Organ and Tissue Donation and Recovery Nursing CE Course

organ donor in the US was 95 years old, and 1 out of every 3 organ donors is over 50 (Muco et al., 2023; National Institute on Aging, 2022).

Myth: Many patients are too sick to donate their organs.

Fact: Eligibility for organ donation is evaluated on a case-by-case basis. Individuals with chronic conditions are encouraged to join the donation registry as they may still be eligible (ATF, 2023; Muco et al., 2023; National Institute on Aging, 2022).

Myth: Organs are given first to the rich, famous, and influential.

Fact: Medical algorithms are used to assess relative need and stratify potential organ recipients based on numerous objective factors such as time spent on the waiting list, blood type, and match to the available organ; a patient's income, power, race, and celebrity status are not considered as factors in these decisions (ATF, 2023).

 

Myth: Organ donation is expensive.

Fact: The efforts to resuscitate a patient at the end of their life may be expensive and often misinterpreted as organ donation costs, but these are separate and are the family's responsibility. The family is also responsible for the cost of final arrangements. The organ retrieval costs are incorporated into the organ transplant process for the recipient and are not charged to the donor (National Institute on Aging, 2022). Living donations are paid for using the recipient's insurance (private or public) coverage; however, some living donors have difficulty maintaining insurance coverage at the same rate as before the donation. Donors may also experience lost wages from needing time off work. The National Living Donor Assistance Center (NLDAC) provides financial assistance to living donors to help cover the costs of travel, including meals and hotels, lost wages, and additional childcare or eldercare costs (HRSA, 2023a; Lewis et al., 2020; Thomas et al., 2019).

The History of Organ Donation in the US

The National Organ Transplant Act was first passed in the US in 1984 and established the OPTN. The act specifies that a private, non-profit organization must run the network under a federal contract. The United Network of Organ Sharing (UNOS) was granted this federal contract in 1986 and has maintained it ever since. Worldwide, there are two types of systems to acquire organ donations from individuals: opt-out or opt-in. A country or state that follows an opt-out system presumes that every individual is willing to be an organ and tissue donor unless they specifically choose to opt out of donating. This system follows presumed consent. The other system is the opt-in system, which the US follows. In this system, an individual must express their desire to be an organ and tissue donor upon death. In this system, no one is presumed to be a willing donor unless they give express consent. Although 90% of American adults support organ donation, only 60% are registered donors (Etheredge, 2021; HRSA, 2023b; UNOS, n.d.-c).

In the US, approximately 17 people die daily awaiting organ transplants. There are 104,234 individuals currently on the national transplant waiting list, including children, with a new person added every 10 minutes. Of those on the list, 44,529 are between 50 and 64. Every donor has the potential to save eight lives. Of those awaiting an organ transplant, 85% are awaiting a kidney, 10% a liver, and 3% a heart, while the rest are awaiting a pancreas, lung, or other body part, including a hand or abdominal wall structure. In 2022, the kidney was the most transplanted organ, with 25,499 transplants performed (HRSA, 2023b).

In 2019, then-President Donald Trump signed an Executive Order that endorsed the development of more transparent, reliable, and objective metrics to measure OPOs and streamline the matching and delivery of donated organs, thereby reducing the discard rate. It also highlighted the Kidney Accelerated Placement project, a UNOS program designed to accelerate the placement of hard-to-place kidneys, thereby increasing organ utilization. Other improvements included having filters attached to the transplant programs used by OPOs to allow flexibility in listing the specific organs needed, reducing the amount of time that a transplant organization has to respond to the offer of a potential organ, upgrading the organ matching system to include diagnostic images of the organs being donated, and the creation and sharing of new analytic tools to identify further areas of improvement (UNOS, n.d.-a).

In 2022, 42,887 organ transplants were performed, which set an annual record and was an increase of 3.7% from 2021. For the first time, kidney transplants exceeded 25,000, with records also set for liver, heart, and lung transplants. A total of 14,903 individuals became deceased organ donors, which is the 12th year in a row that deceased donation numbers have set an annual record, with donations increasing by 7.5% from 2021. As the medical criteria for organ donation continue to broaden, the organs donated come from different eligibility categories. In 2022, 4,776 individuals were DCD donors, an increase of 14% from 2021. 5,789 donors were over 50, which is the first time that the number of donations from that age group exceeded 5,000. In 2022, 6,466 individuals became living donors, a slight decrease from the 2021 totals; however, the statistics on living organ donation have varied considerably from year to year. A record of living organ donation was set in 2019 with 7,389, followed by a sharp drop off to begin the 2020s, likely due to the COVID-19 pandemic. Although typically living donors donate a kidney, increasing numbers of other organs have been donated. In 2022, there were 603 living donor liver transplants, which set an annual record of 6% above the number in 2021 (UNOS, 2023).

Who Can Donate?

Most individuals can donate, with rare exceptions related to systemic infection (e.g., sepsis, bacteremia) and actively spreading cancer. In specific circumstances, some organs and tissues can be donated despite these conditions. Age is not a disqualifying factor, as neonates and older adults (into their 90s) have donated organs and tissues. Organs donated from older donors carry increased risk and somewhat decreased function, limiting viable donations to the kidneys and the liver in most older adults. Pediatric patients (under the age of 18) require informed consent from an adult guardian or parent to donate tissues or organs. While religious beliefs are a common concern amongst prospective donors, most religions allow organ and tissue donation as a selfless gift of life. The specifics regarding a handful of common religious organizations and their views regarding organ donation are discussed in Table 1 (HRSA, 2021d; National Institute on Aging, 2022; Rosenbaum, 2020; Tullius & Rabb, 2018)

Table 1

Common Religions and Their Views Regarding Organ and Tissue Donation

Religious Organization	Official Position Regarding Organ Donation
Catholicism	The Vatican has deemed organ and tissue donation morally and ethically acceptable. Pope John Paul II stated that Christians should accept organ donation as an act of charity.
Chrisitan Church (Disciples of Christ)	The church encourages its members to enroll as organ donors and views donation as sharing God's love. This position was outlined in 1985 resolution #8548.
Episcopal Church	The church passed a resolution in 1982 urging its members to seriously consider donating tissues, organs, and blood in the name of Christ, who gave his life for others.
Evangelical Covenant Church	The church included organ donation in a resolution passed at the 1982 Annual Meeting to increase awareness of this issue and encourage members to sign and carry an organ donor pledge card in their wallets.
Islam	Due to the clear positive results, the Fourth Conference of the Islamic Fiqh Council endorsed living kidney/liver donation and deceased organ donation if the donor gives informed consent before death.
Judaism	Judaism sanctions and encourages organ and tissue donation. Jewish scholar Rabbi Elliott Dorff says this supersedes the religious rules regarding the treatment of a dead body, allowing for delays in burial for organ donation to honor the deceased. It is not considered an act of desecration or lack of respect. Deceased organ donation has been termed a "commanded obligation" by the Conservative Movement's Committee on Jewish Laws and Standards in May of 1996.
Lutheran Church	A 1984 resolution passed by the Lutheran Church states that organ and tissue donation contributes to the well-being of humanity and is an "expression of sacrificial love for a neighbor in need."
Mormon Church of Jesus Christ of Latter-day Saints (LDS)	The LDS church states in Handbook 2: 21.3.7 that donation is "a selfless act that often results in great benefit."
Presbyterian Church	Most Presbyterian denominations encourage organ donation, as evidenced by a 1983 resolution from the Presbyterian Church (USA) regarding donation's live-giving benefits.
Southern Baptist Convention	It resolved in 1988 that voluntary organ donation should be encouraged "in the spirit of stewardship, compassion, and alleviating suffering."
United Methodist Church	The church formally encourages organ and tissue donation in church policy statements and a component of resolution # 139 in 2000.

(Donor Alliance, n.d.; HRSA, 2021b)

Once a potential donor has been identified, their risk for hepatitis C virus (HCV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV) transmission should be assessed. Those at increased risk include those who utilize intravenous (IV) recreational drugs and those who engage in high-risk sexual activities (multiple sexual partners, unprotected sexual intercourse, and men who have sex with men). If determined to be at increased risk, nucleic acid testing can be performed to test for the three infections. In recent years, advances in nucleic acid testing and antiviral treatment for HCV have allowed donors at increased risk for infection to be considered for organ and tissue donation. With informed consent, donors positive for HCV can donate organs to recipients already known to be infected with HCV or uninfected recipients willing to undergo antiviral treatment after receiving the organ. The antiviral treatment protocols for organ recipients can achieve undetectable levels of HCV in over 95% of recipients after 12-24 weeks of treatment. Similarly, donors found to be infected with HIV or HBV may still be permitted to donate organs to recipients with known HBV or HIV infection, assuming informed consent (Centers for Disease Control and Prevention [CDC], 2021; Thomas et al., 2019; Tullius & Rabb, 2018; World Health Organization [WHO], 2023a, 2023b).

 

What Can Be Donated?

Deceased donors often donate solid organs, although living donors can donate one of their kidneys, lungs, or a portion of their pancreas, liver, or intestines. Living donors can donate blood or platelets via venipuncture, or stem cells may be donated via bone marrow, umbilical cord blood, or peripheral blood (with pharmacological provocation using filgrastim [Neupogen]). Filgrastim (Neupogen) stimulates neutrophil proliferation, differentiation, and maturation, generating an increased number of mature circulating neutrophils. Deceased donors can donate their kidneys, liver, lungs, heart, pancreas, and intestines. The first hand transplant occurred in 2005, and the first face transplant was performed in 2007. After the donor's organs have been retrieved, various tissues can be donated within 24 hours of death and stored in tissue banks for later use (Aghedo & Gupta, 2023; Hertl, 2022b; HRSA, 2021c).

Each donated organ is matched independently with the most suitable recipient, except for heart/lung and pancreas/kidney transplants, which may be matched as a set. The matching process is done through the OPTN by UNOS and in collaboration with local OPOs. The match is based on blood type, body size, the severity of the recipient's medical condition, the geographic distance between the donor and the recipient, the length of time that the recipient has been on the waitlist, and the recipient's immediate availability to undergo surgery (OPTN, n.d.).

Additional specific details are also considered with varying importance for each organ donated. Potential heart recipients are rated with a status code based on the severity of the condition, but physical location is also crucial due to the limited time constraints. Body size is also considered important for heart recipients. A heart transplant is the treatment of choice for patients with severe dilated or restrictive cardiomyopathy, end-stage heart disease secondary to coronary artery disease (CAD), valvular disease, or congenital heart disease. Unfortunately, heart transplant recipients' 10-year survival rate is only 50%. Patient education regarding the importance of faithfully maintaining medication regimen adherence and psychosocial support in the form of support group participation and individual psychotherapy is crucial (Hertl, 2022a; Ignatavicius et al., 2021).

The Donation Process

A living organ donation involves the transplantation of an organ, usually a kidney or a portion of a liver. This procedure was first performed between a pair of identical twins in 1954. Living donations are often conducted between family members for an optimal match of immunological factors and blood type. Organs procured via living donations are preferred over organs from deceased donors, as they are not subject to the tissue damage incurred from decreased blood flow, decreased oxygenation, and increased inflammatory proteins associated with the dying process. Recipients also have better outcomes when receiving organs from a living donor. The cost to the donor associated with a living organ donation can be a deterrent. The recipient and their medical insurance provider cover the direct medical costs. The National Living Donor Assistance Center (NLDAC) supports donors with funding for additional expenses, such as travel, lodging, and meals (Finger, 2023b; HRSA, 2023a).

The first successful organ donation from a deceased donor was in the 1980s. This was largely due to the development of cyclosporine (Sandimmune) and its ability to prevent organ rejection. The two currently available methods for deceased donation in the US include DCD and DBD. These two distinct methods will be discussed in detail, as well as what differentiates the two. The initial regulations for determining death in a potential organ donor were addressed in the Uniform Determination of Death Act in 1980 by the National Conference of Commissioners on Uniform State Laws and adopted by both the American Medical Association (AMA) and the American Barr Association (Starr et al., 2022; UNOS, n.d.-b; Walters & Kleiman, 2023). Death was defined as "the irreversible cessation of circulatory and respiratory functions" or "of all functions of the entire brain" (Starr et al., 2022, para 1).

DCD refers to the donation of organs following the withdrawal of life support in patients who have suffered a severe neurological injury, and there is no expectation that the patient will have any meaningful survival. These individuals require life support yet do not officially meet the qualifications of brain death. This often occurs after cardiac arrest or due to severe heart disease. Research suggests performing a multimodal neurological prognostication after all instances of significant cardiac arrest but not before an initial 72-hour waiting period. The American College of Cardiology (ACC) and the American Heart Association (AHA) both recommend that cardiac arrest patients be evaluated for the potential of organ donation. In 5%-10% of cardiac arrest patients, the cerebral edema is so severe that they meet the DBD criteria (see below). Unfortunately, the DCD process in cardiac arrest patients typically precludes using the heart (unless the warm ischemia time is less than 30 minutes). For any of the organs to be viable for donation, the patient must expire within 60 to 120 minutes following the withdrawal of life support. In about one-third of cases, none of the available organs are viable for donation due to inflammatory and hypoxic tissue damage (American Society of Anesthesiologists [ASA], 2022; Dominguez-Gil et al., 2021; Rosenbaum, 2020).

When the medical community in the US was standardizing a method for DBD, a universal definition of brain death had to be established first. A patient is defined as being in a persistent vegetative state if their brain no longer performs any cortical function, but the brainstem's function remains intact. Conversely, brainstem death involves a lack of brainstem reflexes despite a few cortical functions and hypothalamic integrity (such as osmoregulation). Finally, brain death or whole-brain death involves the biological death of the entire brain, with no cortical or brainstem functions remaining (Munakomi & Al Khalili, 2023). The brainstem reflexes include:

• the corneal reflex causes the eyelid to blink after lightly touching the cornea
• the pupillary light reflex causes pupillary constriction with direct bright light
• the oculocephalic reflex causes rotation of the patient's gaze in the opposite direction when the head is rotated to one side or the other briskly
• the oculovestibular reflex causes eye movement when 50 mL of ice water is infused into the patient's ear canal
• the gag reflex causes throat constriction (a gag) after stimulation of the posterior pharynx with a spatula or tongue depressor
• the cough reflex causes a cough after stimulation of the carina with a bronchial catheter
• the withdrawal reflex to noxious stimuli along the route of cranial nerves (Munakomi & Al Khalili, 2023)

DBD occurs commonly after trauma, stroke, aneurysm rupture, or due to a brain tumor. To qualify, the patient must satisfy the three diagnostic qualifications established by the AAN in 1995, which was last revised and reviewed in 2010. The three diagnostic criteria include a patient in a coma with a known underlying cause, the absence of any brainstem reflexes, and the presence of apnea (Aboubakr et al., 2023; Starr et al., 2022).

 

Discussions with Family

Federal and state laws require hospitals to contact the locally assigned OPO after identifying potential organ donors. The Gift of Life Donor Program (GLDP) encourages hospital staff to initiate a referral to the OPO for any patient who is neurologically injured, dependent on mechanical ventilation, or is deemed to have a non-recoverable condition. A consultation with the OPO is recommended before discussing or even mentioning the possibility of organ donation to a patient or family member; however, this possibility should be considered for every patient who might qualify to increase the overall rates of organ donation worldwide. A pre-mention is acceptable, and the nurse should share small pieces of general knowledge regarding organ donation with the family if asked. It is the OPO's responsibility to determine the suitability of the potential donor. To do this, the OPO will ask the medical team several initial screening questions about the patient and their medical status to determine if they are a potential donor, and then assign a representative to travel to the hospital directly to assist if the screening questions indicate a potential for donation. The OPO representative will search the state database of registered organ donors and the DMV records regarding organ donor status. They will collect the medical and social history via the electronic medical record and confirm the information with the family when appropriate. Federal law mandates that only certified clinicians who have completed organ donation training approach the family to discuss organ donation. Providers who discuss organ donation with families alone have the lowest consent rate. It is best practice for a member of the OPO to approach families with the healthcare team (Haliko & Arnold, n.d.; Timar et al., 2021).

When the conversation regarding organ donation occurs with a potential donor family, this conversation must be separated in both time and space from the conversation regarding the patient's prognosis. For example, if life support will be withdrawn or brain death has been confirmed, these conversations should happen separately from (and before) any conversation regarding organ donation. This concept is called decoupling. When decoupling does not occur, the consent rate for donation decreases by roughly one-third. Families must be allowed time to process and accept their loved one's prognosis before being asked to discuss the next steps. For potential DBD donors, the family should fully understand the concept of neurological death. For potential DCD donors, the family should have already discussed and accepted their loved one's prognosis and decided to withdraw support (Haliko & Arnold, n.d.; LifeShare University, n.d.; Timar et al., 2021).

Studies indicate that the healthcare provider's perceived skill and personal relationship with the family are important factors cited by families during the discussion and, eventually, the decision to donate the organs of a deceased loved one. Trust must be established first. Organ donation conversations should be held privately, and the healthcare provider(s) present should be very knowledgeable regarding the donation process to answer questions quickly and confidently. These conversations are best had using a multidisciplinary team, and some recommend that a different group of providers should be present for the organ donation conversation than prior conversations regarding prognosis and withdrawal of support. Information should be communicated clearly, comprehensively, and comprehensibly, focusing on sensitivity, compassion, caring, confidence, positivity, and family well-being. The medical team should outline the roles of various professionals, the step-by-step process of donation, and any impact on funeral arrangements. For example, many families are relieved to learn that, in most cases, they can still proceed with an open-casket funeral for their loved one following organ donation. After this conversation, the OPO representative will obtain informed consent from the patient's legal next of kin or designated decision-maker. They are also responsible for logistical details such as contacting UNOS, which manages the OPTN in the US, and arranging transport of the organs following procurement (The Alliance, n.d.; Haliko & Arnold, n.d.; Timar et al., 2021).

If the initial reaction from the family during the organ donation conversation is reluctance or hesitation, it is acceptable to explore and discuss the reasons underlying their feelings further sensitively. However, the medical team should avoid appearing apologetic, guarded, aggressive, or coercive when talking about organ donation with family members. If the prior discussion was had with an untrained staff member or led to a misunderstanding of the facts, a second attempt may be made with a more experienced team and concrete action plan. A repeat attempt to discuss organ donation with a family may also be reasonable in situations where additional relevant clinical information is now available, the patient in question has since been confirmed as a registered organ donor, or advance directives with specific instructions regarding organ donation have since been located. Unconditional support should be provided to the patient's family before, during, and after the donation process, regardless of whether they elect to provide consent (Shemie et al., 2017).

 

Assessment and Care of the Potential Organ Donor

Managing a patient after the declaration of brain death but before organ donation can be complicated. Brain death typically leads to a systemic inflammatory response, a catecholaminergic discharge, and diabetes insipidus (DI) with hypovolemia due to the sudden decrease in antidiuretic hormone (ADH) production. The nurse must maintain the patient's blood pressure to perfuse their organs and avoid hypotension, with a goal mean arterial pressure of at least 60 to 65 mm Hg. The patient's urine output must also be monitored while maintaining euvolemia, with a goal of at least 0.5 to 1 mL/kg/hour of urine output. DI typically presents with large amounts of dilute urine output and dehydration (i.e., increased serum osmolality and hypotension). There are no specific recommendations regarding using vasopressors or inotropes to maintain perfusion; however, vasopressin (Vasostrict) is preferred for managing DI in these patients if it does develop. These measures will help protect the kidneys and ensure adequate perfusion of the patient's other organs. Vasopressin (Vasostrict) is associated with increased organ recovery rates. The medical team should avoid hypervolemia and utilize lung-protective ventilation techniques and lung recruitment strategies as needed to protect the lungs. Insulin, glucocorticoids, and thyroid hormones are commonly incorporated to correct hormonal imbalances. Various tests may be performed to assess the health and viability of the patient's organs before procurement. All potential heart donors should have an echocardiogram performed. A cardiac angiography may be performed if the donor is over 40 or has multiple cardiac risk factors for premature CAD. A bronchoscopy may be indicated to assess the patient's anatomy and airway clearance. Additional laboratory or imaging studies may be recommended to evaluate further the health and functioning of the liver, kidneys, and pancreas. Despite the numerous considerations required to optimize potential organ donors following brain death, the primary advantage is that these patients may remain on cardiovascular life support throughout the process. These patients are transported to the operating room to retrieve the organs without any significant period of warm ischemia (Bag et al., 2023; Tullius & Rabb, 2018).

Despite the increase in DCD, there remains a wide margin of variability between OPOs in using these donors. Patients who may have the potential to donate organs following cardiac death are managed similarly to the abovementioned considerations, with a primary focus on maintaining euvolemia, hemodynamic stability, and utilizing lung-protective ventilation techniques. These patients may retain some brain function, so they may not require DI or hormonal imbalance management. As previously stated, the health and viability of a donor's organs following cardiac death are directly related to the length of time between the withdrawal of cardiovascular and ventilatory support, the declaration of cardiovascular death, and the surgical procurement of the organs, or the warm ischemia time. The health of the patient's organs is optimized if there are less than 60 to 120 minutes (1 to 2 hours) between the initial withdrawal of life support and organ retrieval/preservation. Often, patients over the age of 65 will not be able to successfully donate healthy organs following cardiac death, while DBD donors may be significantly older (Dopson & Long-Sutehall, 2019; National Academies of Sciences, Engineering, and Medicine [NAESM], 2022; Seshadri et al., 2023; Tullius & Rabb, 2018; Walters & Kleiman, 2023).

Following procurement, tissue biopsies may be performed to assess the organ viability, especially regarding kidneys. After procurement, most organs must be stored until they can be implanted into the recipient. To preserve the organs ex vivo, safe and reliable methods are needed. Based on the organ being stored, the preservation times vary. Recently developed ex-vivo perfusion techniques have improved the health and viability of transplanted organs by reducing the risk of tissue damage during warm and cold ischemia. Normothermic perfusion techniques such as ex-vivo normothermic machine perfusion (EVNMP) have extended the accepted preservation times of some organs, making it possible to transport these organs a greater distance to the intended recipient. This is because EVNMP maintains oxygen delivery to the organs and allows for adenosine triphosphate (ATP) production to continue, preventing irreversible cellular injury that occurs with other types of preservation. Currently, EVNMP is used for heart, lung, and liver transplants. Hypothermic perfusion at 0 to 12° C (32 to 53.6° F) is the most beneficial for kidney preservation (Finger, 2023c).

 

Barriers and Facilitators to Organ Donation

The barriers and facilitators to increasing the number of healthy organs transplanted are numerous, varied, and, at times, difficult to identify and characterize accurately. Experts in the field advocate for an increase in national public health campaigns educating the public about the importance and safety of living kidney donations. Social media and technology are an unexpected yet potential facilitator of living organ donation. MatchingDonors.com is an internet site first developed in 2004 where those in need of an organ and those willing to donate a kidney or a portion of their liver are connected electronically. As previously stated, additional financial support for living donors is now available to offset hardships such as lost wages and childcare for living donors (Lewis et al., 2020; Thomas et al., 2019).

In prior studies, nurses have cited concerns regarding the donation of organs following cardiac death. Respondents noted that they felt the mandatory 5-minute observation period for asystole was insufficient (14%), that the patient would suffer or experience pain (11%), or that there would be legal repercussions (8%). A recent qualitative study of pediatric intensive care unit (ICU) nurses in the UK identified the following significant barriers to discussing the option of organ donation with patients' families: a lack of knowledge and resources regarding the organ donation process, assumptions about the family/guardian's views regarding organ donation, and a general reluctance to engage in sensitive conversations with patients' families. Less commonly reported barriers included moral or religious objection, organ donation not being in the patient's best interest, undue burden on the medical staff, discomfort discussing a "taboo topic," and the fear of being perceived as insensitive or inappropriate by the family. The positive personal and professional attitude toward organ donation and the quality of the nurse/family/patient relationship were facilitators of discussing organ donation with families that were consistent throughout the study (Dopson & Long-Sutehall, 2019). The nurses participating in the study specified an increased level of comfort and willingness to approach families regarding the possibility of donation if they were given the following support:

• written information regarding organ donation to review and distribute
• simulation sessions to practice having sensitive, challenging, and uncomfortable conversations
• annual updates from the institution's transplant coordinator regarding any changes in the donation process/policy, resources for families, and typical/commonly asked questions and how best to respond (Dopson & Long-Sutehall, 2019)

To increase the success of family conversations, healthcare institutions should create a team specifically trained and experienced in tissue and organ donation. This team can help streamline the process while minimizing the impact on the donor's family. These teams typically include a nurse, social worker, pastor, and provider. This additional moral and emotional support for the families often helps them view the experience as positive and rewarding (Muco et al., 2023). The recent invitational forum in Canada identified the following qualities and characteristics that are essential for those involved in organ donation discussions:

• "a good communicator, listener, and facilitator with high emotional and cultural intelligence
• open, honest, collaborative, and patient
• self-aware, non-judgmental
• comfortable in dealing with families in crisis
• trained and experienced in dealing with conflict
• compassionate
• passionate and knowledgeable about organ donation
• confident in their ability to be successful
• able to work well with various personalities" (Shemie et al., 2017, p.S22)

Ethical Questions That Remain

For organ donation to be a widely accepted practice with high donation rates, individuals must view the system as trustworthy and transparent. Transplant medicine inherently contains several pertinent ethical considerations, such as (NAESM, 2022):

• How are the donors being treated?
• Who makes decisions, and on what grounds?
• Is death being hastened for the sake of donated organs?
• Is the donor or family well-informed?
• Is the recipient well-informed?
• Are the recipient (and donor, if a live donation) prepared with adequate care and resources following the procedure?
• Are there ulterior motives underlying the donation?

The dead-donor rule has been in effect since the beginning of transplant medicine. IDD, or live donation prior to planned withdrawal (LD-PPW), continues to provoke ethical discussions amongst organ transplant experts. IDD has the potential to be another option for organ donation and may increase the number of quality organs available for transplantation. These patients are anesthetized, and their organs are removed in an operating room under general anesthesia, making organ donation the official cause of death. While performed in other countries, this process has not been sanctioned by the OPTN. An ethics committee review in 2016 cited ethical concerns; specifically, patients with a severe neurological injury who could not provide informed consent of their own accord were of concern to the committee members. The stress of this ethical dilemma on the surrogate decision-maker was felt to be unreasonable by the committee. One committee member described this as a political problem, not an ethical one (OPTN, 2016). The committee cited "potential risks that are too great at this time based on the responses and substantial concern from the nine other committees, lack of community support, and substantial challenges (OPTN, 2016, p. 5)." There is no data to determine if LD-PPW would lead to an effective increase or decrease in the number of organs available for transplantation. Currently, any surgical program that proceeds with this method of donation in the US could be held legally liable for accelerating the death of a patient, even with a signed consent form. In Canada, where physicians have recently been granted legal immunity to facilitate a comfortable and somewhat hastened death by terminally ill patients, transplant teams continue to abide by the "5-minute no touch" rule before initiating the organ and tissue recovery process (OPTN, 2016; Rosenbaum, 2020).

US public opinion may be less divided than in medicine regarding these ethical questions. A 2021 survey was conducted and included 2,644 Americans over 18. Of the participants, 53% were registered organ donors, compared to the national average of 58%. Participants were presented with a hypothetical case study describing a patient who suffered a severe neurological injury leading to a persistent vegetative state, reliant on life support. They were then asked if the patient should be allowed to donate their organs, even if it meant causing their death to do so. The majority of respondents agreed with IDD. Of these, 68% to 74% agreed with IDD in general, in the presented case study, when referring to the decision regarding a loved one or donating their own organs. In contrast, 8% to 13% disagreed with these statements. If the respondent was unsure of their loved one's wishes regarding organ donation, only 47% agreed to donation, 28% were neutral, and 25% disagreed. These results challenge the belief that the general public does not support or would perceive IDD negatively (Washburn et al., 2021).

Unfortunately, the ethical concerns regarding the lack of equity in access to medical care amongst individuals of certain racial or ethnic groups also extend into the transplant medicine world. In 2021, more than 28% of individuals on the transplant list were non-Hispanic Blacks. Asian Americans, Pacific Islanders, Native Americans/Alaskan Natives, non-Hispanic Blacks, and Hispanic individuals have higher rates of certain chronic diseases that affect their vital organs; this increases the need for organ transplantation in these groups. Certain blood types are also more common among these populations. Since organs must be matched based on the donor and the recipient's blood type, individuals belonging to these groups must register as organ donors. Strategies to address this inequity include community efforts to increase public awareness and education regarding organ donation and improved primary care access to reduce the secondary need for organ donation. While enhanced organ allocation efficiency is still warranted, transitioning from a location-based allocation system to a need-based system several years ago improved the equity of donated organs (Lewis et al., 2020; NASEM, 2022; Office of Minority Health, 2022).

 

Future Research to Optimize Organ Donation and Reduce Transplant Need

Most research in the field of transplantation is focused on optimizing the tissue health of donated organs before, during (see prior discussion regarding ex vivo perfusion techniques), or after the transplant process. Enhanced early identification of potential organ donors and expanding the currently existing organ donor criteria are strategies that should be evaluated to improve the organ shortage across the country. Public awareness and education are vital to obtaining consent, as research consistently indicates that donation consent rates are directly related to the public's level of understanding. The usefulness of mild hypothermia is being explored in managing potential organ donors immediately following brain death declaration. The potential role of immunosuppressants and antioxidants in donors before organ procurement is being studied. Ex vivo perfusion techniques allow more time for organ and tissue assessment before placement. Immediately following reperfusion, significant tissue injury occurs related to inflammation, apoptosis, epigenetic changes, and oxidative stress. Immune therapies targeted at reducing or limiting this damage are ongoing but are struggling to overcome the small number of patients enrolled in their clinical trials. Stem cells, anti-inflammatory T cells, and regenerative agents are being explored to enhance the repair process following this initial tissue damage. Pharmaceutical companies are exploring methods to enhance the effectiveness and reduce the adverse effects of immunosuppressive agents given to organ recipients (Lewis et al., 2020; Tullius & Rabb, 2018).

An area that can be expanded upon is the use of organs donated by older adults. Recent studies have demonstrated that older donor age is linked to poor outcomes following the transplantation of a liver, kidney(s), pancreas, heart, and lung; however, the onset of adverse effects varies based on the organ transplanted. More organ-specific research is needed to determine the safety and effectiveness of utilizing specific organs from older donors (NASEM, 2022).

The organ transplantation system is complex and involves multiple agencies and stakeholders nationwide. A committee convened by NASEM considered opportunities where the federal government could set guidelines and clear goals for the transplantation system to improve equity and quality care. Having ambitious goals in the past has led to record donation and transplantation numbers. It is also concluded that unifying the current fragmented system under a single entity could save additional lives and make donated organs a national resource with fairer means of allocation; however, this has been met with pushback from healthcare professionals who believe that organs recovered from a particular geographical area should be used for a recipient in that same area. Although organ donation and transplantation have increased under the current system, the number of donated but not transplanted organs has also increased. This indicates that the allocation process is not working as effectively as possible. The hope is that more individuals will be able to receive a needed organ, and fewer donated organs will be discarded (NASEM, 2022).

The UNOS information hotline, 888-TX INFO-1 (888-894-6361), can be contacted for additional details regarding transplantation. For information regarding organ and tissue donation, call 800-292-9548 (UNOS, n.d.-a)

References

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