Identifying and Referring Potential Organ Donors, Article Review Example

Jane Franklin, RN BN, works in the Critical Care Organ Donation Program at Capital Health in Halifax, Nova Scotia as an Organ Donation Coordinator.

Abstract

Critical Care nurses are at the front line of efforts to improve organ donation and support the success of organ transplantation. However, the benefits of organ transplantation continue to be limited by a shortage of available organs. One of the reasons that organ donation opportunities are missed is that clinicians, including critical care nurses, do not identify and refer potential organ donor patients for further assessment. If referrals are not made in a timely manner the opportunity to donate may be lost, negatively impacting potential donor families as well as transplant recipients. In this article it is argued that the use of clinical referral triggers within a supportive framework of Organ Donation Programs, donor legislation and donor registries provides critical care nurses with an effective way to ensure that donation opportunities are not missed.

Key words: Clinical referral triggers, organ donor identification, donation legislation, organ donation programs, donor registries.

Background

Organ transplantation is a successful treatment option for many patients with end-stage organ failure. Unfortunately, patient waitlists for solid organ transplants have continued to increase while donation rates have not, resulting in a shortage of organs. Increased demand for organs is partly due to the improved outcomes of organ transplantation, and also because patients are living longer while they wait (Norris, S., 2009). Low organ donor rates may result from several factors including low recruitment of donors and lack of altruism (Norris). The decreased number of donors has also been attributed to changes in the incidence of brain death, which is itself a rare phenomenon (1-2% of hospital deaths), yet is a prerequisite for organ donation in most situations. Potential organ donors are patients who have suffered an irreversible brain injury, and after a period of unsuccessful treatment a decision has been made to withdraw life sustaining therapy. The number of patients who suffer neurological death is decreasing in most Western countries, mainly due to advancements in treating and preventing the main causes of severe brain injury: intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury  (deGroot, Wijdicks, van der Jagt, Bakker, Lingsma, Ijzermans & Kompanje, 2011). Studies have also shown that there is a gap between the number of people who say they would donate and the number who actually do (Siminoff, Mercer, Graham & Burant, 2007).  This is a factor that can be addressed in part by the care that the potential donor and families receive in the critical care unit.

Efforts to address the shortage of organs have included the introduction of tools such as clinical referral triggers, to help nursing and medical staff identify potential donors. Referral triggers provide a standard set of clinical criteria for use within a particular health care organization or facility, to improve donor identification.  The significance of donor identification and referral is that it initiates the process of donor assessment by the Organ Donation Program in a timely manner, which is a predictor of positive donation outcomes (Brown, Foulkrod, Dworaczyk, Thompson, Elliot, Cooper & Coopwood, 2010).

The Importance of Organ Donation in Critical Care Nursing

Front line clinicians in Critical Care and Emergency Departments play a very important role in identification and referral of potential organ donors, because organ donors are identified only in the critically ill patient population. All nurses in critical care have opportunities to improve the experience of donation for families as well as to improve organ donation rates (Daly, 2006). Unfortunately, one of the most significant barriers to organ donation is the failure of nurses and physicians to refer potential donors in a timely manner, if at all (Daly). Nurses may not be aware of clinical referral triggers in their organization, or they may be unsure of how or when to contact the Organ Donation Program for assistance. In some cases staff may not lack awareness but may choose not to refer for other reasons, such as a perception that a donation request would add to the family’s emotional burden, or skepticism about the benefits of transplantation (reference). In these cases the end result is the same – families may not be given the opportunity to choose donation, or in some cases they may not have the opportunity to support the expressed donation intentions of their loved one. Consider the following example.

 Clinical scenario

A patient named G.K. has suffered a massive subarachnoid hemorrhage and has been admitted to the intensive care unit. After a week of unsuccessful treatment, the neurosurgeon speaks with G.K’s family about discontinuing life support. G.K’s family is devastated, but they agree with the decision because he would not want to live that way – “on those machines”. In their state of grief, G.K’s family has forgotten that he had recently made a point of telling them that he had taken the necessary steps to sign his province’s organ donor registry. He had done this to show support and gratitude when a co-worker recently receive a life-saving heart transplant following a sudden illness.

G.K. met the hospital’s clinical criteria to be assessed as a potential organ donor, but neither the nursing staff nor physician team made a referral to the Organ Donation Coordinator. They assumed that a donation request would add to the family’s emotional burden. When G.K’s family thought about organ donation themselves a few days after his death, they made an inquiry to the Organ Donation Program. They were disappointed to learn that he had not been referred, and found it hard to understand why the ICU team had not asked them about donation.

Discussion

This situation would have had a different outcome if the ICU staff had used the clinical criteria (referral triggers) to identify G.K. as a potential donor, and discussed an action plan with the local Organ Donation Program. Donation Coordinators can assess medical suitability of potential donors, check donor registries (if available), and provide guidance with requesting family consent. It should never be assumed that a patient’s family would not want to have the chance to donate. In this example, if G.K. had become an organ donor his family would have had the comfort of knowing that his final wish had been honoured, and several lives may have been saved.

Donation is an important part of end of life care.

Families are always part of end of life discussions in Emergency Departments and in Intensive Care Units. After a decision has been made to discontinue life support, donation discussions should be included in planning end of life care for the patient and the family. The Organ Donation Program should be consulted before such discussions to ensure that the family is given correct information before a request for donation consent is made (Simpkin, Robertson, Barber & Young, 2009). ). Unduly delaying the donation conversation has been shown to have a negative effect on family consent for donation (If it is determined that donation is a possibility, the patient’s legal next of kin or substitute decision maker will be asked to sign consent for organ donation. As illustrated in the example above, it is the family’s right to be given the choice to make.

Donation can provide comfort to the donor’s family.

Many donor families have said that because their loved one was able to help someone else, donation was the only good thing that came out of a tragic situation. When families are presented with the option of donation, they often see great value in the gift and in the opportunity to help a person in need. Donation Programs support families to make the choice that is right for them, and a freely made choice to donate can provide a sense of comfort. Donation is also comforting to families when their loved one has previously expressed donation intentions and they are able to carry out those wishes. It is often difficult for Critical Care nurses to make the switch from life-saving treatment efforts to comfort care for donation, but they have a valuable role to play in helping the family through this process with the support of Organ Donation Programs (Peiffer, 2007).

Donor registries and family requests for donation.

Nurses in Critical Care must be prepared to respond to family requests for organ donation. When donation is discussed with a family it is very helpful if they know their loved one’s intentions. Some provinces have a provincial organ donor registry or a patient may have signed a donor card. With registries, the Organ Donation Program will be able to access the information and inform the family. If the patient has not made their intentions known, the Donation Coordinator can provide guidance with discussing what the family thinks their loved one would have wanted to do. The following provinces have donor registries in Canada at this time: BC, ON, NS, NB. In the other provinces people can indicate their donation wishes by signing a donor card or placing a designated sticker on their driver’s licence or their provincial health card.

Organ Donation Saves Lives

In Canada, the number of people who require an organ transplants is increasing. In 2010, there were 4,529 Canadians waiting for transplants (Canadian Blood Services, 2011). Of those, a total of 2,153 organs were transplanted but 247 people died while on the waitlist (Canadian Blood Services). One organ donor can potentially save the lives of up to 8 people. If a patient is also a tissue donor (tissue = skin, bone, corneas, heart valves) a single donor can help up to 75 more people (Trillium Gift of Life, 2011). The largest group of patients on the organ waitlist are waiting for a kidney transplant and there were 3,300 people on that list in 2010 (Canadian Blood Services). Living donation is also possible and is providing transplants for many patients, however the need remains great.

Identifying Potential Organ Donors

The majority of organ donors are declared neurologically deceased. In recent years, patients have also been able to donate organs after cardiac death under certain circumstances, but so far this group of donors has remained limited due the strict requirements surrounding the type of death and the timing of death following removal of life support. They account for approximately 20% of organ donors and in most programs can donate only kidneys and liver. Donors after neurological determination of death (also called brain death) are able to donate are heart, lungs, liver, kidneys, pancreas and small intestine for transplantation.

Brain death is defined as the complete and irreversible loss of all brain and brainstem function (Lazar, Shemie, Webster & Dickens, 2001). In Canada, brain death is determined by two physicians who have skill and knowledge in treating patients with severe brain injury and in determining brain death (CCDT, 2003).  The most common causes of brain injury leading to brain death are intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury (deGroot, et al.).

End of Life Decisions

When the difficult decision has been made to withdraw life support for a patient with a severe irreversible brain injury, the potential for organ donation may exist. In these cases, the patient’s family must be given sufficient time to accept that their loved one will not recover and that further treatment is futile – before organ donation is discussed with them (de Groot, Jansen, Bakker, Kuiper, Aerdts, Maas, Wijdicks, van Leiden, Hoitsma, Kremer & Kompanje, 2010). It is also important to ensure that families are given enough time to consider the request for donation consent after it is made (Simpkin, et al.). Families are more likely to consent to donation when they feel that they have been given enough information, as well as enough reassurance about the process (Siminoff, et al.). This highlights the need for communication between hospital staff and the Organ Donation Program.

Clinical Referral Triggers

Clinical referral triggers provide hospital staff with indicators to help them identify potential donors and make appropriate referrals to an Organ Donation program. Hospitals and Organ Donation Programs should collaborate to develop a set of referral criteria and ensure that critical care clinicians are educated in how to use them. Such criteria may include the patient having low neurological activity indicative of imminent death (such as a score of five or less on the Glasgow Coma Scale) the patient being intubated and ventilated, and the physician hav­ing had an end-of-life discussion with family. When patients are assessed for organ donation potential according to clinical triggers, sedatives, paralytics and other medication therapy should be taken into consideration.

Exceptions to the Triggers.

In developing a system for referring potential organ donors, hospitals must also establish any contraindications that will preclude a referral. For example, a patient who is being actively treated for cancer would most likely not be a candidate for organ donation. Organ Donation Programs can provide guidance with determining what (if any) conditions would make a referral unnecessary. If families have asked the medical or nursing team about donation, the Donation Coordinator can answer any questions the family may have about a patient’s medical eligibility.  Although Health Canada provides a list of medical contraindications for organ donation, potential donors with medical exclusionary factors may be considered for donation under the specific conditions of exceptional release and should therefore be referred (Health Canada, 2010). In such cases, the transplanting surgeon would be required to assess the risk, inform the proposed organ recipient of the situation, and obtain their informed consent before proceeding with the transplant.

The Referral and Next Steps.

The organ donation referral is usually made to a donation and/or transplant coordinator, who is usually a registered nurse in a hospital based organ donation program or provincial resource centre. The referral leads to further assessment of the patient’s medical eligibility for donation by the coordinator using a standard set of criteria set out by transplant programs and Health Canada. Consultation may be required with the coordinator’s affiliated transplant program regarding medical eligibility, and this information is communicated to the critical care team in a timely manner. If the patient is not medically eligible it is not necessary to discuss donation with the family, unless they have made the request for donation. In this case they should be provided with accurate information from the Donation Coordinator regarding the eligibility decision.

Why Referral Triggers are Necessary

The literature shows that the use of hospital specific clinical referral triggers leads to early referral of potential organ donors. If the Donation Program or other outside entity imposes referral indicators, staff may not be as inclined to use them as when they have developed the indicator for use in their own facility. Early involvement of the Donation Program leads to a better donation experience and increased family satisfaction because families receive correct information about donation in a timely manner, and a planned, individualized approach is used to request their consent (reference). Every organ donation situation is unique because families experience grief in different ways and for potential donor families, the critical event is the death of their loved one – not organ donation (reference).

Overcome Barriers to Donation in the Intensive Care Unit.

Clinical referrals triggers address one of the main barriers to donation which is that nurses and physicians may not know specific criteria for identifying a potential donor, or how to make a referral. Standardized tools for referrals are helpful to busy critical care clinicians, especially because the opportunity for organ donation is a rare rather than routine event in the ICU. ICU staff members who have negative attitudes about donation are encouraged not to discuss donation with families but to have another staff member make the referral and speak with the family. Donation discussions should be planned to take place earlier rather than later and in a supportive environment, as long as the family has accepted the ICU medical recommendation to stop life support. If the request for donation is made too late in the process the family’s stamina may be exhausted, and they may be emotionally unprepared to make any more decisions (Siminoff et al.).

Timely Referral of Potential Organ Donors.

Timely referral of potential donors makes donation possible because medical management is required in order to preserve the option of donation. In most cases this involves supporting the patient’s blood pressure instead of a non-escalation of treatment, as end of life discussions take place or are planned. Patients who become organ donors are maintained on a ventilator and medications for hemodynamic support until the recovery of organs in the operating room, which may take place up to 24 hours after the identification of the patient as a potential donor. Most Organ Donation Programs provide medical management guidelines and a physical presence in the ICU to support staff for the duration of the process. Medically supporting the donor will only be effective for a certain period of time after brain death before heart and breathing can no longer be maintained.

Quality Initiatives.

Clinical referral triggers are an important part of Donation quality initiatives that are used to identify “missed referrals” during chart audits of deceased patients in critical care areas. Hospitals and/or Donation Programs conduct audits to track cases where patients who met referral triggers were not referred. In this way, the quality of Donation improvement initiatives can undergo retrospective analysis, and the incidence of eligible organ donors in individual facilities can be monitored. To improve Donation quality, hospitals and Donation Programs set measurable targets for family approaches (usually 100%), family consent (usually 75%), the number of potential donors who become actual donors (conversion rate), and organs recovered per donor which measures the effectiveness of medical management and organ allocation to recipients (CCDT). Critical Care staff play an important role in supporting Donation Programs to meet these targets.

How Organ Donation Programs Support Hospitals

Clinical referral triggers establish formal relationships between Organ Donation Programs and staff in critical care through the requirement that staff contact the Donation Coordinator when a patient who meets the indicators is identified. Donation Programs and hospital staff work together to support patients and families who go through the donation process in the ICU. Trust in the Organ Donation program and cooperation between the parties is essential to effectively deliver donation services in a timely and compassionate manner.

The Role of In-House Coordinators

Many hospitals have dedicated organ donation coordinators who are on call for donation referrals, to answer family questions about donation, and to provide donation support and education as needed. Coordinators may be the Organ Donation Program staff or they may work in hospitals and liaise with provincial donation programs to provide services. The in-house coordinators typically work with Critical Care and Hospital Donation committees to share information and identify opportunities for quality improvement. By working at the organizational level with their service provider partners, the Organ Donation Coordinators can ensure that hospital needs are addressed regarding patient population (pediatrics for example) and patient ethnic and cultural needs (translators, spiritual advisors, language requirements for print materials) so that donor family care can be individualized as much as possible. As well, representatives of minority and culturally diverse groups can be invited to participate in donor family support groups and related activities.

Hospital/District Donation Policies

Organ Donation Programs collaborate with hospitals to develop and implement policies and procedures related to organ and tissue donation practices. In some provinces, policies are standardized at the Health District level, and some provinces such as Nova Scotia are working on developing a provincial policy that will standardize most aspects of donation at the provincial level for all health organizations. The Organ Donation Program facilitates donation by working with all stakeholders to ensure that donation information is accurate and up to date for distribution across the province or District, and to ensure that staff receive the relevant education and training needed to implement the policies. Critical Care nurses are a very strategic group of stakeholders in organ donation policy.

Accreditation Standards for Organ Donation

In 2010, Accreditation Canada, the Canadian Standards Association, and Health Canada introduced new standards for organ and tissue donation (Accreditation Canada, 2011). All Accreditation Canada client hospitals will be held accountable to these standards, even those who do not have organ donation on site. Any hospital with an ICU and/or Emergency Department is included because they have the capacity to identify and refer potential organ donors to Organ Donation Programs. Clinical referral triggers are an important aspect of the new standards, and Organ Donation Programs play an important role in working with hospitals to meet these standards. For example, hospitals must have a process for donor identification and referral (this includes clinical referral triggers) and be able to demonstrate that they have educational programs for staff to enable them to use the established referral process for their facility.

Organ Donation Laws

Health Canada Regulations for the Safety of Organs and Tissues

Since 2007, donation has been regulated under federal law in Canada (Food and Drugs Act) to ensure that the distribution of cells, tissues and organs that have not been processed in accordance with safety standards is prohibited (Health Canada 2011). All organ donation programs are required to register with Health Canada and comply with these Regulations.  The Regulations were developed in consultation with stakeholders over a 2 year period and are subject to periodic review.  The purpose of the Regulations is to minimize any potential health risks to those who receive cells, tissues or organs in transplants (Health Canada).  It is important for Critical Care nurses to be aware of the fact that organ donation is a strictly regulated activity in Canada.

Provincial Donation Legislation

Every province has its own provincial organ and tissue donation legislation. The provincial laws are aligned with Health Canada Regulations, and are very similar to each other (Gill, Klarenbach, Cole & Shemie, 2008). Hospital/District Donation Policies are aligned with their province’s legislation and contain varying levels of detail depending on the type of hospital and donation services provided. Provincial Donation laws typically define criteria such as who may sign consent for donation, who can determine neurological death, and also set out requirements to ensure that hospital staff to offer the option of donation to families in appropriate circumstances. Nurses in Critical Care can be aware of aspects of provincial donation laws that impact nursing care of potential organ donor patients, through education provided by Organ Donation Programs.

Required Request and Required Referral Legislation.

There has been a growing interest in Canada in provincially mandating either request for organ donation, or referral of potential organ donors. It is controversial whether or not such an initiative would actually increase donor rates, and if it would be worth the investment of resources to maintain such a system which would require the implementation of a reporting system for all deaths in the province (Norris). Some provinces have found that existing hospital data reporting systems have been found to be inadequate for provincial donation purposes, which must include details that are currently not captured in data that is required to be reported to provincial governments. British Columbia and Ontario at this time do have legislated required referral (or mandatory reporting of deaths), New Brunswick and Nova Scotia have required request legislation, and Manitoba has both required request and required referral. It has been argued that while laws to support donation initiatives are necessary, there may be a larger and more immediate benefit in working with modifiable factors to improve donation at the level of donor identification, referral, and consent (Simpkin et al.). I would argue that donation laws are equally important to operational level improvements because they provide much needed support for many important and practical aspects of donation services delivery.

Recommendations for the Future.

In Canada, the Canadian Blood Services has taken on a national oversight role in the field of donation. Since it started in 2008, this group has successfully implemented national registries for hard to transplant kidney recipients, as well as national waitlists for organ recipients. Another initiative at the national level that is gaining attention is the idea of a national, ‘intent to donate’ list – a national version of the provincial donor registries. Gill, et al. (2008) recommends that initiatives to increase donation should be implemented uniformly across Canada, so that consensus between provinces is achieved, and resources to support innovations are made available. They also suggest that a national registry will not occur without further development of formal processes to introduce other improvements such as national standards, protocols and guidelines, and accurate metrics to assess the progress of donation programs (Gill, et al.).

Conclusion

Critical care nurses are on the front line of donation and play a vital role in identifying and referring potential organ donors. By using clinical referral triggers and working with local organ donation programs, nurses can be knowledgeable about initiating the donation process at the appropriate time and in a compassionate manner. Many people are waiting for an organ transplant that may happen due to the generosity of a stranger – if front line nurses and medical staff are able to ensure that families of potential donors are given this choice to make.

References

Accreditation Canada (2009). Organ and Tissue Donation and Transplantation – Enhancements to Critical Care Services Standards.

Brown, C., Foulkrod, K., Dworaczyk, S., Thompson, K., Elliot, E., Cooper, H. & Coopwood, B. (2010). Barriers to Obtaining Family Consent for Potential organ Donors. The Journal of Trauma, Injury, Infection, and Critical Care, 68 (2), 447-451.

Canadian Blood Services (2011). Canadian Blood Services Urges Revamp of Organ Donor System. Retrieved from, http://www.theglobeandmail.com/life/health/new-health/health-news/canadian-blood-services-urges-revamp-of-organ-donor-system/article2059580/

Canadian Council for Donation and Transplantation (2003). Severe Brain Injury to Neurological Determination of Death: A Canadian Forum. April 9 – 11, 2003. Vancouver, BC. Report and Recommendations. Retrieved from, http://www.giftoflife.on.ca/assets/pdfs/1SBINDD_English.pdf

Daly, B. (2006). End-of-Life Decision Making, Organ Donation, and Critical Care Nurses. Critical Care Nurse, 26 (2), 78-86.

De Groot, Y., Jansen, N., Bakker, J., Kuiper, M., Aerdts, S., Maas, A., Wijdicks, E., van Leiden, H., Hoitsma, A., Kremer, B. & Kompanje, E. (2010). Imminent Brain Death: Point of Departure for Potential Heart-beating Organ Donor Recognition. Intensive Care Medicine, 36, 1488-1494.

DeGroot, Y., Wijdicks, E., van der Jagt, M., Bakker, J., lingsma, H., IJzermans, J. & Kompanje, E. (2011). Donor Conversion Rates Depend on the Assessment Tools Used in the Evaluation of Potential Organ Donors, Intensive Care Medicine, 37, 665-670.

Gill, J.S., Klarenbach, S., Cole, E. & Shemie, S.D. (2008). Deceased Organ Donation in Canada: An Opportunity to Heal a Fractured System. American Journal of Transplantation, 8, 1580-1587.

Health Canada. (2011). Cells, Tissues and Organs. Retrieved from, http://www.hc-sc.gc.ca/dhp-mps/compli-conform/info-prod/cell/index-eng.php

Lazar, N., Shemie, S.D., Webster, G. & Dickens, B. (2001). Bioethics for Clinicians: 24. Brain Death. Canadian Medical Association Journal, 164 (6), 883-886.

Norris, S. (2009). Organ Donation and Transplantation in Canada (PRB 08 – 24E). Library of Parliament, Parliamentary Information and Research Service. Retrieved from, http://www.parl.gc.ca/Content/LOP/ResearchPublications/prb0824-e.htm#C-Use

Peiffer, K. (2007). Brain Death and Organ Procurement. American Journal of Nursing, 107 (3), 58-67.

Siminoff, L., Mercer, M., Graham, G. & Burant, C. (2007). The Reasons Families Donate Organs for Transplantation: Implications for Policy and Practice. The Journal of Trauma, Injury, Infection, and Critical Care, 62 (4), 969-978.

Simpkin, A., Robertson, L. and Young, J. (2009). Modifiable Factors Influencing Relatives’ Decision to Offer Organ Donation: Systematic Review. BMJ Online First, 339:b991. doi:10.1136/bmj.b991

Review

With regard to the article, the writer displays a high level of understanding of the topic of the essay, which is intent on illustrating how the matter of transplanting in hospitals is affected by the limited level of available organs that can facilitate the procedure. The writer displays a clear flow of ideas based on the structure that is intent on defining the general problem and demonstrating a matter of how the problem has proven to be a major concern to the procedure.

The writer demonstrates a simplistic use of the English, which makes the article easy to read as well as follow. This means that the article can be read by individuals who may have a limited level of understanding of the English language. The writer structures the article in a manner that ensures that the essay is simple to read and understand the elements, which all relate to the topic of the article.

The writer uses a lot of references in the article, which serves to illustrate that they did a lot of research in order to structure the essay in accordance to the requirements. The concentration of the essay in Canada serves to illustrate how the problem of the lack of organs affects the country. this element is ideal as it is the basis of the article, however the writer should use small references in terms of comparing the problem in Canada to other countries so as to indicate whether the problem is only concentrated on Canada or not.

The article is very informative, the article is well researched and thus the reason for the high level of relevant data that addresses the topic of the essay. I believe a little more reference to other countries or regions may shed light as to whether the problem may only be limited to Canada. That may be the only minor problem in a rather informative and well structured article.