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Organ, Tissue, and Eye Donation

The Bridge to Life

Keith Rischer RN, MA, CEN

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Today’s Objectives…

Discuss the current ethical issues surrounding organ donation and transplantation.

Discuss the steps required in the organ procurement process.

State the criteria for selecting a transplant recipient. Describe the criteria required to establish brain death. Compare and contrast the organ procurement process

for donation after brain death vs. cardiac death. State the interventions necessary to prevent organ

rejection.

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Ethical Issues Regarding Transplant

Definition of death Respect for the dead Organs for sale

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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 20080

10,00020,00030,00040,00050,00060,00070,00080,00090,000

100,000

Deceased Donors Transplants - Living and Deceased Donors Wait List

*Based on OPTN data through March 31, 2008

www.OPTN.org

The Growing Need

Organ Donors vs Wait Listed Patients

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We pledge to provide the bridge

between the loss of life and the gift of life

Through organ & tissue donation & transplantation.

We believe that life is a gift to share

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LifeSource Service Area

ND

SD

MN

WI

Douglas County

St. Croix County

Pierce County

Fargo

Sioux Falls

Rochester

Saint Paul office

•Duluth

Rapid City •

•Bismarck

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Corneas (1905)

Heart/Heart Valves (first fresh valve – 1955) (first heart – 1967)Lungs (1963)

Liver (1963)

Pancreas (1969)

Kidneys (1954)

Intestines (1987)

Skin (1822)

Bone/Connective Tissues (1668)

Blood Vessels (1955)

What organs & tissues can be donated?

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Overview of the Donation Process

Identification

Referral

Family Approach – team huddle

Assessment and Donor Management

Allocation – UNOS

Recovery

Family Follow-Up

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with the incident causing the death and continues through the bereavement. Every health care professional who interacts with the family is part of the process, and every step impacts on the family’s ultimate decisions regarding donation.”

Margaret B. Coolican, RN, MS, CDENational Donor Family Council

“The process of donation begins………

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The Identification Process 

• Call 1-800-24-SHARE (1-800-247-4273)

• Donation is not mentioned to the family prior to making the referral call.

• Clinical Trigger Card – quick process reference • Refer all patients within one hour• Call is mandated, you do not need permission to call

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The Process: Legislative Initiatives

HCFA (Health Care Financing Administration), 1998Name changed to Centers for Medicare and Medicaid

Services (CMS) 2001

1. Call 1-800-24-SHARE on ALL deaths. There are no exclusions.

2. Approach of a potential donor’s family must be done by a procurement organization representative or an individual trained by the procurement organization.

 

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Donor Designation

Donor designation is the practice of ensuring that an individual’s documented wishes about

donation are fulfilled.

“giving the donor a voice”

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Decisions are made with respect to personal choice

(Informed and Voluntary)

Autonomy

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Clinical Triggers for Donation Imminent Brain Death

Ventilated Severe neurologic injury

Loss of two or more brain stem reflexes• Pupillary• Corneal• Oculocephalic / Dolls eyes• Oculovestibular / Cold calorics• Oropharyngeal

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Potential Organ Donor ReferralDevastating Brain Injury / Ventilator Dependent

BRAIN DEATH EXAMINATION

Exam c/w brain deathDeath determined by neuro

criteria

Donation discussed with family (LifeSource)

Patient supported during organ evaluation & allocation

Surgical recovery• Withdrawal of support

• Pronouncement of death• Surgical recovery

Patient evaluated as potential DCD candidate

• Family/MD initiate topic W/D med treatment• LifeSource Coord discussion with family• Family supportive of donation

Exam Not c/w brain death

Donation after Cardiac Death

Donation after Brain Death

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Brain Death

Definition: Complete and total cessation of all brain function, including the brain stem.

Causes:• Intracerebral hemorrhage• Head trauma• Anoxia• Brain tumor

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Brain Death Testing

Confirmatory Testing• Cerebral angiogram• EEG• Cerebral blood flow• Observation period

Clinical Exam

• Absent brain stem reflexes

• No motor response to pain

• Apnea

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Family Communication: Brain Death

Patient looks alive

Heart is beating

Chest is moving

Patient is warm

Patient’s skin has color

No outward evidence

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Phrases to Avoid

HarvestLife support

One chance in a millionKeep alive until donation

Only a miracle can save him now

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Family Understanding

Families who donate and families who do not donate voice similar understandings of brain death; however,

Upon closer questioning, families who do not donate had a much less accurate understanding of brain death.

Franz et al. “Explaining Brain Death: A Critical Feature of the Donation Process,” Journal of Transplant Coordination 7 (1):14-21, March 1997.

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Nurse’s Key Donation Roles

Facilitate the identification and referral process

The Physician’s key role is to help the family understand brain death.

The LifeSource Donation Coordinator’s key role is to help the family understand donation options.

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Organ Donor Assessment

Past & current medical/social history Laboratory assessment

• General and organ specific blood work• Serological studies• Cultures

Physical assessment 12-lead EKG, echo, angiogram CXR, bronchoscopy

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Organ Donor Management

Begins after brain death with donor designation or family authorization

Extensive testing to determine organ function

Monitoring and responding to rapid clinical changes

Optimizing hemodynamic status• IV access• Triple lumen central line• Peripheral IV

Arterial line

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Assessment/Management Goals

Goal: Adequate organ perfusion• SBP normal value for age• HR normal value for age• UO 1-2 cc/Kg/hr• Final PaO2 >350• CVP 4-8 (mmHg)• Normothermia

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Organ Matching (allocation)

DonorInformation

DonorInformation

RecipientInformationRecipient

Information

United Network for

Organ Sharing (UNOS)

United Network for

Organ Sharing (UNOS)

• Blood type• Size• Severity of illness• Wait time

Procurement Surgery

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Recovery done at donor hospital• Surgeons from transplant centers• LifeSource preservationist

When are we going to the OR?

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Donation After Cardiac Death

Organ donation after the cessation

of all cardiopulmonary function

(cardiac death) rather than

organ donation after the cessation

of all brain function (brain death).

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Potential Organ Donor ReferralDevastating Brain Injury / Ventilator Dependent

BRAIN DEATH

EXAMINATION

Exam c/w brain deathDeath determined by neuro

criteria

Donation discussed with family (LifeSource)

Patient supported during organ evaluation & allocation

Surgical recovery• Withdrawal of support

• Pronouncement of death• Surgical recovery

Patient evaluated as potential DCD candidate

• Family/MD initiate topic W/D med treatment• LifeSource Coord discussion with family• Family supportive of donation

Exam Not c/w brain death

Donation after Cardiac Death

Donation after Brain Death

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When Patient is a Potential Tissue and/or Eye Donor

LifeSource Tissue Services or Minnesota Lions Eye Bank Donation Coordinators will work with you:

To assess the patient’s donation

opportunities

Plan the family connection

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Corneal Transplantation Regional anesthesia – outpt procedure Donor corneal graft sutured into place Postop

• Antibiotic ointment, pressure patch, shield• Lie on non-operative side to decrease intraocular

pressure• Watch for rejection: cloudy cornea, reduced

vision Potential eye donor at time of death

• Head of Bed 30 degrees• Antibiotic drops• Close eyes and small ice pack• Discuss eye donation with family

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Criteria for Selection for Organ Recipient

Life expectancy of less than 1 year Age generally less than 65 years old Absence of active infection Stable psychological status No evidence of drug or alcohol abuse Ability to follow instructions regarding meds and self care Cardiac –

• New York Heart Association class III or IV• Normal of slightly increased pulmonary vascular

resistance

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Heart Transplantation Comparable body weight and ABP compatibility into

recipient less than 6 hours after procurement Posterior wall of recipient atria left anchor the donor

heart Watch carefully for concealed postop bleeding Transplanted heart is denervated and unresponsive to

vagal stimulation (HR about 100). Responds slowly to exercise or position change

75% survival after 3 years To detect rejection – endomyocardial biopsies

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Complications

Infections Rejections

• Hyperacute: remove organ• Acute: Increased immunosuppressives• Chronic: conservative management

Hemorrhage Fluid and electrolyte imbalances Pulmonary atelectasis

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• Ongoing Support

• Family Connection newsletter

• Holiday booklet

• Communication between donor families and recipients

• Local donor family quilt

Donor Family Services Provides

A Bereavement Book is given to families at the time of their loved one’s death

Family follow-up