The Gift of Life
Organ, Tissue and Eye Donation on the Critical Care Unit
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NORS is a non-profit and exists to recover organs and tissue to save lives, not to benefit shareholders or owners. Decisions about the direction of the organization are led by a board of directors representing different people and business within the donation process.
NORS is a federally designated organ procurement organization by Centers for Medicare and Medicaid Services (CMS) and must abide by CMS rules and regulations. There are 58 total OPO's nationwide. Each hospital receiving Medicare funding must have a contract with their assigned OPO. OPO's must be independent of hospitals and transplant centers to ensure ethical boundaries exist to separate patient care and the transplantation of donated organs and tissues.
NORS service area includes Nebraska and Pottawattamie Co, IA and are currently contracted with 99 facilities for organ donation and 86 facilities for tissue donation. It does not facilitate whole body donation for science or living donation, only cadaveric organs and tissue procurement.
NORS
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"To maximize the recovery and quality of organs and tissues for transplant while maintaining sensitivity, compassion, and respect for people of all cultures."
° 114,771 people waiting in the United States today
° Usually around 450 registered in Nebraska
° Each year more than 7,000 people die waiting
° About 50 from Nebraska
° About 40 organ donors in Nebraska out of nearly 16,000 deaths
° 6,000 hospital deaths
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1. Patient must have suffered a non-survivable neurological injury.
2. Must be on mechanical ventilation to maintain the viability of the organs for transplantation. They must be oxygenated until the last moment to minimize the warm ischemic time.
3. Must be declared brain dead or meet criteria for DCD (Donation after Circulatory Death) donation.
° There are no age restrictions for donation. The oldest organ donor in Nebraska was 79.
° There are few medical restrictions: patients with hepatitis, drug abuse history, or even some cancers may still be eligible to donate.
° NORS staff will determine medical suitability upon referral of the patient.
° Organ function is important! Organs must be functioning properly in order to be transplanted as this will have a large effect on survivability.
° Identify the potential donor
° Patient has suffered a severe brain injury, is ventilated, and has lost any brain stem reflexes.
° Refer the patient to NORS quickly
° Agreements define this as 60 minutes. This ensures optimal outcomes for transplantation.
° Do not speak with patients decision-maker about donation options
° CMS regulations dictate that only a member of NORS or someone trained by NORS may initiate the donation discussion.
° Do not de-escalate care!
° Blood pressure, urine output, oxygenation, electrolytes, glucose
° Often times, de-escalation of care occurs on non-survivable injuries. This can drastically affect the gift that can be donated and may be detrimental to the survivability of the transplantation recipient.
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Jessica became a hero to two strangers by donating her heart and lungs. |
° "Why don't you spend some time with your loved one while I make some phone calls to our team who will meet with you to discuss this process"
° Immediate notification to NORS
° It is required that hospital staff avoid telling the family that the "donation people" will be coming or any statement similar to that.
° NORS staff are specially trained in assisting families with end-of-life care decisions and want to ensure that the family is allowed the opportunity to discuss donation with an expert in this field.
° "My goal is to provide great care for your loved one, I will get you in contact with someone who is an expert in this field."
° Immediately contact NORS and explain conversation.
° Notify NORS immediately of any changes in the patient plan of care.
° Change to comfort care, peg and trach, etc.
° Contact NORS with any plans to perform brain death testing.
° It is important for NORS to be aware of any brain death testing so they can be available when testing is complete to huddle with hospital staff.
° Identify signs of brain death.
° Do not de-escalate care!
° Blood pressure, urine output, oxygenation, electrolytes, glucose
1. Cerebrum - Vagal Activation
° ↓ HR, ↓ cardiac output, ↓ BP
2. Pons – Mixed Vagal and Sympathetic
° ↓ HR, ↑ BP, irregular breathing
3. Medulla Oblongata – Sympathetic
° ↑ HR, ↑ BP, thermoregulatory impairment, endocrine dysfunction
4. Spinal Cord – Sympathetic Deactivation
° ↓ HR, ↓ cardiac output, ↓ BP
° Clinical diagnosis made by hospital staff.
° The practice for declaring brain death varies from hospital to hospital.
° Legal and ethical definition of death:
° Only an individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.
° This definition is the state regulation for declaring death.
° Most common is clinical exam, coupled with confirmatory testing.
° Clinical exam is simply physically testing the brain stem reflexes with the absence of sedation or paralytics and a normal blood pressure and temperature. The absence of all of the reflexes could suggest brain death.
° Apnea testing
° Pre-oxygenation of the lungs, draw blood gasses, disconnect from the ventilator, wait 8-10 minutes, visually looking for any signs that the patient is not brain dead, re-connect to vent, draw blood gasses. A brain dead patient will have a PCO2 greater than 40 or will have risen more than 20.
° Cerebral Blood Flow Study
° Nuclear medicine, shows the blood flow through the brain, involves transporting a patient.
° EEG
° Can have some errors with false positives.
Donation After Circulatory Death (DCD): The patient will be extubated and die naturally. The organ recovery will occur following the declaration of death by cardiopulmonary means. This is the way donation was done prior to the brain death method in the 1970's.
° Initiated by decision to withdraw life-sustaining therapies
° Non brain dead patients
° Additional age and medical criteria
° Good candidates will die shortly after removal of life-support, usually within 60 minutes.
° Time to death is evaluated on a case-by-case basis and includes such factors as organs to be recovered, organ function, patient history, etc.
° A family does not know what to expect when dealing with a catastrophic event, they just want you to save their loved ones life.
° Families struggle with making decisions about comfort care.
° Declare the patient brain dead to add finality to the situation.
° After their loved one has died we can transition to making after-death decisions.
° Gains trust with the family knowing that the hospital did everything in their power to save their loved one's life.
° The family no longer needs to make a decision about comfort care.
° The family knows that the patient died because of their injury and not their decision to withdraw support.
° No conversations about the "if's" and organ donation. This can appear as if we are hoping for death and the family may still have hope.
1. Huddle
° NORS, nurse, physician, family support, other important staff
2. Timely approach for donation
° Quicker is usually not better
° Coupled vs. decoupled
3. Brain death declared if the patient appears arreflexic prior to speaking with legal decision-maker
4. Location
5. Appropriate Requestor
NORS is striving to ensure that the conversation with the legal decision-maker is effective rather than just appropriate (mention by trained staff). This helps ensure that the decision regarding donation is made in the ideal circumstances and the legal decision-maker has the best opportunity to make the decision they need to make.
NORS accepts care and all charges at the time of consent. In the event of brain dead organ donation, NORS will accept all care of the patient and write orders through the NORS medical director. For DCD organ donation, the attending physician from the hospital will still write all of the orders for the patient with the guidance of NORS clinical staff.
The initial order set varies based on donor condition, age, organ function, and a wide variety of other factors. NORS may request consults from physicians within the hospital to best evaluate and manage organs. Some things that may be included:
° Blood draw
° Labs
° Bronchoscopy
° Echocardiogram
° T4
° Lung Recruitment
Allocation is facilitated by the United Network for Organ Sharing (UNOS). They create the guidelines for listing patients for transplant, define allocation procedures, and manage the entire waiting list. A recipient list by organ is created by UNOS for each donor. NORS will work through the list trying to find acceptance for each transplantable organ. Variables such as blood type, tissue type, recipient condition, donor condition, size, weight and more are taken into consideration when running lists. In order to ensure that the gifts can be maximized, a back-up recipient is established to avoid discarding any transplantable organs.
UNOS.org
Surgery generally occurs 24-48 hours following consent though time may vary widely based on family requests, number of organs to be transplanted, and patient stability. Families will be encouraged to say their goodbyes prior to transport. However, in some rare instances, the family may request special consideration and this is dealt with on a case by case basis in cooperation with the hospital leadership. Hospital staff, transplant center staff and NORS staff will be in the OR during surgery. For DCD, only hospital staff and a NORS representative will be in the OR during the death process, following death the transplant staff, other hospital staff, and the remainder of the NORS staff will enter the OR.
° Prep and drape
° The patient is prepped and draped from the chin to the pubis and to the anterior axillary line.
° Initial incision
° Initial incision is from sternal notch to the lower middle quadrant and the chest is opened.
° Dissection
° Organs are isolated for recovery.
° Cross-clamp
° The aorta is cross-clamped.
° Flushes and icing
° The organs are flushed and iced as quickly as possible following cross-clamp of the aorta.
° Removal of organs
° Organs are recovered with the necessary vasculature for transplantation.
° Back table and packaging
° Each organ is inspected, packaged, and appropriate paperwork and documentation is completed.
° Organ transport
° Organs are handed off to the recovering surgeon or transported to the appropriate transplant center.
° Prep and drape
° The patient is prepped and draped from the chin to the pubis and to the anterior axillary line.
° In some instances, the prep and drape will not occur until after death declaration depending on hospital policy.
° Extubation
° The attending physician will extubate the patient.
° Extubation typically occurs in the OR, but may occur in other locations depending on logistical concerns and hospital policy.
° Death declaration by hospital staff
° The attending physician will declare death upon meeting hospital parameters for death declaration.
° Initial incision 5 minutes after death
° Initial incision is from sternal notch to the lower middle quadrant and the chest is opened.
° Flushes and icing
° The organs are flushed and iced as quickly as possible.
° Dissection
° Organs are isolated for recovery.
° Removal of organs
° Organs are recovered with the necessary vasculature for transplantation.
° Back table and packaging
° Each organ is inspected, packaged, and appropriate paperwork and documentation is completed.
° Organ transport
° Organs are handed off to the recovering surgeon or transported to the appropriate transplant center.
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Scott has had the opportunity to watch his boys grow up since his heart transplant in 2007. |
Organ times can vary widely based on donor condition, recipient condition, transplant center processes, etc.
° Heart: 4 hours
° Lung: 4-6 hours
° Liver: 6-10 hours
° Pancreas: 12-18 hours
° Intestine: 6-12 hours
° Kidneys: 24 hours
° Up to 72 with a perfusion pump
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° Avoid amputation
° Accelerates, promotes, and allows healing
° Restores mobility
° Vascularization
° Restore normal appearance
° Returns sight
° Restores independence
° Cardiac death
° Brain dead patients and organ donors may be tissue donors as well
° Age and medical criteria
° Recovery must occur within 24 hours of death
° If there is no know time of death an last known alive time will be used. The body must be cooled by the 12 hours mark or else the recovery must occur within 15 hours.
° No embalming prior to tissue recovery
° If embalming has begun, donation is no longer an option. Please ensure that tissue and eye screenings are completed or screeners are aware if you plan on calling the funeral home
° Coroner case is okay
° NORS staff will work with the coroners to assess donation potential. In most coroner cases, donation is still an option
As a staff nurse, you are our eyes and ears when it comes to screening candidates for donation potential. Please make us aware of any of the listed medical conditions or of any other conditions that you feel may disqualify the patient for tissue or eye donation early in the process.
° Age varies over time based on surgeon preference, current best practices, and federal guidelines
° Any number of medical conditions may exclude a patient
° Current infection
° Some cancers (may not exclude eye donation)
° High risk medical/social history
° Hemo/Plasmadilution
° Clean incision sites
° Identify the potential donor
° Patients that are not yet dead may be referred, but in many cases, additional contact will be required after the patient is declared deceased
° Refer the patient to NORS quickly
° Agreements define this as 60 minutes.
° There are a number of entities that must work together to ensure that donation can occur and the early the referral is received, generally the better the outcome.
° Have the chart available
° Because of the number of questions included in the medical screenings, it is useful to have the chart available. It is useful to review the H&P, vitals, and labs prior to the referral call if time permits.
° Do not speak with patients decision-maker about donation options
° CMS regulations dictate that only members of NORS or persons trained by NORS to approach families can speak with them about donation. NORS will only speak with those families whose loved ones have been deemed eligible for donation.
° Multiple screenings with NORS staff will determine patient eligibility
° Screenings can vary from just a few minutes to sometimes upwards of 20 minutes.
° Communicate plans for the body with NORS staff
° Do not contact funeral home without contacting NORS first
° Never release a body to the funeral home before contacting NORS and alerting them of the plans.
° Make NORS aware of any special time requirements
° If you have other more urgent matters, please communicate this with the screener and the screening can be completed later or other options can be investigated. Also communicate any known timing issues from the family or hospital.
° Legal decision-maker contact information
° The only thing NORS requires is a contact phone number.
° If the patient appears to be a possible tissue or eye donor and the family would like to leave the hospital, please ask "if there may be additional questions that arise, is there a number we can contact you at?"
° NORS will contact the family
° Due to the length of time it takes to complete the screenings, in most cases the family will have already left the hospital. NORS will contact the family at home about their donation options.
° Discussion about opportunity
° NORS will talk with the legal-decision maker about what options for donation exist and obtain consent if required.
° Medical/social history screening with family
° NORS will talk with a good historian for the patient (usually a close family member) concerning the patients medical and social history. This is required by current FDA regulations to ensure the highest quality of recovered tissue for transplantation. The screening is very similar to the med/social screening done while donating blood.
° Authorization paperwork with family
° If the family verbally consented to donation, an official consent form will be completed.
° Following consent, NORS will request a copy of the entire patient chart. This is required through current FDA standards.
° The chart must be received prior to beginning any recovery, this usually means faxing the chart. If the chart is very large or time constraints may inhibit this option, work with the NORS coordinator to investigate other options.
° Patient will be transported to a sterile recovery facility
° NORS maintains a recovery suite at the office in Omaha and transports a majority of patients to this facility for the tissue recovery. In other instances, NORS staff may drive or fly to the hospital and complete the recovery utilizing one of the hospital operating rooms.
° Prep and drape
° Patient is prepped and draped from chin to feet.
° Initial incision
° Incisions are made from the shoulder to the wrist for arm bone recovery, from the hips to the ankles for leg bone, saphenous vein, and fascia lata recovery, and the chest plate is removed for heart valve donation. Additional incisions may be required for specialty grafts which require special consent from the family of the donor.
° Removal of donated tissue by trained staff
° NORS trained recovery staff perform the tissue recovery.
° Reconstruction
° Following the recovery of donated tissues, the body is reconstructed which allows for an open-casket viewing. NORS staff work with the family regarding burial plans to determine which tissue can be recovered.
° Transportation to funeral home
° The body will be transported to the funeral home of the families choosing following the recovery.
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Chase received a bone graft that helped him avoid the amputation of his arm due to an osteosarcoma. |
° Tissue is sent to tissue processor
° Tissue is packaged and transported to the tissue processor.
° Tissue testing
° Tissue is tested for a variety of things to ensure transplantation safety.
° Quarantine
° Tissue is quarantined for a set amount of time and tested again before being sent out for transplant.
° Release for medical use
° Tissue is released to surgeons who will be performing the transplants.
° Donated tissue may remain viable for up to 3 years if freeze-dried and 5 years if frozen.
° Centers for Medicaid and Medicare Services (CMS)
° The Joint Commission
° Health Insurance Portability and Accountability Act (HIPAA)
° Revised Uniform Anatomical Gift Act (UAGA)
1. Must have an agreement for organ, tissue, and eye donation.
2. Ensure that the family of each potential donor is informed of their options.
3. Requestor must be from NORS or trained by NORS to request consent.
4. Encourage discretion and sensitivity with respect to families of potential donors.
5. Hospital must work cooperatively with NORS, tissue bank, and eye bank.
° Imminent death referral within 60 minutes
° A patient with a severe brain injury who is currently ventilated and:
1. Has clinical findings consistent with a GCS of 4, OR
2. Has the loss of 3 or more neurological functions, OR
3. For whom physicians are evaluating a diagnosis of brain death, OR
4. For who a physician or family is considering life-sustaining therapies be withdrawn
° Death referral within 60 minutes
° NORS assesses donation potential
° Hospital will utilize interventions to maintain potential organ donation patients organ viability
Consent is not required for patient information when screening for organ, tissue, or eye donation.
° Defines consent and donation laws in Nebraska
° Donor authorization
° If you register in the Nebraska donor registry this is your consent at the time of your death.
° If not registered, consent is passed to legal decision-maker.
° Establishes consent hierarchy
° Disallows de-escalation of care on potential donors
° Addresses coroner restrictions for organ, tissue, and eye donation
1. Register on-line at www.nedonation.org
2. Register at the DMV
3. Make your wishes known in you will or some other legal document
° You are a voice for those waiting for transplants
° Advocate for the patient wishes
° Provide a way to aid in the family grieving
° Regulations say so
° You may need a transplant someday
° Who doesn't want to save or enhance a life?
° Talk to your family
° Learn their wishes
° Express your wishes
° Register your wishes
° Only about 1 in 40 deaths are eligible to donate
Any questions, please contact Robin Higley with NORS at RobinH@nedonation.org
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Thank you on behalf of Shirley and the thousands of others who have been given a second chance at life. |
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