Many people express a wish to be a donor before they die and take steps during their lifetime to designate themselves as a donor. A person may use one of a variety of methods to express an intention to be an organ and tissue donor: signing a donor card, indicating intent to donate when applying for or renewing a driver's license, or joining a donor registry. Some people also place statements of their wishes in their will. One of the more effective steps, in addition to documenting wishes, is to have a family conversation about donation. Some people even talk about donation with their attorney or physician so everyone is aware of their wishes!
Many organ donors are accident victims (motor vehicle, fall, gunshot wound) who have suffered severe or eventually fatal injuries -- often a head injury. However, other potential organ donors are those who have suffered some type of bleeding within the brain or an event that stopped the flow of oxygenated blood to their brain. After being called to the scene of such an accident or incident, emergency medical personnel immediately begin life-saving procedures while the patient is transported to a hospital. When the ambulance or helicopter arrives at the hospital, the patient is met by a team of highly-trained doctors and nurses ready to employ all possible measures to save the life before them.
If the injuries are severe, the patient is usually placed on a life-support system, to include a mechanical respirator, monitors, and fluids and medications to support bodily functions. Doctors perform tests to determine the extent to which the brain and other organs and tissues have been damaged as a result of the injury. If tests show the brain is no longer alive, or that they are in very grave condition, the family is informed of their condition. In the case where the the brain has ceased to function, the patient is pronounced brain dead. This legally and physically means that the patient is dead.
You may have heard stories of people suddenly "coming to" in the morgue or at their own funeral. Is it possible to be alive after being officially pronounced dead? If so, why would you want to take the risk of donating your organs? This may be of concern for some people -- and it shouldn't be for two reasons. First, the goal of the medical profession is to preserve life. Second, only after every life-saving measure has been used -- and a patient has in fact, died -- would the process of organ donation proceed.
So what is the definition of "death" and how is it determined? Death may be pronounced in one of two situations: When a person's heart stops beating (cardiac death) or when the person's brain permanently stops functioning (brain death). While in some cases, organs can be donated by people who have died when their hearts have stopped beating, most donated organs are transplanted from people who have died as a result of brain death.
It is helpful to understand brain death before you make the decision to be a donor. Your brain needs oxygen to keep working. When the brain is injured it swells, or bleeding around the brain cramps it's space. This swelling or reduced space can prevent blood from entering the brain. When blood, which carries oxygen to the brain, stops flowing, the brain dies. This condition is brain death. A person who is brain dead has no awareness, cannot think, feel, move or breathe. A person who is brain dead shows no brain activity and no longer feels pain or suffering. The definition of brain death has been legally determined by means of the Uniform Determination of Death Act, passed in 1981.
Brain death is a permanent condition that cannot be reversed. Without a functioning brain, the rest of the person's organs can be kept working for a short time using a mechanical support system. Once this system is switched off, the body will stop working because the brain is not working to tell it to continue functioning. A brain dead person on mechanical support may look as though they are sleeping -- they might be warm to the touch, and their chest will be rising and falling to the pace of the ventilation machine. However, because the brain is dead, the person is dead.
Several medical professionals perform a number of tears at separate times before a person is pronounced brain dead. These individuals are NOT associated with the transplant team. If these tests prove that brain death has occurred, the body is kept on mechanical support to maintain the organs until the family is offered the opportunity to make end-of-life decisions for their loved one, including donation.
The organization responsible for coordinating organ donation and transplantation are the organ procurement organizations (OPOs). Each of the 58 OPOs across the country is a Federally-designated non-profit organization that works with the hospitals in their designated geographic area to identify potential donors. These service areas may cover a single state or parts of adjoining states. In addition to identifying donors and obtaining consent for donation, the OPOs are responsible for the evaluation, preservation, allocation, recovery and transport of donated organs, and to support transplant activities in their area.
Federal Law requires that hospitals report all deaths and imminent deaths (a person on a ventilator who is near death) to the local OPO. Notification by the hospital allows an OPO coordinator to go to the hospital to determine if the deceased person is medically suitable to be a donor. After the family has learned of their loved one's death or grave prognosis from the attending physician, they will be given time to process this information and spend time with their loved one. At the appropriate time, the health care team introduces the OPO coordinator, someone who works regularly with families in these circumstances, to discuss the situation with the family members. The coordinator provides care and support to the potential donor family, providing them information on donation and offering them the opportunity for their loved one to give the gift of life. The vital organs of the brain dead person are kept oxygenated by a mechanical support system until the patient and family wishes are determined. If it is determined that the deceased person is not going to be an organ donor, the mechanical support system is discontinued by the hospital. If the family supports donation, the coordinator obtains the necessary medical information and history, legal consent, and then arranges for the surgical recovery. Placement of organs, donor management, organization of the recovery and transplant team(s), arranging transportation for all organs and care of the donor and donor family are the job of the transplant coordinator, who is sometimes on site for more than 24 hours attending to their case. Mechanical support of the donor's organs is maintained until the organs are surgically removed.
The Federal goverment passed the Uniform Anatomic Gift Act in 1968 that paved the way for individuals to express their wishes to be a donor and to have that decision unequivocably carried out by a designated agency. Many states have passed supporting legislation that recognizes certain forms of written intent to be a donor as legal and binding. Family consent, according to these laws, is not necessary for that deceased person's organs and tissues to be donated. These laws are known as "first person consent" and are based on the belief that the donor's wishes should be paramound and should not be overridden by family members. If the deceased person had not designated themselves to be a donor, the family is asked to make the decision whether to donate. In states with first person consent, OPO representatives take care to talk to the family before the removal of organs to make sure the family understands and appreciates their loved one's decision to save the lives of other people through organ donation.
In other states, even if a deceased person had signed a donor card or otherwise indicated their intention to be a donor, the family will still be asked for their consent before organs and tissues are donated. A specially trained OPO representative explains the donation process, answers questions and offers the family the option of donating their loved one's organs and tissues. The family is given time to consider and disucss their decision. If the deceased had indicated their intent to donate, it is often much easier for family members to make a decision. That decision, at such a difficult and traumatic time, becomes even easier if the deceased had discussed their wishes with loved ones.
So why do people say no? While more than 85% of the US population say they support donation, when faced with the decision, less than half say yes. Most often, is it because they are unaware of their loved one's wishes concerning donation. Other reasons include lack of understanding about how donation and transplantation work, mistrust in the healthcare system or overwhelming apathy. Misconceptions often hinder a family decision -- the OPO coordinator works hard to provide the facts and dispel the myths concerning donation.
To learn more about the ways to declare an intention to be a donor in your area, please check the UNOS factsheet on Donor Designation by State or The Organ Donor Initiative to locate your local organ procurement organization. If you need further assistance, please e-mail Pandora with your specific information.
Immediately following the identification of the deceased as a donor, the process of organ placement (also known as allocation) begins. Information about the donor, such as body size, blood type, and geographic location, is entered into the UNOS computer system. This network identifies potential recipients on the national waiting list who best match the available and consented organs. Based on medical and scientific criteria, a list of potential recipients is generated for each of the donor's organs. One donor may be able to supply organs and tissues for many recipients.
Where does the number 8 come from when donor advocates refer to how many people can be impacted through organ donation?
It comes from the number of most commonly transplantable organs in the human body. There are three thoracic organs -- the heart and two lungs. There are five transplantable organs in the abdomen -- intestine, pancreas, two kidneys and the liver (which is sometimes split in two, depending on the size of the organ and the recipient size/needs.) While we'd love to be able to maximize the gifts from every donor, there are times when that is not possible. Things like age, injuries, and certain diseases or infections that render organs not suitable for transplant. It's the job of the transplant surgeon to ultimately decide what organs will best function for their recipient's needs. (Eventually, I'll have a page here that will describe in detail the transplantable organs and tissues, and what disease processes or injuries render them in such a state to need to be replaced via transplant.)
The OPO specialist assists the hospital staff in supporting the donor and maintaining good oxygenation to the transplantable organs. A specific recipient for each organ is identified, often times with backup waiting should something turn up unfavorable in the first patient (reducing a missed opportunity for someone to come off of the waitlist.) The transplant surgeons are often involved in the care and management of the donor, offering advice and management preferences to keep their expected organ in top shape for their potential recipient. In some instances, a surgeon from transplant teams will come to the hospital where the donor is and surgically remove the organ to be donated to their recipient, and return it to their hospital for transplant. In other cases, the OPO will locate a recovery surgeon, perform the recovery while quickly preserving the organs and transporting them to the recipient's transplant center where they await their surgery. Tissues, if donated, are recovered after any vital organs, but quickly enough as to reduce the chance of organ or tissue deterioration. The usually quick removal of organs and tissues minimizes any delay in funderal arangements. Recovery is also done in such a manner that an open-casket funeral is still possible.
A word on tissue donation:
From 50 to 100 people can also be impacted by tissue donation. Tissue donation can happen either from someone who is an organ donor, or after cardiac death, when the heart has actually stopped. Bone (usually from the arms and legs, as well as pelvis and ribs), connective tissue (tendons and ligaments), skin, vessels (femoral and saphenous veins), cardiac tissue (pericardium and heart valves) and eyes/corneas can be donated to significantly impact the lives of others. Tissues change lives by restoring sight, mobility and circulation, and in some cases, salvaging a limb, protecting the body from infection or even alleviating the risks involved in taking blood-thinning medications (for human valve recipients). Many people can donate tissue, even when they've died in a car accident, at home or even from things like cancer. (Cancer patients make up approximately 60% of the national pool of corneal tissue!) The evaluation for suitability for tissue donation is far different from that of organ donation, as tissue transplants are considered life-enhancing, not life saving, and human gifts of tissue are regulated by the FDA (Food and Drug Administration.) An extensive medical and social history is required of every donor, as is a detailed screening of their health, physical condition and any risk factors that might jeopardize the donor pool. These things might include travel to malaria or HIV-endemic countries, being in areas prone to Mad Cow Disease, being exposed to infectious blood, smallpox, SARS or being known to have an infectious disease like hepatitis. The screening is not unlike the questions you'd be asked when donating blood or blood products like plasma or platelets at the Red Cross or a community blood center.
Donor programs ensure that the names of donors and recipients remain confidential, but most donor families appreciate knowing that a gift of life came from their tragic circumstances. The OPO follows up with the donor family in the way they have requested, in the form of a phone call and/or letter, informing them of the recovery and how their loved one's organs and tissues were used. Some families request that they be called when the recovery is complete. While the names of recipients remain confidential, donor families can request updates about recipients by contacting their OPO. Often recipients ask OPOs to pass letters on to a donor's family expressing their gratitude. This can be of great comfort to donor families. Recipients may eventually meet donor families if both parties agree to the meeting. Feedback and support is also given to the hospital care team through whose collaborative efforts the donation occurred.
Bereavement counselors from the OPO often reach out to the donor family within the weeks and months after a donation has occurred to ensure they are coping effectively. This is especially important around special events like birthdays and the anniversary of their loved one's death. Social workers provide one-on-one and group counseling, and many OPOs hold support group meetings specifically for recipients or donor families where they can share their experiences with others in similar circumstances. Donor families as well as recipients are living proof that donation worked for them, and they are often the most loudly-heard message that can be gotten out to the public. Donor families, living donors and recipients often participate in donor awareness events for their transplant center and OPO, spreading the message about sharing the Gift of Life. For information and a wonderful online resource for donor family support, please experience Healing the Spirit, a service of LifeNet of Virginia.
For more resources on organ donation and transplantation, visit my links page or the UNOS Resourse Page.
