Organ donation can occur in two ways. First, following death by neurologic criteria. Patients who have sustained unsurvivable brain injuries or insults and who meet all criteria for death declaration by neurologic criteria qualify for this type of donation. These patients are maintained on mechanical ventilation and organ recovery can occur after consent from their families. Potential recoverable organs include heart, lungs, kidneys, liver, pancreas, and small bowel. The second donation possibility is termed donation after cardiac death. Patients who have sustained severe neurologic injuries with no hope of recovery but do not meet brain death criteria may qualify for this type of donation. Following a family’s or surrogate’s decision to withdrawal support and terminate care, an approach regarding this potential donation process may be made. Once consent is obtained, the patient is moved to an appropriate setting and life support is withdrawn. After the patient is declared deceased (usually must occur within 60 minutes of withdraw of support) limited organ recovery can occur within 5 minutes of cardiac cessation. Recoverable organs include kidneys, liver, possibly pancreas, and possibly lungs. Historically, this is how organ donation occurred at its beginning.

Tissue donation may occur up to 24 hours after death from any suitable donor. Family consent must be obtained. Recoverable tissues include eyes, skin, bone, heart valves, veins, dura, fascia, tendon, meniscus, cartilage, and cochlea. Greater than 500,000 tissues are transplanted annually.

Identifying potential donors as early as possible must be a priority. Instituting hospital wide criteria or “early referral clinical triggers” for which the local procurement agency is called will identify potential organ donors early. Those criteria should include intubated patients with a grave prognosis or severe acute brain injury/insult and one of the following: Glasgow Coma score less than 6, brain death evaluation has begun, the patient is being considered for withdrawal of life sustaining therapies, or a DNR is being instituted. The organ procurement agency, once notified, can assess the patient for suitability for donation and assist in the next steps toward donation. Any member of the health care team can make the call. To enhance organ donation, referral rate should be as close to 100% as possible.

As a physician, your role is to treat the patient and family first. The patient must be aggressively resuscitated and all injuries diagnosed and treated. The cause of the brain injury must be identified and the decision that the loss of brain function is irreversible must be justified. Other reasons for the patient’s profound neurologic deficits must be considered (i.e. drug over dose, chemical paralysis, high spinal cord injury, metabolic/electrolyte disturbances, etc.). Normal physiologic parameters including temperature, blood pressure, and electrolytes must be maintained. Along with treating the patient, the family must be kept involved. Ensure that they understand the diagnosis and prognosis for the injuries and that everything is being done to save their loved one. Give them consistent messages between care providers. Let them know and help them understand when the time for brain death declaration arises and what it means. Once brain death has been declared, help the family understand that this is true legal death and is irreversible. Give them time to grieve. Only then should the issue of organ donation arise.

All families must be asked about organ and tissue donation, it is the law. Every hospital must have a “designated requestor” who has been trained appropriately. For most institutions, this is the organ procurement coordinator. Studies have shown higher consent rates when an organ procurement agent makes the request (67%) vs. hospital staff (9%). When hospital staff and the organ procurement coordinator request together, consent rates are as high as 75%.2 The timing of the request is also important. Cutler et al. 3 demonstrated a 78% consent rate when organ donation was discussed after notification of death. Following consent, the process for evaluation of suitability as a donor begins. All further hospital charges are paid for by the procurement agency. The patient’s time of death is at the time brain death or death by neurologic criteria is declared. Now patient management focus shifts from cerebral protective strategies to optimizing donor organs for transplantation.

As emergency department physicians, we can play a crucial role in the process. We should continue to aggressively resuscitate these types of patients. Early identification of these patients and notification of the organ procurement agency can and should occur in the emergency department. We should step back and consider the option of organ donation prior to withdrawal of life support in the emergency department. We can push for admission of this type of patient so that resuscitation can continue and the family can be given time to consider their options. We should provide consistent communication to the family. Help them understand the gravity of the situation and answer their questions. Often, we are the only attending talking to the patient’s family for the first few hours of their hospital stay. Due to the fact that we often are one of the few attending physicians in the hospital at all hours, we should become knowledgeable and capable of determining death by neurologic criteria. When called to help with declaration, we should make time to help. In our own lives, families, and communities, we can become educators of the importance of this issue and the need to discuss it.

In April 2003, Health and Human Services Secretary Tommy Thompson joined with key national leaders and practitioners from the nation’s leading transplantation and hospital communities to launch the Organ Donation Breakthrough Collaborative. The Collaborative is intended to dramatically increase access to transplantable organs. Their goal is to achieve organ donation rates of 75% or higher. This Collaborative will allow hospitals to send multidisciplinary teams to participate in an intensive series of Collaborative Learning Sessions and establish action periods. These teams will draw from the experience of practitioners with high donation rates and will learn to adapt, redesign, test, implement, track, and refine their organ donation processes.4 Institutions are already seeing dramatically increased referral and consent rates. It is certainly possible that JCAHO and the Medicare administration may add organ donation to its “best performers” criteria thus adding financial incentives. Overall, the issue of organ donation has entered national prominence and will become increasingly important to your hospital. Despite the size of your hospital, you can still play an enormous role. One organ donor can benefit 7 or more people. For those recipients, your contribution to their lives is immeasurable.

John was a 32 year old healthy man when he developed a devastating subarachnoid hemorrhage while lifting weights. From his family’s generosity a 22 year old woman received a new heart, a 12 year old boy received half of John’s liver and a 1 year old baby the other half, a 35 year old woman received a new kidney as did a 57 year old teacher, and finally two people received the gift of site from John’s eyes. This one gift gave new life to 7 individuals. Organ transplantation can provide comfort to the grieving and benefit to the living, isn’t that what we as physicians are sworn to do?

References:
1.) HRSA statistics for 2003
2.) Klieger J, Nelson K, Davis R, et al. Analysis of Factors Influencing Organ Donation Consent Rates. Journal of Transplant Coordination,1994; 4:132-34.
3.) Cutler JA, et al. Increasing the Availability of Cadaveric Organs for Transplantation: Maximizing the Consent Rate. Transplantation, 1993; 56(1)225-28.
4.) Organ Donation Breakthrough Collaborative Charter