Solid Organ Donation

Organ transplantation has a major role in the management of organ failure – that is, of a single organ system of the kidneys, small bowel, liver, pancreas, heart, or lung, and of combined organ failure of the heart and lung, the kidney and pancreas, the liver and kidney, or liver and small bowel. Transplants may be needed because of primary organ disease, such as chronic inflammatory disease of the kidneys or cardiomyopathy, or because of secondary effects of a disease – for example, people with diabetes needing kidney, islet cell and/or pancreas transplants, and people with cystic fibrosis needing lung transplants. There is a shortage of organs for transplant resulting in long waits for transplantation and a significant number of deaths among those awaiting transplantation, and among those not considered for transplantation because of organ scarcity. The following recommendations focus on identifying potential donors and obtaining consent for solid organ donation under current legislation.

Types of Organ Donation

The opportunity to donate organs is uncommon from the ED, as most donors die on an Intensive Care Unit.

Most deceased organ donors die from a devastating acute brain injury such as a spontaneous intracranial haemorrhage, ischaemic stroke or severe head trauma. Organ donation is possible in two circumstances following such brain injury:

Identifying Patients Who Are Potential Donors

Organ donation should be considered as a usual part of 'end-of-life care' planning.

Clinical Trigger Factors

• Catastrophic brain injury with:
  • Absence of one or more cranial nerve reflexes AND
  • Glasgow Coma Scale (GCS) score of 4 or less not explained by sedation
• Decision to perform brainstem death tests to diagnose neurological death
• Intention to withdraw life-sustaining treatment in patients with life-threatening or life-limiting condition expected to result in circulatory death

Referral Process

• Healthcare team should initiate discussions with specialist nurse for organ donation when criteria are met
• Early referral improves donation opportunities

Capacity and Best Interest Decisions

Patients with Capacity

• Obtain patient's views on and consent to organ donation
• Respect advance decisions and preferences

Best Interest Decisions (Lacking Capacity)

• Establish whether facilitating organ donation would be in patient's best interests
• Clinically stabilize patient in appropriate critical care setting during assessment
• Do not withdraw life-sustaining treatments until donation wishes explored

Assessment Factors

• Patient's known wishes and feelings (advance statements, NHS organ donor register)
• Beliefs or values that would influence patient's decision
• Other factors patient would likely consider
• Views of family, friends, and care team
• Anyone named by patient to be consulted

Seeking Consent

• For patients lacking capacity:
  • Refer to advance statements if available
  • Check NHS organ donor register for recorded consent
  • Explore with those close to patient whether views were expressed
• If prior consent not ascertained, seek consent from those in qualifying relationship
• If nominated representative appointed, seek consent from them

The Multidisciplinary Team

• Medical and nursing staff involved in patient care (led by identifiable consultant)
• Specialist nurse for organ donation (SNOD)
• Local faith representative(s) where relevant
• Whenever possible, maintain continuity of care with team members involved in patient care
• Team should have necessary skills and knowledge to provide appropriate support and accurate information

Discussions in All Cases

Preparation Before Approach

• Identify patient's potential for donation with specialist nurse
• Check NHS organ donor register and advance statements
• Clarify coronial, legal and safeguarding issues
• Seek information on:
  • Clinical history of potential donor
  • Key family members
  • Need for family support (faith representative, interpreter, etc.)
  • Other key family issues
  • Cultural and religious considerations

Approach and Discussion

• Approach in private, compassionate setting at suitable time
• Plan approach with MDT
• Ensure understanding that death is inevitable or has occurred
• Discuss donation as usual part of end-of-life care
• Use open-ended questions and positive language
• Avoid apologetic or negative language

Information to Provide

• Assurance of focus on patient care and dignity
• Confirmation that standard of care remains same regardless of donation decision
• Rationale behind treatment withdrawal decisions
• Clear explanation of donation process and requirements
• Consent documentation
• Reasons why donation may not proceed even with consent

Organisation of Identification, Referral and Consent Processes

Hospital Policies

• Each hospital should have policy and protocol consistent with recommendations
• Identify clinical team to develop, implement and review policies
• ICU units should have named lead consultant for organ donation

Required Skills and Competencies

• All healthcare professionals should understand:
  • Principles of DCD vs DBD
  • Diagnosis of death using neurological or cardiorespiratory criteria
  • Explanation of neurological death to families
  • Use of clinical triggers
  • Donor management processes and protocols
  • Professional standards for organ donation and end-of-life care
• Consultant staff should have specific knowledge in:
  • Law surrounding organ donation
  • Medical ethics applied to donation
  • Diagnosis and confirmation of death
  • Transplantation potential differences
  • Physiological optimization techniques
  • Communication skills to improve consent ratios

Current Legislation

Excluded Groups

• Under 18 years (16 in Scotland)
• Lack mental capacity to understand arrangements
• Visitors to England, not living there voluntarily
• Lived in England for less than 12 months before death

Contraindications