Organ Donation and Trauma
Organ Donation and TraumaBy Tristan Saggese
Hello. For those of you that dont know me, my name is Tristan,
and today Ill be talking about the organ donation process as it
related to trauma and trauma hospitals. 1
Some Important InformationDonation restrictions / contradictions
30% of organ donations are from trauma patients Before donation:
Identify and evaluate donors, Obtain consent, Brain Death,
Before I introduce my three studies, I wanted to take a few
minutes to discuss some pertinent information.
Before organ harvesting can proceed, a lot has to take
In years past, criteria for organ donation used to be fairly
strict, limiting harvesting to donors aged 10-50 years of age
without co-occurring conditions. With the increasing demand for
organs, donation from an expanded donor pool has loosened
According to the New England Organ Bank and the California
Transplant Donor Network (CTDN) some current quote unquote absolute
contradictions include: Age older than 80 years, HIV infection,
Active metastatic cancer, Prolonged hypotension or hypothermia.
In the united states, approximately 30% of organ donations come
from trauma patients; the graph on the left hand side, sourced from
United Network for Organ Sharing, shows the causes of death of
patients that donated organs from 1999 to 2009.
Finally, before organ donation can occur a complicated, step by
step process, typically orchestrated by an organ procurement
organization (or OPO), takes place. Before organ donation occurs,
OPOs Identify donors, Evaluate potential donors, Confirm diagnosis
of brain death, Arrange consent from family, Clinically manage the
potential donor, Obtain permission for visiting transplant surgeons
to remove organs, and Preserve and package organs for
Its a long process.
Brain DeathBrain death confirmation No overwhelming
consensusLess time after brain death = More successful
transplantsCriteria for Brain Death?
Before harvesting organs occurs, a crucial step in in the
process is, of course, confirmation that a patient is brain
There is currently no defined consensus on the most appropriate
manner to for brain death diagnosis.
We know that the number of successful organ transplants
increases as the time between Brain death and organ harvesting
lessens; so, its important in cases of critically injured trauma
patients that a speedy diagnosis take place to maximize donation
Finally, some early giveaways for brain death include: Hemo
dynamic lability, Heart rate instability, Decreased bronchial
secretions; to conclude the confirmation of brain death, a
physician must show a Correction of potentially reversible causes
of coma, the absence of brainstem reflexes and a "Lack of
Cardiac DeathWhen Brain Death hasnt been confirmedUnited States
uses Cardiac Death indicator
There are instances in which the families of critically injured
patients decide to discontinue care (as recovery is seemingly
unachievable); although patients may not meet the guidelines
required for Brain Death confirmation, donation may be possible for
patients demonstrating cardiac death; note, the protocol for
diagnosis of cardiac death varyies; the process usually involves
quote withdrawal of mechanical support followed by rapid organ
procurement after the clinical pronouncement of death end
The United States has utilized the Cardiac death standard for
justification of donation, but not all countries do.
Geisinger Medical Center, PennsylvaniaPublished 1992Efficiency
of donation Process
Okay, now on to the papers.
I picked this first paper because it outlined the process and
protocol for assessing trauma patients eligibility for organ and
This article was published at the Geisinger Medical Center in
Pennsylvania. Although published in 1992, I think the study
highlights some important findings.
The purpose of this study was to assess the efficiency and
reassess the requirements for organ donation from patients
experiencing trauma-related mortality.
MethodsObserved108 patients admitted for trauma-related injury
over 36 month period. Characterized patients based on many
This study carried out a Randomized, retrospective analysis of
108 patients admitted to the Geisinger Medical Center for
The study then characterized patients based on a wealth of
characteristics, including, Pre-morbid diagnosis, method of brain
dead protocol, documentation for a request for organ procurement,
potentially salvageable organs, organs harvested, and factors
related to the inability to procure organs. They used the data to
conclude reasons for lack of organ donations, and highlight areas
The authors of the study also distributed a questionnaire to
families of patients who died via traumatic injury to elucidate
reasons that families might have withheld consent for organ
The table details this institutions requirements at the time for
organ donation and tissue procurement.
Table 2, on the left hand side categorizes the mode of death of
the 108 patients involved in the study who were potential organ
donation candidates. I found it interesting, that the majority of
patients, 53%, died via motor vehicle crashes.
Table 3 on the right side shows that, Of the 108 patients,
roughly 80% were ineligible for organ and/or tissue harvesting. The
reasons for ineligibility are categorized in the figure on the
right. Among other justifications for ineligibility, one major
cause was age alone. Other reasons for ineligibility included
sepsis, cardiopulmonary arrest and exsanguineation.
This figure shows the systematic progression from death to organ
For only 22 of the patients a documented request for organ and
tissue procurement was made by the attending physician, and brain
death protocol was utilized for 17 patients. Among other reasons
for failure of organ removal, the main reason for unsuccessful
organ procuration was refusal by the family.
Ultimately, as is shown in the figure, only 12 of the 108, or
roughly 11 percent, of the trauma patients became actual organ
Generally, approximately 12% of trauma patients become actual
donors, the study says.8
Conclusions // TakeawaysIncreasing professional education64%
consent refusalPublic education! Arbitrary age boundaries
This study, siting, similar studies, posits that increasing
professional education could increase the retention rate of
potential organ donors eightfold.
The study garners support for the idea that failure of families
to consent, and not so much failure to identify potential sources
for donations, was the most significant reason for loss of
donations. 64% of potential organs and tissues were lost as a
result of families refusal.
Interestingly, the study suggests that age should not be a
barrier to donation. Other studies have shown that organ donations
of older patients can yield significant amount[s] of functioning
organs and tissues In other words, potential donors should accepted
over a wider age range to cope with increasing demands
Ultimately, the questionnaire for families that refused organ
donations failed. 9
Department of Surgery at the University of MissouriPublished
This next study, for the people portion of my presentation, was
published in the Journal of Trauma in 2001 at the Department of
Surgery at the University of Missouri, in coordination with other
medical centers, and the Center for Organ Recovery and Education in
Pittsburgh, and Gift of Life Donor Program in Philadelphia.
The purpose of this study was to evaluate the opinions of
Pennsylvania trauma surgeons regarding their role in organ
donation, and the role of Organ procurement organizations (or OPOs)
in organ donation success. Further, the study hoped to highlight
ways to increase the conversion of potential organ donors into
actual organ donors.
Note: OPOs also known as organ procurement organizations were
created to cope with the increasing demand for organ donations.
These non-profit OPOs are meant to quote procure and distribute
organs for transplantation endquote, and to educate both the public
and medical personnel on info regarding the donation process, among
other jobs. 10
Methods18 question survey96 active trauma surgeons71 trauma
surgeons repliedPurpose: donation and OPOs
The study utilized an 18 question survey developed at a regional
trauma center in Johnstown, Pennsylvania.
The purpose of the survey was to highlight trauma surgeons
opinions on OPOs and the donation organ process as a whole. The
questions asked are quite interesting, and the surgeons responses
are often quite variable.
The survey was distributed to exactly 96 trauma surgeons, 71 of
whom (or 76%) replied with their answers.
The table on the right hand side, details types of trauma
centers the surgeons worked in, and the types of ICUs the surgeons
ResultsBroad range of results and opinions
The study yielded some important findings and a wide range of
Table 3 includes some intuitive results: almost all trauma
surgeons either agreed or strongly agreed, naturally, that
transplantation of postmortem organs is an reasonable and effective
Further, most of the surgeons were familiar with the organ
donation criteria. Interestingly, More than 85% of the trauma
surgeons surveyed in Pennsylvania disagreed with the idea that
treating a critically ill patient (prior to brain death) for the
purposes of organ preservation is a professional conflict.
Further, 87% of the surgeons surveyed agreed that it is their
professional responsibility to maintain organ viability to preserve
the patients and familys right to donate organs and tissues. But,
only 74% percent agreed that is was their responsibility to
maintain organ viability for the benefit of patients awaiting
Table 4 shows that 21 percent of the trauma surgeons surveyed
only employ their institutions brain death policy when the family
of the deceased patient wants the patient to become a donor. Also,
interestingly, 23% of the surgeons surveyed disagreed when asked if
they routinely pronounce patients brain dead who meet brain death
Finally, one of the most fascinating results, in my opinion, was
the fact that only 42 percent of the trauma surgeons agreed that
there is adequately established criteria for pronouncing pediatric
patients brain dead. 35% provided no response to the question, and
only 4% answered as strongly agree
Of those 71 trauma surgeons surveyed, 23% disagreed that the OPO
should be involved in assessment and management of patients prior
to confirmation of brain death.
The results of the study showed that, even If trauma surgeons
mostly supported some involvement of OPOs, 42 percent of those
surveyed thought only the attending physician should have a say
whether a family get referred to an OPO. That said, a majority
agreed that the decision to refer a patient to an OPO shouldn't be
made by just the attending physician.
Finally, an overwhelming majority of those surveyed agreed that
the decision about whether a patient is suitable for organ donation
should be up to both the attending physician and the OPO. Note:
these questions were not mutually exclusive.
The table on the right hand side deals with who should approach
the family of deceased patients to ask for consent for organ
donation; 73% of trauma surgeons thought it was solely the trauma
surgeons responsibility; 60% thought the OPOs should approach the
families and 80% agreed that having the attending physician and OPO
cooperate and work together in approaching families for consent is
a reasonable alternative to having just one take on the burden.
Finally, more than 75% of respondents agreed that they could
influence the organ donation decisions made by the families of
brain dead patients. 15
Conclusion Hospital-wide donation education programs How to
approach?The how and when may of the approach may be
importantExample: Decoupling Pediatric brain death
The study came to a variety of conclusions regarding the
effectiveness of OPO programs.
First, the study supported the idea that hospital-wide organ
donation education programs help procurement of viable organs;
ultimately though, the study posits, its the publics lack of
understanding of brain death and organ donation that cause their
reluctance to consent to donating deceased loved ones organs.
The study also suggests that in-hospital organ education
programs should focus on strategies for how to approach families,
and not so much how to identifying potential organ donors.
80% of the surgeons surveyed indicated that it was the role of
both the attending physician and the OPO representative to approach
families. Whatever the case, those trauma surgeons surveyed agreed
they had some influence in families decisions.
Finally, the study suggests that the how and when to approach
the family of a critically injured, brain dead patient can be
equally if not more important than the who;
Studies have shown that when the discussion for organ donation
and brain death are decoupled, (in other words, undertaken by two
different parties--the OPO and the physician, for instance),
donation occurs more frequently
Lastly, the survey clearly shows that the protocol for
determination of brain death in children 5 years or younger needs
to be further developed.16
Practice University of Southern California Keck School of
MedicinePublished 2007 In-house coordinator program (IHC)
Finally, for my paper on practice, I chose a study was carried
out by the department of surgery, Division of Trauma and Critical
Care, at the University of Southern California Keck School of
Medicine. The study was published in 2007.
The purpose of the study was to test if implementation of
in-house coordinators (or IHCs) from OPOs could effectively
increase organ donation rates at level 1 trauma centers, and USCs
medical center specifically.
BackgroundOrgan Donating Breakthrough Collaborative
(Collaborative) Aggressive management protocol In-house coordinator
program with help of OPOs
I want to briefly go over some background details before I get
to the bulk of the study.
Due to the overwhelming demand for organ transplants, the the
Department of Health and Human Services implemented a new program
called the Organ Donating Breakthrough Collaborative (or
Collaborative) in the early 2000s. In short, the purpose of the
program was to maximize potential organ donations at hospitals with
the greatest potential for donation. The collaborative set its goal
at a 75% organ donation rate.
Although Division of Trauma and Critical Care at the USC Medical
Center implemented an aggressive management protocol for brain-dead
potential organ donors in 1999 that drastically increased organ
donation success, the program fell short of the 75% goal of the
Thus, in 2001, the USC medical center adopted an in-house
coordinator program orchestrated by a local OPO to improve methods
of approaching and educating families to increase its organ
donation rates and success.
This study assesses the success of the in-house coordinator
program after implementation at a level 1 trauma medical
Methods Two full time in-house coordinatorsIHCs provided
extensive Family support Timely discussion of organ donation Time
with familiesPre and Post IHC periods compared
In 2001, the USC medical center employed two full time in-house
coordinators, both trained OPOs, to oversee the organ procurement
process. The overarching purpose of their employment was, of course
to increase the number of donations by potential donors. Among
other things, IHCs were tasked with providing family support
Family support entailed spending extensive time with potential
donors families before and after confirmation that their loved ones
were brain dead, and orchestrating timely discussion of of the
prospect of organ donation with the families.
The study compares the effectiveness of the organ procurement
processes before and after the implementation of the IHC program;
that is, from January 1998December 2001 (the pre-IHC period) and
from January 2002December 2005 (the post-IHC period)
The study had some interesting and significant results; first,
as shown in the top red row, the number of trauma patient donors
increased (almost to a significant degree) after implementation of
the IHC program, although the other donor demographics didnt really
change between the two periods
Further, the number of overall donors, the organ donation
consent rate, and the conversion of potential into actual donor
rates significantly increased with introduction of the IHC
Also, although trivial, I found it interesting that the average
number of organs donated per brain dead patient was about 3.5.
Table 2 shows that there was an overall 90% decrease in the
missed referrals. In other words, failure to refer families of
potential organ donors to one of the OPOs decreased overall by 90%!
Further, there was a 39% increase in the total number of
Also, the number of organs transplanted increased by 17% in the
post-IHC introduction period.
CONCLUSIONOPOs significantly effect trauma and other patient
donations More time spent with families Transplant coordination
programs Time of interaction? 33% of IHC hospitals achieved 75%
conversion rate goal Consent is still an issue
Studies like this one have shown that increasing the involvement
of OPOs in the organ procurement process positively effects consent
rates (or, families decisions to donate).
Hospitals around the country have employed similarly Successful
transplant coordinators (usually physicians) responsible for quote
identifying potential donors, managing their hospital course, and
consenting family members. endquote. As a result, the consent and
conversion rates in trauma hospitals have increased
In conclusion, this study posits that the time of interaction
with families of potential donors could drastically effect consent
rates. Many level 1 trauma centers have changed their policies to
allow OPOs to discuss the prospect of donations earlier that
confirmation of brain death now.
The study notes that following introduction of the IHC programs,
consent of families is still a major issue at trauma hospitals, and
more effective strategies for consent must be discovered, although
tremendous progress has been achieved with programs like the IHC at
USCs medical center. 22
Concluding ThoughtsHigh demand for organs; we still need
strategies to increase donations Age-related factors? IHC
Today, there remains an ever-increasing demand for organ
The supply, of course, needs to be increased in a fashion that
serves that demand. Its unclear whether that means altering the
restrictions for potential donors, or administering more active
in-house coordination programs at trauma hospitals with a high
volume of potential donors.
Huge progression has been made in recent years, and with the
establishment of programs like Collaborative. And surely more
progress in procuring organ donations is yet to come. 23
ReferencesFinger, Erik B. "Organ Procurement Considerations in
Trauma." : Overview, Organ Distribution, Criteria for Organ Donors.
N.p., 2016. Web. 18 Aug. 2016. Johnson, Colleen M., Lee S. Miller,
and Stanley J. Kurek. "Result Filters." National Center for
Biotechnology Information. U.S. National Library of Medicine, Mar.
2001. Web. 19 Aug. 2016. Kennedy, Alfred P., John C. West, and
Stephan E. Kelley. "Result Filters." National Center for
Biotechnology Information. U.S. National Library of Medicine, Oct.
1992. Web. 19 Aug. 2016. Salim, Ali, Carlos Brown, Kenji Inaba,
Angela Mascarenhas, Pantelis Hadjizacharia, Peter Rhee, Howard
Belzberg, and Demetrios Demetriades. "Improving Consent Rates for
Organ Donation: The Effect of an Inhouse Coordinator Program." The
Journal of Trauma: Injury, Infection, and Critical Care 62.6
(2007): 1411-415. Web.