A. Myth: The donor family pays for organ and tissue recovery. Fact: The recovery agency, not the family, pays all of the recovery costs for organ donation.

B. Myth: Donors cannot have an open casket funeral. Fact: Organ and tissue donation will not affect whether one can have an open casket funeral.

C. Myth: Anyone over 50 years old is too old to be a donor. Fact: Organs can be successfully recovered from donors well into their seventies.

D. Myth: Potential donors do not receive the best medical care. Fact: Saying "Yes" to donation on your driver’s license will not affect efforts to save your life or the medical care that you receive. Organ recovery takes place only after all attempts to save a life have been exhausted, and death has been declared.

E. Myth: Most religions are against organ donation. Fact: Most major religions approve of donation and consider it a gift or an act of charity.

F. Myth: A black market exists for organ dontion. Fact: A black market for organs does not exist in the United States. The National Organ Transplant Act makes it illegal to sell human organs and tissues.

G. Myth: Famous or rich people get organs first. Fact: Fame or fortune cannot “give you an organ first." Patients are matched to organs based on blood type and/or tissue type, medical urgency, time on the waiting list, and geographic location.

II. New Federal Mandate effective August, 1998

A. ALL Hospitals who receive Medicare funding must report ALL patient deaths to their local organ procurement organization (OPO).

B. Hospitals must ensure that family of every potential donor is informed of their option to donate organs or tissues.

C. Hospitals must work with their local (OPO) to educate staff on donation issues.

D. All hospital staff members, who offer families the option of donation, must complete a training program on “approach” and “consent." These people are then known as “designated requestors.”

III. Two Types of Donors

A. Heart Beating 1. Can be organ and/or tissue donors 2. Must remain on a ventilator for several hours 3. Must meet brain death criteria

B. Non-Heart Beating 1. Can be tissue donors only 2. 12-24 hours after death to recover tissues

IV. Transplantable Organs From Heart Beating Donors

A. Heart B. Lungs C. Liver D. Kidneys E. Pancreas F. Intestine

V. Types of Brain Injuries Leading to Brain Death

A. Gunshot Wound B. Head Trauma C. Stroke D. Tumors E. Intracranial bleed like an aneurysm or trauma F. Anoxic Brain Injury like drowning or hanging

VI. Cerebral Anoxia (Oxygenation Starvation)

A. Lack of blood Flow to any Part of the Brain due to: 1. Heart Attack 2. Shock (Hypovolemia) 3. Blockage of artery (Stroke or Emboli) 4. Hemorrhage (Intracranial bleed) 5. Increased Intracranial pressure from trauma B. Lack of Oxygen in the Blood Flowing to the Brain due to: 1. Respiratory disease (Asthma) 2. Poisoning (Carbon Monoxide) 3. Suffocation 4. Drowning 5. Anaphylactic Shock

VII. The Injured Brain

A. Brain Swelling (skull is rigid) B. Compression of Blood Vessels C. Decreasing Blood Flow D. Lack of Oxygen and Nutrients to Brain Cells E. Brain Cell Death F. Swelling Continues, Cycle Perpetuates

VIII. Definition of Brain Death

A. Total and irreversible loss of brain function, including the brain stem B. Is synonymous with death C. Is different than chronic or persistent vegetative state

IX. Reversible Conditions That Must be Corrected Before Declaring Brain Death

A. Drug Effects (sedatives, paralytics) B. Hypothermia (Temp < 32) C. Shock (need adequate blood pressure to perfuse the brain, ie MAP >60) D. Metabolic Abnormalities (Hypo or Hyperglycemia) E. Electrolyte Imbalances (Potassium, Sodium) F. Some Intracranial Lesions (Large Subdural or epidural hematoma)

X. Clinical Criteria for Brain Death

A. No response to external stimuli B. No deep pain reflex C. Apnea despite adequate carbon dioxide stimulus (Determined by an apnea test…see attached handout) D. No Brain Stem Reflexes 1. No pupillary response to light 2. No corneal reflex 3. No oculocephalic reflex (Doll’s Eyes) 4. No oculovestibular reflex (Cold Calorics) 5. No Cough 6. No Gag

XI. Confirmatory Tests

A. EEG: No electrical Activity B. Nuclear medicine Perfusion Scan: No Blood Flow C. Four Vessel Brain Angiogram: No Blood Flow

XII. Counseling the Grieving Family

A. Helping the family understand brain death is a team effort B. Give consistent information C. Brain death is the legal time of death D. Avoid words like: 1. “Keeping him going” 2. “Breathing for him” 3. “Life Support”

XIII. Legal Considerations

A. Brain Death is accepted in all 50 states B. Brain death time and date is the LEGAL TIME OF DEATH C. Physician declaring brain death cannot be involved in the removal or transplantation of organs.

XIV. Making the Request for Organ Donation

A. Timing is extremely important: Family MUST FIRST UNDERSTAND AND ACCEPT that brain death has occurred. B. Someone must approach the family and ask. ( Can be the MD, RN, Social worker or Clergy) C. Person who approaches MUST complete a training course on approach and consent (per federal mandate) D. Person is then known as a “Designated Requestor.”

XV. Factors that Influenced the Decision to Donate

A. 73%: Something positive would come from our loss B. 66% My loved one would have wanted to help someone C. 56% Our loved one could live on D. 40% We wanted to help someone E. 31% Loved one verbally expressed the wish to donate

XVI. The Donation Process

A. Identification and Referral 1. Call your local Organ Procurement Agency as early as possible and provide information about your patient similar to “nurse's report.” a. Ventilator Patients: please call before removing the ventilator or supportive IV meds to preserve the option of organ donation for the family.

b. Medical Examiner Cases: Donation is still possible. OPO will obtain permission from the ME or Coroner’s office. Hospital only needs to report the death.

2. All Brain dead patients are potential organ donors until ruled out by the Organ Procurement Team. Each donor is evaluated based on the critical need of organs in the local or regional area on any given day.

B. Initial Donor evaluation 1. Admission History, Hospital Course and Lab Trends 2. Physical Exam and Assessment 3. Medications 4. Past Medical and Social History

C. Consent 1. Offering the option of donation to a family is called “approach” and can be done by a trained hospital staff member (RN, MD, Social Worker, Clergy, or Procurement Coordinator) 2. Consent must inform family about all details of donation 3. “Anatomical Gift Form” to designate which organs and tissues will be donated and if they are for transplant and/or research

D. Donor maintenance 1. All donors must be maintained on a ventilator up until organ recovery in the O.R. 2. Must be clinically managed to optimize organ viability and function 3. Typical physiologic responses include: a. Hypotension b. Hypothermia c. Electrolyte Imbalances d. Diabetes Insipidus

4. Blood testing for: a. Infectious disease screening (4-5 hours) (Usually completed prior to O.R.) b. Tissue Typing (4-6 hours) c. CBC, Chemistries, Liver & Kidney function d. Blood, Urine, and Sputum Cultures

5. Organ Specific Testing a. Heart: CXR, Echocardiogram, Angiogram if age>45 or by MD request b. Lung: CXR, Sputum Gram Stain, Oxygen Challenge Test, Bronchoscopy

6. Matching Organs to Waiting Recipients a. Blood Type b. Tissue Typing (Kidney and Pancreas only) c. Height and Weight d. Medical Urgency e. Time on the Waiting List f. Geographic Location

7. Phone Calls (Usually >100) a. To transplant Centers for organ placement b. Within hospital for lab and test results c. Coordinate surgical teams (can include > 4) d. Coordinate perfusion personnel e. Coordinate tissue recovery

E. Organ and Tissue Recovery 1. Takes place in the Operating Room 2. 1-4 Hours depending on number of organs

F. Organ Preservation Times 1. Heart 4-6 hours 2. Lung 4-6 hours 3. Liver 8-16 hours 4. Pancreas 8-16 hours 5. Kidney 24-36 hours

XVII. Non-Heart Beating Tissue Donors

A. Eyes for Corneal Transplant 1. Procure within 6-8 hours after cardiac death

B. Skin 1. Procure within 12-20 hours after cardiac death 2. Top, thin layer, thickness of a “Kleenex” 3. Used for burn patients 4. Taken from thighs, abdomen and back

C. Bones (Iliac crest and long bones of the arms and legs)

1. Procure 12-24 hours after cardiac death 2. Lateral incisions made & surgically closed 3. Prosthetic bone device replaced

4. Iliac Crest (hip bone) a. most widely used graft b. wedges used for fusions in the neck and/or back

5. Vertebral Bodies a. used as chips and crushed bone in hip surgery and dental applications

6. Long Bones of Arms & Legs a. Used for trauma and cancer patients to avoid amputations

7. Tendons a. Achilles and patellar for injuries, etc.

D. Fascia 1. Taken from thigh area 2. Usually “rolled” and used as tendon or ligament replacements 3. Recently being used for bladder suspensions

E. Femoral and Saphenous Veins 1. Used for Vascular or Coronary Artery Bypass Grafts 2. A-V Fistulas for dialysis patients 3. Peripheral Vessel Replacement

F. Heart Valves 1. Aortic and Mitral, used for valve replacements 2. After processing are returned to the Donor Hospital to use for their patients 3. With Allograft valve; recipient avoids lifelong anticoagulant meds

XVIII. Non-Heart Beating Tissue Preservation Times

A. Corneas 2-4 weeks B. Skin > 5 years * C. Heart Valves > 5 years * D. Bone > 5 years * E. Tendon > 5 years *

XIX. Typical OPO Services

A. Hospital Development 1. Education and Support to all hospitals in their regional area

B. Regional Education To: 1. Jr. High School Health Classes 2. High School Drivers Ed Classes 3. Nursing Schools 4. Civic Groups 5. Department of Motor Vehicles (DMV) 6. Anyone who is Interested

C. Bereavement 1. Licensed Clinical Social Worker on Staff 2. Support and follow-up to all donor families for at least two years 3. Annual Ceremony to honor and remember donors

D. Web Site: WWW.IDSLIFE.ORG

XX. How to Best Support Potential Donor Families

A. Keep family members well informed during the entire hospitalization B. Answer all of their questions to the best of their understanding a. assess their understanding of grave prognosis b. clarify the concepts of a brain death diagnosis c. help them come to an acceptance of the diagnosis C. Facilitate family conferences as needed D. Assess a family’s readiness to be approached about organ & tissue donation E. Don’t ever be afraid to make sure the offer of donation is presented to a family; You cannot tell them anything worse than they have already heard.

THE MOST IMPORTANT ISSUE: IF YOU DO NOT ASK A FAMILY ABOUT DONATION…..

YOU HAVE MADE THE DECISION FOR THEM …….

AND TAKEN AWAY THEIR CHOICE

“Transplantation was a leap of the human spirit that transcended mere numbers. Death we know has a necessary purpose, replacing the old and infirm with fresh life. But in its clumsy way death gathers up spring flowers, too.

Transplantation meant we were no longer at the mercy of this arbitrariness. We had a say in the outcome.”

Reg Green Donor father and author of the book- “The Nicholas Effect, A Boy’s Gift to the World”