This may include family consent. The DoH document – Legal issues relevant to non-heart beating donation states ‘maintenance of life-sustaining treatment may be considered in the best interests of someone who wanted to be a donor if it facilitates donation and does not cause them harm or distress, or place them at significant risk of experiencing harm or risk.’ Monitoring and treatment should continue until the family have been approached for donation. It is necessary to maintain treatment if the patient is to be a donor. The family will only be approached for organ donation after the futility of treatment and withdrawal of life sustaining treatment discussion has taken place with the family and only when the family understand that death is inevitable. Once the clinical staff and SN-OD have established that the time is right to approach the family for donation, the SN-OD will be available to answer any questions and explain the process. If the family decline donation, withdrawal of life sustaining treatment will take place as decided by the doctor. The SN-OD will stay to support the family and staff. If the family wish to proceed with donation the SN-OD will

Obtain verbal consent from the next of kin

Contact the Coroner to ensure no restrictions to donation

Take written consent

Take a medical / social history from the next of kin

Prepare the family / next of kin for what will happen during the process and answer all questions

Arrange for bloods to be taken for tissue typing and virology

Arrange for couriers to take bloods to specialist labs

Undertake a complete physical assessment of the patient


Arrange for clinical tests to be carried out as necessary (chest x-ray, ECG etc)

Place all information on the Electronic Offering System (EOS)

Ensure organs are offered appropriately

Liaise with theatres to book an appropriate time for retrieval

Arrange for retrieval teams to arrive at the specified time

Liaise with Anaesthetist to be available for transfer to the anaesthetic room and be available to pronounce death – or to be present on the unit if withdrawal is taking place on Critical Care

Assist with transfer to theatre (if withdrawal is taking place there)

Monitor the patient and record the observations throughout the withdrawal of life sustaining treatment

Coordinate teams in theatre

Ensure all organs are despatched to transplant centres

Ensure all family wishes regarding care after death are carried out (including handprints and locks of hair if requested)

Assist with care after death / viewing by family

Ensure all documentation is completed

Support the family throughout

Contact the family if requested with outcome of donation

The SN-OD and CLOD will offer debrief sessions for all staff involved within two weeks of donation.

Process of withdrawal of life sustaining treatment

Withdrawal will take place either in the anaesthetic room or critical care area where the patient is being cared for. This will enable a controlled transfer of the body into theatre after death has been pronounced. The retrieval team(s) will be scrubbed and waiting quietly in theatre when withdrawal takes place. If being used the anaesthetic room will be prepared by the theatre staff with the assistance of the SN-OD to remove any unnecessary equipment, cover windows and arrange chairs for the accompanying family / next of kin. If withdrawal is taking place in the anaesthetic room the patient will be brought there with monitoring in place and, once the family, staff and retrieval team are ready, the endotracheal tube will be removed / ventilatory support stopped and inotropic support discontinued. Any analgesia or sedation that is being used for patient comfort measures will continue as planned / prescribed. Withdrawal of life sustaining treatment can happen as above in the Critical care area if this is more appropriate. The family will be offered the opportunity to stay throughout the withdrawal of treatment if they wish to do so. The nurse caring for the patient will remain with the patient, family and the SN-OD. The patient will be kept comfortable throughout.

The SN-OD will be responsible for monitoring the patient, liaising with the retrieval team(s) in the theatre and ensuring that the retrieval team(s) remain quiet at all times. The SN-OD will also assist with the reassurance of the family / next of kin. Once cardio-respiratory arrest has occurred, there will be a five minute stand – off time in which the body is not disturbed (to ensure no auto-resuscitation is likely). Following this the Anaesthetist will


pronounce death according to the Code of Practice for the Diagnosis and Confirmation of Death (Academy of Medical Royal Colleges 2008). Following this the patient will be moved into theatres with the SN-OD and theatre staff. The family will be supported by the nurse caring for the patient and if in the anaesthetic room will accompany them back to Critical care relative’s room. The department staff will ensure that the family / next of kin have all the relevant paperwork they need and know when to contact the Bereavement office.

Timeframe

In order for organs to be in optimal condition for transplantation, lack of organ perfusion must be kept to a minimum. The length of time that organs can be without good blood flow before irreversible damage starts to occur is dependent on the particular organ. As a result, once withdrawal has occurred, the retrieval teams will not be able to retrieve if the patient does not die within a specific time frame.

Heart / lungs – the retrieval team will normally stand down sixty – ninety minutes after withdrawal

Liver – the retrieval team will normally stand down two hours after withdrawal

Kidneys – the retrieval team will normally stand down two – four hours after withdrawal

(Timings will be dependent on the retrieval teams in attendance and may vary) Once the retrieval teams have stood down, if the patient and family are in the anaesthetic room they will return to the Critical care area or to a pre-planned ward bed where the patient will be kept comfortable. If withdrawal took place in the Critical care area care will continue for the patient there or they may be moved to a ward bed. It is the responsibility of the nurse in charge of the Critical Care Unit to inform the Site Manager if a bed may be required following withdrawal of treatment. Once the patient has had treatment withdrawn it is the SN-OD’s responsibility to keep the nurse in charge of the unit informed of developments in the donation process.

Donor assurances

The SN-OD / Tissue Services Coordinator will undertake a full patient assessment. This is with an aim to minimise the risk of transmission of infections and diseases and to ensure that all relevant donor information is obtained, interpreted and accurately relayed, to enable recipient centres / tissue establishments to make an informed decision regarding organ / tissue suitability (NHSBT 2010).

Positive virology

Blood samples for virology testing and tissue typing are taken from every potential donor in order to ascertain suitability as outlined above. These samples are tested on behalf of the transplant teams in laboratories outside the Trust. The results are made available to the transplant teams. If the results of any samples tested negate donation for reasons that could potentially impact on the health and well-being of the next of kin / significant others the senior clinician has a duty of care to ensure they are made aware of this possibility. Permission to collect these samples and to perform these blood tests is sought and recorded within the consent process. Consent is also taken to access medical notes and to contact the GP of the deceased to request details of medical history.

Conscientious objection Clinical staff who have conscientious objections to donation cannot be expected to take part in the process, but neither can their objection be allowed to deny any patient or their family the opportunity


of donation when it involves a process that has received local and national endorsement (Murphy & Logan 2009). Conscientious objection may be permissible if sufficient staff of equal grade who are willing to provide the service. Conscientious objectors must ensure that their patients are aware of the care they are entitled to and refer them to another professional. Conscientious objectors must not compromise the care of their patients (Savulescu 2006).

Potential tissue donors

The quality of life for many people can be improved by the transplantation of tissues such as eye tissue (to restore sight), bone, blood vessels, meniscus, tendon, skin (to treat burns) or heart valves (to treat acquired cardiac disorders or congenital malformations). Tissue does not deteriorate immediately following cessation of the heart beat due to its low metabolic requirements, allowing more time for tissue retrieval. The option of donation can therefore be offered in a variety of clinical settings.

The potential for tissue donation exists for all patients who have died as in-patients on any ward or in the critical care areas. Unlike solid organs, which are considered life-saving, tissues are considered to be life-enhancing and therefore there are significant numbers of contraindications to tissue donation. Each individual will be assessed by a Specialist Nurse from NHSBT Tissue Services to establish their suitability to be a donor. Following the death of the patient the family may be approached by a doctor or nurse to establish whether tissue donation is something they would wish to consider. The family may bring the subject up themselves and the staff must be able to facilitate their wishes. If a patient is placed on the end of life care pathway, tissue donation may be raised when the form is being completed before death to establish the patient’s wishes. If the family indicate that they would consider tissue donation, they should be told that a specialist nurse from Tissue Services will telephone them at home later in the day following the death to discuss the patient’s medical and social history, and to gain consent if donation is possible. It is preferable to establish a suitable time for the Specialist Nurse to ring so the family can be prepared for the call.

The member of staff will page Tissues Services on 0800 432 0559. A member of staff from Tissue Services will phone the person making the referral and gather details of the patient. The patient’s healthcare records will be needed to ensure all information is given. The next of kin telephone number and the GP details will be required. Out of hours a message may be left and the Tissue Services Coordinator will phone the ward in the morning.

The mortuary staff must be informed that the patient may be a tissue donor. If the death occurs at night, they must be contacted as soon as the offices open. If the patient is not suitable to be a tissue donor the ward staff may be told immediately and can give this information sensitively to the family if they are still in the department. If the family have gone home, the member of staff may ask the Tissue Services Coordinator to contact the family to let them know or may phone the family themselves, if they feel comfortable to do so. Tissue donation is carried out in the mortuary by trained Tissue retrieval staff. Tissues must be retrieved within 24 hours of death (in exceptional circumstances some tissues may be retrieved up to 48 hours). Corneas must be retrieved within 24 hours of death.


The body must have two identification bands with 3 clear points of identification on it and be transferred to the mortuary within 6 hours of death occurring. Tissue donation does not prevent a body being viewed by the family. Families will be fully informed by the Tissue Services staff of any changes to the appearance of the body.

Whole body donation / donation for research

An individual may wish to leave their body to a school of anatomy or a specific research tissue bank. This decision must have been made by the donor in life with full capacity and registered with a school of anatomy or tissue bank. It is the donor’s family responsibility to contact the relevant school of anatomy and inform them of the donor’s death. At this point suitability would be assessed by the school of anatomy. The SNOD will be able to provide further advice on this if required.

Guidance for Critical Care consultants in managing the care of the potential organ donor

referred from the A & E

Should a patient meet any of the criteria for referral to the SN-OD the ITU Consultant will be asked by the clinician in charge of the patient’s care to take over the management of the patient. This will include those patients whose CT scans have been sent for a neurosurgical opinion. In the event that the neurosurgeons can offer no surgical intervention, the Consultant will make a clinical management decision. If brain stem death testing or withdrawal of life sustaining treatment

is planned the UK Organ Donation referral line (24-hour on-call service) on 03000203040 must be called. The SN-OD will discuss the potential for donation and mobilise to the hospital to support the team if there is a potential.

The Consultant will arrange for the patient to be transferred to ITU to await results of neurosurgical opinion / brain stem testing / supporting to brain stem testing / withdrawal of life sustaining treatment.

In the event of no Critical Care bed availability, the Consultant will arrange, with the Site Manager, for the patient to be cared for in the most appropriate clinical area, for example, recovery. Discussions with family / next of kin regarding donation will take place only once the family have understood the results of brain stem tests or understood the futility of further support. Discussions with the family / next of kin will be planned collaboratively with the Consultant / clinicians / nursing staff and SN-OD. The SN-OD will provide national / regional guidelines for donor management for all potential donors following brain stem death. All patients considered to be potential donors will continue to be on monitoring equipment until such time as the next of kin have been approached for donation.

6. TRAINING REQUIREMENTS

Recommendation 11: All clinical staff likely to be involved in the treatment of potential organ donors should receive mandatory training in the principles of donation. There should also be regular update training. (DOH Task Force, 2008).


Staff working in critical care areas such as ED, ITU and theatres should attend annual training updates on organ donation. These sessions will be delivered face to face and cover the skill and knowledge base as directed in the NICE guideline 135. The training will be undertaken by the CLOD and/or SN-OD. Training records will be kept. Separate training will be provided to staff in other departments who may be involved in the process of tissue donation as the programme is developed within the hospital.

7. MONITORING AND AUDIT

The SN-OD will undertake a monthly potential donor audit of all patients who die within the A & E and ITU. Any cases of missed referrals will be investigated by the SN-OD and the CLOD informed. The SN-OD will monitor rates of potential organ donor identification, referral and approach to the family and consent to donation. The SN-OD will report the monthly data to the CLOD. The Organ Donation Committee will report six monthly to the WSH Board through the usual Clinical governance process and the Medical Director. The data will be held by NHSBT who will monitor it each month. A 6 monthly report will be compiled by NHSBT comparing local and national data based on the potential donor audit data supplied and they will provide WSH with a benchmark against national performance. This report will be sent directly to the Chief Executive.

8. APPROVAL AND IMPLEMENTATION

Approval

Approval of the document will be through the Clinical Standards Committee

Implementation

This document will be available electronically on the Trust intranet in the Pink Book

9. REFERENCES

Academy of Medical Royal Colleges (2008). A Code of Practice for the diagnosis and confirmation of death.

www.aomrc.org.uk/.../42-a-code-of-practice-for-the-diagnosis-and-confirmation-of-

death.html Academy of Medical Royal Colleges, UK Donation Ethics Committee (December 2011) An ethical framework for controlled donation after circulatory death Coroners Act (1988) London. HMSO

Department of Health (2008). Organs for Transplants; A report from the Organ Donation Taskforce. Approaching families of organ donors- best practice guide. http://odt.nhs.uk/pdf/family_approach_best_practice_guide.pdf

http://www.aomrc.org.uk/.../42-a-code-of-practice-for-the-diagnosis-and-confirmation-of-death.html

http://www.aomrc.org.uk/.../42-a-code-of-practice-for-the-diagnosis-and-confirmation-of-death.html

http://odt.nhs.uk/pdf/family_approach_best_practice_guide.pdf


Accessed 02/08/2018 Department of Health (2010a) Guidance for Donor Coordinators working with Coroners http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_114801.pdf Department of Health (2010b) Organ and Tissue Donation; An aide memoire for Coroners Department of Health’s Advisory Committee on the Microbiological Safety of Blood and Tissues for Transplantation (MSBT) (2000) Guidance on the Microbiological Safety of Human Organs, Tissues and Cells used in Transplantation

General Medical Council (2010) Guidance for doctors. Treatment and care towards the end of life: good practice in decision making.

www.gmc-uk.org/guidance/ethical_guidance/end_of_life_care.asp

Intensive Care Society (2004). Guidelines for Adult Organ and Tissue Donation.

www.uktransplant.org.uk/...transplants/donor.../ICS_guidelines_for_adult_organ_and_t

issue_donation_chapter_5(nov2004).pdf NHS Blood and Transplant (2010). Standards of Practice for Specialist Nurses Organ Donation. The Human Tissue Act (2004) London: HMSO http://www.legislation.gov.uk/ukpga/2004/30/contents

Human Tissue Authority (2009) Code of Practice 2; Donation of solid organs for transplantation Murphy F (Bereavement and Donor Coordinator) (2009) Required Referral for Organ and Tissues Donation Policy, Royal Bolton Hospitals NHS Foundation Trust Murphy PG & Logan L (2009) Clinical leads for organ donation: making it happen in hospitals Journal of the Intensive Care Society 10(3); 174 – 178.

National Institute for Health and Clinical Excellence (2011) NICE Clinical Guideline135 - Organ donation for transplantation: improving donor identification and consent rates for deceased organ donation NHS Blood and Transplant (2009) Organ and tissue donation; your questions answered www.organdonation.nhs.uk

NHS Blood and Transplant (2009a) Donation Committee: Information for Donation Committee Chairs NHS Blood and Transplant (2009b) Organ donation and religious perspectives

NICE Guidance 135 Organ Donation for Transplantation (December 2011) Improving donor identification and consent rates for deceased organ donation

Savulescu J (2006) Conscientious objection in medicine British Medical Journal; 332; 294 – 297 (http://www.practicalethics.ox.ac.uk/Introduction/Conscobj294.pdf accessed 29/6/2010)

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_114801.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_114801.pdf

http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_care.asp

http://www.uktransplant.org.uk/...transplants/donor.../ICS_guidelines_for_adult_organ_and_tissue_donation_chapter_5(nov2004).pdf

http://www.uktransplant.org.uk/...transplants/donor.../ICS_guidelines_for_adult_organ_and_tissue_donation_chapter_5(nov2004).pdf

http://www.legislation.gov.uk/ukpga/2004/30/contents

http://www.organdonation.nhs.uk/

http://www.practicalethics.ox.ac.uk/Introduction/Conscobj294.pdf%20accessed%2029/6/2010


Document configuration Author(s): Linda Warne (SN-OD)

Other contributors: Approvals and endorsements: Debra Baker, Ian Frost

Consultation:

Issue no: 1

File name:

Supercedes:

Equality Assessed

Implementation

Monitoring: (give brief details how this will be done)

Other relevant policies/documents & references: Operating Theatre Guideline No 54

Additional Information:


Appendix 1 - The Human Tissue Act 2004

The Human Tissue Act 2004 came into force in 2006, to regulate the removal, storage and use of human organs and tissues. The Act covers aspects of consent, licensing, codes of practice, anatomical specimens, trafficking and transplants.

The Act:

Regulates the removal, storage and use of human tissue. This is defined as material that has come from a human body and consists of, or includes, human cells.

Makes consent the most important principle for the lawful retention and use of human tissue

Establishes the Human Tissue Authority to:

o Advise on and ensure compliance with the Act

o Develop national operational procedures and guidelines

o Licence activities using human tissue

Makes it an offence to have bodily material (which includes hair, nail and gametes in this context) with the intention of analysing the DNA, without the consent of the individual from which it was obtained (or those close to them if they have died)

Makes it lawful to take minimum steps to preserve the organs of a deceased person for use in transplantation while steps are taken to determine the wishes of the deceased, or, in the absence of their known wishes, obtaining consent from someone in a qualifying relationship.

It is also hoped that it will improve public confidence, so that people will be more willing to agree to the use of tissues and organs in research.

The tables below identify who can give consent. Qualifying relatives relationships are ranked in order for when consent is being sought.

Living competent adult, or competent child willing to make a decision

His / her consent

Living child (incompetent, or competent but unwilling to make a decision)

Consent of a person with parental responsibility

Deceased adult 1. His / her consent before death 2. If no prior consent, consent of a nominated representative 3. If no representative, the consent of a qualifying relative

Deceased child 1. Consent of the person with parental responsibility 2. If not available consent of an individual in the capacity of qualifying relative immediately before death

Qualifying Relatives in order of ranking 1. Spouse or partner 2. Parent or child 3. Brother or sister 4. Grandparent or grandchild 5. Niece or nephew 6. Stepfather or stepmother 7. Half brother or half sister 8. Friend of longstanding


Appendix 2 - Referral guideline

IDENTIFYING AND REFERRING A POTENTIAL

ORGAN DONOR

When a clinical decision has been made to Brain Stem Test OR when no further treatment options are available and a plan of Withdrawal of Treatment has been made please refer to a Specialist Nurse-Organ Donation (SN-OD).

The absolute contra-indications to donation are suspicion of CJD. ALL other cases should be referred and will be explored as a potential organ donor by a SN-OD.

UK Organ Donation referral line (24-hour on-call service) on

03000203040

GUIDELINE FOR REFERAL OF A POTENTIAL ORGAN DONOR, MINIMUM

NOTIFICATION CRITERIA DoH ORGAN DONATION TASKFORCE RECOMMENDATIONS, 2008

The SN-OD should be notified as soon as the decision to perform brain stem death tests has been made.

The SN-OD should be notified as soon as the decision to withdraw active treatment has been made.

This notification should take place even if the attending clinical staff believes that donation might be contra indicated or inappropriate.


Appendix 3 - Flow chart for donor referral

YES NO

See tissue

referral

flowchart

NO

Pathway for Donor Identification and Referral

Patient intubated and ventilated?

YES NO

Patient dies in the department? Any of the following

Brain stem death tests planned.

GCS 4 or less

Absence of 1 or more cranial nerve reflexes

Pupils fixed

No corneal reflex

No cough / gag reflex

No response to painful stimuli

OR

A decision has been made to withdraw active

treatment (extubate)

Management as

directed by clinician

YES

If the patient is in the Accident and Emergency Department contact the ITU Consultant and refer the

patient.

Page UK Organ Donation referral line (24-hour on-call service) on 03000203040

Leave your name, department, hospital name and direct line number

A Specialist Nurse in Organ Donation (SN-OD) will phone back within 20 minutes

You will be asked: patient details, current history / past medical history, blood results, plan,

details of next of kin and what they know. Have the patient’s notes with you

The Specialist Nurse will confirm if the patient is a potential donor (including checking the

Organ Donor Register and may involve advice from transplant surgeons).

If not able to donate organs, you may be advised to make a referral to Tissue Service.

If the SN-OD confirms that the patient is a potential donor, the SN-OD will make a plan to mobilise to

the department.


Appendix 4 - Flow chart for donation after brain death

Donation After Brain Death (DBD)

Patient is suspected brain stem dead or brain stem herniation is a likely event

UK Organ Donation referral line (24-hour on-call service) on 03000203040

Plan for BSD Tests discussed with family by ITU Consultant

DONATION DISCUSSION IS NOT INITIATED AT THIS TIME

Brain Stem Death tests undertaken as per the Code of Practice for the Diagnosis and

Confirmation of Death (Academy of Medical Royal Colleges 2008).

Patient diagnosed brain dead?

YES NO

With Consultant agreement SN-OD to be present to

support explanation of BSD test results

Only when the family understands that death has occurred

will option of organ donation be discussed with the family

(this may happen as a separate conversation)

Family in support of organ donation?

NO YES

Family are thanked for

considering donation

and treatment is

discontinued.

The family are

supported by the nurse

and SN-OD where

appropriate and last

offices are performed.

SN-OD works with the critical care team to optimise the patient for

donation. The SN-OD will also:

Complete the Consent and Patient Assessment with family

Contact the Coroner and GP (where able)

Undertake a physical examination and assessment of the patient

Send blood samples for virology and tissue typing

Request a CXR, ECG, ECHO

The patient is registered with ODT and the allocation of organs

commences. Potential recipients are alerted and mobilized. SN-OD

will liaise with theatres, critical care staff, anaesthetist and organise

retrieval teams to attend. Where consent has

been taken for tissue

donation, retrieval will

take place in the

mortuary Patient transferred to theatre with anaesthetist when surgical teams

ready. Bedside nurse to accompany family to theatre if required.

When donation is complete SN-OD performs last offices with theatre

staff. The deceased can be viewed by the family if desired. SN-OD

will contact family as agreed to update and support.

Decision may be made to

wait and re-test

OR

Plan made to withdraw

(see Donation after

Circulatory Death

flowchart)


Appendix 5 - Flow chart for donation after circulatory death

Donation after Circulatory Death (DCD)

Clinical decision to withdraw active support (documented)?

Patient intubated and ventilated?

UK Organ Donation referral line (24-hour on-call service) on

03000203040See referral flow chart

Is the patient a potential for donation?

(confirmed by the SN-OD)

NO YES

Continue end of life care as

planned

Consider tissue donation

(follow tissue referral and

donation pathways)

NO YES

Family are thanked for

considering donation

and treatment is

discontinued.

The family are

supported by the nurse

and SN-OD where

appropriate and last

offices are performed

SN-OD will: Complete the Consent and Patient Assessment with

family

Contact the Coroner and GP (where able)

Ensure blood samples for virology and tissue typing sent

Obtain CXR

Request further blood tests (where necessary)

Undertake a physical examination and assessment of the patient. The patient is registered with ODT and the allocation of organs

commences. Potential recipients are alerted and mobilized. SN-

OD will liaise with theatres, critical care staff, anaesthetist and

organise retrieval teams to attend.

Discussion with family regarding futility of continuing active

treatment. Donation options must only be discussed AFTER

the futility conversation. The family must understand that

death is inevitable BEFORE being offered donation. The SN-

OD will mobilise to attend donation discussions.

Family in support of organ donation?

NO YES

If asystole does not occur by

times set by retrieval team,

they will stand-down.

Patient is transferred to

unit/ward for end-of-life-care.

Wait for 5 minutes – family say ‘goodbyes’ then nurse leaves with

family. Patient is certified then transferred immediately to operating

table.

When donation is complete SN-OD performs last offices with theatre

staff.. The deceased can be viewed by the family if desired. SN-OD

will contact family as agreed to update and support.

Doctor and nurse to accompany patient (and family) to anaesthetic room to carry

out withdrawal of treatment

Patient dies within 4 hour timeframe?


Appendix 6 – Flow chart for tissue donation

Patient has died in the department?

YES NO

Relatives Present? Management as directed by clinician

YES NO

When discussing the

collection of the

death certificate

with the family, ask

if they would like to

consider tissue

donation.

YES NO Thank the family and

continue with family

care.

Pathway for Referring a Potential Tissue Donor

When discussing

the collection of

the death

certificate with the

family, on the

phone, ask if they

would like to

consider tissue

donation.

If no next of kin

then donation

cannot happen.

How to ask the family

“There is a possibility that xx may be able to

help others by becoming a tissue donor.

They may be able to give the gift of sight, or

help those with burns or other serious

injuries. If this is something that you would

like to know more about, I can phone a

Specialist Nurse who will phone you at

home, later in the day, to discuss it with

you.” Family consent?

You will be asked: Patient details, current history / past medical history, blood results, details of

next of kin. Have the patient’s notes with you. They will tape the phone call (so that they can

transcribe the information to the consent form).

Page Tissue Services on: 0800 432 0559 (24 hour pager service)

Leave your name, department, hospital name and direct line number. A Specialist Nurse will

phone back.

The Specialist Nurse will confirm if the patient is a potential donor and will arrange to contact the

family. If the patient is not a potential donor, the Specialist Nurse will ring them and explain why.

(Tissue donation takes place within 24-48 hours in the mortuary)


Appendix 7 - The Organ Donation Committee

West Suffolk Hospital Tissue & Organ Donation Committee

Terms of Reference

1. Purpose

To influence policy and practice to encourage the consideration of organ or tissue donation in all appropriate situations. To identify and resolve any obstacles to this.

To ensure that a sensitive and appropriate discussion about donation can feature in end of life care, wherever located and wherever appropriate, recognising and respecting the wishes of individuals.

To maximise the overall number of organs donated, through better support to potential donors and their families

2. Objectives

To ensure the purpose is achieved, the Committee is responsible for the following: 2.1 To lead on donation policy and practice across the hospital/Trust, to raise awareness, and to

ensure that donation is accepted and viewed as usual, not unusual. To maximise organ donation. 2.2 To ensure local policies and all operational aspects of donation are reviewed, developed and

implemented in line with current and future national guidelines and policies. 2.3 To monitor donation activity from all areas of the hospital - primarily from Critical Care areas,

including Emergency Medicine. Rates of donor identification, referral, approach to the family and consent to donation will be collected through the UK Transplant Potential Donor Audit. To ensure submission of the data to NHSBT on an agreed basis and to receive and analyse comparative data from other hospitals.

2.4 To report to the Medical Director and to the Board not less than six monthly, on comparative

donation activity and any remedial action required. 2.5 To participate in all relevant national audit processes; to review audit data on donation activity; to

monitor standards, test adherence to local policy and instigate any required actions. 2.6 To actively promote communication about donation activity to all appropriate areas of the hospital

and to ensure that the information is received and understood. 2.7 To ensure a discussion about donation features in all end of life care wherever appropriate and

to ensure this is reflected in the local end of life policies, procedures and pathways. 2.8 To support the Donor Coordinator and Clinical Lead for Organ Donation. 2.9 To identify and ensure delivery of educational programmes to meet recognised training needs

3. Membership

May vary, but should include the following or equivalents:

Chair - Possibly a lay person, patient or other well-known local figure.


Clinical Lead for Organ Donation SNOD Clinical Lead or senior nurse – ICU Clinical Lead or senior nurse – Emergency Medicine Consultant Palliative Care or lead nurse for palliative care Operating theatre representative - Senior nurse Patient affairs representative Eye bank representative The committee has the option through the chair to co-opt additional members. Possibly also representatives from: Local donor family

4. Quorum Four. This is a strategic group, and whilst deputies can attend, they will not count towards a quorum.

5. Frequency of Meetings Quarterly.

6. Authority

The Donation Committee will have the authority to make and recommend changes to donation policy and practice ensuring full consultation with clinical and management staff as integral to the implementation process.

7. Reporting Procedures The Donation Committee will report six monthly to the Board through the usual clinical governance process and the Medical Director. The report will in due time be part of the healthcare regulator assessment. Benchmark data will be made available for comparison.

8. Attendance

Members of the committee who miss two meetings in 12 months will no longer be invited to the meetings unless a deputy attends. This is to ensure that we have good representation and communication with departments.


Appendix 8



Appendix 9

Documents

Organ and Tissue donation - wsh.nhs.uk€¦ · Organ and Tissue Donation Policy For use in: Critical Care Services, Accident and Emergency, wards, theatres, mortuary For us e by: