The Collaborative Donation Process
To help us work collaboratively, following is a summary of the organ donation process. If you have any questions regarding the donation process, feel free to contact your OneLegacy hospital account executive or procurement transplant coordinator. At the end of this section, nurses have an opportunity to earn two hours of CEU credit by submitting the CEU Take-Home Quiz.
1. Hospital / OPO Collaboration
2. Identifying the Potential Donor
3. Early Referral
4. Declaration of Brain Death
5. Family Support and the Opportunity to Donate
6. Managing the Donor
7. Family After Care
1. HOSPITAL / OPO COLLABORATION
OneLegacy vigorously supports the concept of “Hospital Ownership of Organ Donation” when this ownership is a part of a collaborative effort to enhance donation awareness and support among hospital staff. To this end, the nurses and healthcare professionals of OneLegacy provide the hospital the resources it needs to ensure all staff are educated in the need for, value of, and current practice of donation and transplantation.
In the spirit of collaboration, OneLegacy works closely with your hospital to help you provide quality care and personal attention to families facing the death of a loved one. The following information will help orient you to the nature and extent of our collaborative relationship.
What Are OPOs?
Not-for-profit Organ Procurement Organizations (OPOs) like OneLegacy are federally designated by CMS to serve specific regions of the country and were established to:
Educate the public about benefits of organ donation and transplantation
Recover, preserve and distribute donated organs
Increase the availability of organs for transplantation
Support, promote and assist tissue donation
Medicare Conditions of Participation
The Center for Medicare and Medicaid Services (CMS) has included in its Conditions of Participation a requirement that all hospitals refer all deaths and imminent deaths to the local OPO in a timely manner.
Hospitals are reviewed for compliance by JCAHO and Medicare. To help ensure the hospital performs well in this review, OneLegacy staff prepares a review of the hospital’s donation process by reviewing the hospital’s medical records. OneLegacy then shares with you any opportunities for improvement, both to avoid any future survey challenges with CMS and JCAHO and to help you help your families in crisis.
Hospital / OPO Collaboration
Hospitals and OPOs work together to:
Educate hospital staff on the donation process
Ensure potential donors receie appropriate and aggressive treatment to allow the opportunity for organ and tissue donation
Present families of deceased patients with organ and tissue donation options
Manage the potential donor while testing and placement are performed
Review death records
Why is Collaboration So Important?
Working together is the only way we can prevent the harmful and untimely request for consent, help the family have the opportunity for organ and tissue donation, and maintain the viability of organs upon the death of the donor.
Who Is OneLegacy?
OneLegacy is certified by CMS to facilitate the donation and transplantation process within the seven-county greater Los Angeles area. OneLegacy collaborates with approximately 215 area hospitals and the county coroners to provide donation-related services, including:
Supporting potential donor families in their time of loss
Coordinating the recovery of all medically suitable organs and tissues for transplant.
Ensure organs are effectively placed with 14 regional and many national transplant centers.
Additionally, OneLegacy provides after care support to donor families and educates the diverse communities of Southern California about organ and tissue donation and transplantation.
2. IDENTIFYING THE POTENTIAL DONOR
Criteria for Organ and Tissue Donor Selection
Brain Death Criteria:
Maintained on a ventilator
Heart continues to beat
Donation After Cardiac Death Criteria:
Maintained on a ventilator
Not brain dead
Family and physician have decided to discontinue ventilator support
Patients who meet the criteria for brain death or donation after cardiac death (DACD), are potential donors for the following organs and tissue:
Organs: heart, heart/lung, lungs, liver, kidneys, pancreas, small intestine
Tissue: corneas/eyes, heart valves, skin, bone, tendons, cartilage, veins
Patients who reach cardiac death – no cardiac or respiratory activity – are potential tissue donors only.
Each donor is evaluated on a case by case basis due to variable transplant center criteria.
Signs of Imminent Brain Death
Following are signs of imminent brain death:
Ventilator dependent
GCS of 5 or less (per CMS guidelines)
Plans to discontinue pharmacological support
One or more clinical signs:
Pupils fixed and dilated
No cough
No gag reflex
No spontaneous respiration
No purposeful movement in response to noxious stimuli
3. EARLY REFERRAL
The hospital that takes ownership of the donation process identifies and refers potential donors early and recognizes that the early referral is not “giving up on a patient;” rather, it is an opportunity to provide families a chance to donate. An early referral also attunes us to the potential donor’s medical and family needs in case treatment cannot prevent a decline in the patient’s condition. Early referral (Glasgow Coma Scale of <5, per CMS guidelines) allows OneLegacy coordinators to assist the hospital team in preparing the family for the variety of outcomes.
Early Referral is Critical – and Required
The Center for Medicare and Medicaid Service (CMS) requires hospitals to refer all deaths and imminent deaths to the local OPO in a timely manner. These include:
Imminent brain death: Report as soon as patient shows one or more clinical signs of cessation of brain and brain stem functions.
Cardiac death: Report death as soon as possible, preferably within one hour.
Organs can become non-viable during the time the family considers the donation option. It is essential that the potential donor be properly managed at all times so as to enable adequate hydration, ocular care, etc.
Referral to OneLegacy
Once a potential donor has been identified, the hospital calls OneLegacy’s 24-hour Donor Referral Line, (800) 338-6112. Upon receiving the call, a OneLegacy Coordinator will arrive at the hospital to:
Review the patient chart for donor suitability. It is not necessary to approach a family about donation if their loved one is not a candidate.
Answer any questions or concerns from the hospital staff.
Be available at the earliest possible time when intervention becomes appropriate.
The Nurse’s Role
The ER/ICU nurse plays an essential role in the organ and tissue donation process. Without the nurse’s referral to OneLegacy, the hospital and the family will not have access to the essential services that we provide.
There are a number of proactive steps the nurse can take to ensure the family’s right to consider the opportunity to donate. They include:
Patient Care
Maintain vital signs, including blood pressure, heart rate and normal temperature
Maintain pulmonary care as if the patient were expected to recover (pO2 > 100), even if a DNR or brain death
Obtain requested/necessary organ-specific labs
Ensure adequate urine output and fluid resuscitation
Notify OneLegacy of any changes in the patient’s status
Donor Management Goals:
Do not mention organ donation to the patient’s family. (Premature notification has been shown to reduce family trust in the hospital and caregivers.)
Identify the family’s native/nurturing language
Notify OneLegacy of any visits by family members
4. DECLARATION OF BRAIN DEATH
The hospital that takes ownership seeks to ensure that treatment is not “decelerated” on patients for whom continued treatment is deemed to be futile until OneLegacy has evaluated the patient as a potential candidate to donate and the family has been given the opportunity to choose donation.
The Physician’s Role
The primary role of the physician is to determine and declare brain death.
Confirmatory tests are at the discretion of the physician. Tests to determine brain death include:
A clinical exam, which is required in the State of California
EEG or CBF, although these are not mandatory
Any other tests required by Hospital Policy and Procedure
Once brain death has been determined, it must be documented by two licensed physicians. The notes should state “Patient is Brain Dead” and should be signed with date and time of declaration. Test(s) performed to determine brain death should also be documented.
California Uniform Determination of Death Act (1982)
California Health and Safety Code, Section 7180 et seq..
A person shall be pronounced brain dead if it is determined by a physician that the person has suffered a total and irreversible cessation of all functions of the entire brain, including the brain stem. There shall be independent confirmation of the death by another physician.
5. FAMILY SUPPORT AND THE OPPORTUNITY TO DONATE
Recognizing that families who have the opportunity to donate find tremendous value in the act of donation, the hospital that takes ownership utilizes OneLegacy coordinators and family support staff to provide the explanation, counsel and grief support that the hospital simply does not have the time and current clinical information to offer.
OneLegacy believes that a critical point of our service is to offer families time, attention, information and care. We do this by helping hospital staff answer clinical questions, discuss issues the family will face, share the family’s concerns with their physicians and hospital staff, clarify the diagnosis (as appropriate) and, when we are certain the family is ready, offer them the opportunity to give ever greater meaning to their loved one’s life through donation of organs and tissues to help save lives.
The Approach Process
Formal steps that have been demonstrated to allow families to make informed choices include:
1. Physician informs the family of the death of their loved one
The concept of “brain death” is not an easy one to understand, especially for a family facing the sudden and overwhelming loss of a loved one. It is critical that the family understand “brain death” and have time to acknowledge the death of their loved one prior to approaching them with the opportunity to donate. This “separation of events” is such an important factor that it has a special name: decoupling.
After explaining brain death and the tests that were used to confirm the diagnosis, the physician may use a bridging statement to introduce the OneLegacy representative:
“Someone will be coming in to speak with you regarding some of the end-of-life decisions that you will need to make. He/she works closely with our hospital in assisting families in times like these. He/she can provide you with information and answer any questions you may have. If you need any more information from me, they know how to get in touch with me.”
2. Decoupling
Once the family is informed of the death of their loved one, they are given time alone or with grief support staff to process this information. It is essential to allow the family to ask questions of hospital staff and OPO staff in order to clarify their understanding of the diagnosis and decision that they must address.
3. Discuss end-of-life decisions and the opportunity to donate
A collaborative approach by the OneLegacy coordinator and the hospital health care team has the highest probability of obtaining consent. OneLegacy staff are specially trained to support and speak with families about the medical and personal issues of brain death and, of course, donation. Research has shown that families choose to donate more often when approached by OPO staff rather than hospital caregivers. Families and case research have identified that this variance is due to three reasons:
OPO staff have more time to talk through the family’s concerns;
OPO staff can speak to specific information about the donation process; and
OPOs have specially trained staff who can provide culturally sensitive support to families from our diverse communities.
A number of factors create a heightened need for sensitivity when approaching the family. Family dynamics, language barriers, cultural traditions and religious beliefs—not to mention the emotional nature of the situation—all contribute to a challenging environment for all involved. With their day-to-day experience and extensive training, OneLegacy staff are well prepared to collaborate with hospital staff to approach the family with care and respect and to spend as much time with the family as necessary.
4. Support the family regardless of their decision to donate
Families of potential donors are people in need. Many of them have never experienced the loss of a loved one. Whether a family consents to donation or not, OneLegacy provides information that helps the family begin the recovery process. This includes a checklist of things to be done to prepare for the funeral, lists of mortuaries, grief resources and support groups, and information from the coroner, if appropriate. OneLegacy also provides continued support to each donor family for a year after the loss of their loved one through our Family Services Care Program.
6. MANAGING THE DONOR
OneLegacy Coordinator’s Role
After brain death is declared and consent is given, management of the patient is assumed by the OneLegacy coordinator, whose key responsibilities include the following:
Determine potential donor medical suitability
Provide personal care and support to families
Assist families in understanding clinical issues and end of life decisions
Offer the family the opportunity to donate
Seek coroner approval, when necessary
Medical management of donor patient
Clinical tests for organ suitability
Organ placement (12-20 hours)
Schedule O.R. time with multiple recovery teams
Post-donation support and recognition of donor family
Follow-up with hospital
Management of the Brain Dead Patient
Time is a critical factor as the coordinator maintains the patient’s hydration, blood pressure (> 90) and urinary output. Other key factors include:
Fluid resuscitation
Maintain normothermia
Electrolyte normalization
Cardiovascular support
Ventilator management
Hormone replacement
ACLS
7. FAMILY AFTER CARE
Whether or not a family chooses to donate, OneLegacy’s Family Services Program believes that families who have faced the loss of a loved one are deserving of our best care, support and encouragement.
Grief Support and Resources
From our initial contact with the family in the hospital and continuing on during the weeks and months after the death of their loved one, our specially trained staff focus on providing resources, practical information, and emotional support and guidance. The Family Services Program includes:
Bereavement literature
Grief support referral
Follow-up letters and phone calls
Gatherings and events to honor and remember donors
Opportunities to OneLegacy as a volunteer
Donor Recognition Ceremonies
Each March, OneLegacy hosts invitation-only donor recognition ceremonies to celebrate those who have given the gift of life. Donor family members, transplant recipients and healthcare professionals are invited to share the program of remembrance and inspiration.
Correspondence Between Donors and Recipients
OneLegacy encourages communication between donor families and organ transplant recipients. Donor families and recipients may correspond anonymously with each other whenever they so choose according to specified guidelines. If a donor family and recipient express mutual interest in direct contact or a meeting, the OneLegacy family coordinator and a representative from the recipient’s transplant center will facilitate such a gathering.
Upon review of this section, nurses may download the Organ and Tissue Donation CEU Take-Home Quiz (pdf). Once the CEU Certificate Application is received by OneLegacy, we will reply via fax with the correct answers to the quiz and a certificate of completion.