Donor Hospital Resources
Coroner/Medical Examiner Resources
Administrative Information
Articles of Interest
   
What is Hospital Development?
Education for the Healthcare Professional
The Donor Referral Process and the Healthcare Professional
Brain Death
Donation After Cardiac Death
Cardiac Death Q&A
Tissue Donation Process
Organ Donation Management Guidelines
National Initiative
HIPPA exemption
  As a condition of participation in the Medicare program, the Centers for Medicare and Medical Services (CMS) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires hospitals to report all deaths to the organ procurement organization in its region. The Transplant Network has a team of Hospital Service Coordinators who provide hospitals with information and guidance about the donor process and provide routine compliance reports to them. Each coordinator is assigned to specific hospitals within our region. Such consultative services and partnerships with donor hospital staff ensure a smooth donation process, thereby increasing the number of lives saved every year through organ donation.
    Take our ONLINE COURSE
Self Study Module
Organ Donation Pocket Cards (PDF)
    OPTIMAL REFERRAL AND FAMILY REQUEST PROCESS FOR ORGAN AND TISSUE DONATION

Support Family/Discuss Evidence of Brain Death	Patient admitted with a severe, non-recoverable, neurological injury Transplant Network notified of all imminent deaths of ventilated patients with Glasgow Coma Scale = 5 or less No mention of organ donation Attending physician informs family of grave prognosis and patient undergoing brain death evaluation or outcome of brain death evaluation Hospital staff provides family with support and answers their questions. Continue to describe clinical findings (ie. loss of gag reflex, apnea etc.) to family. Some families bring up the option of donation at this point, staff should acknowledge this request and inform family that the Transplant Network has been or will be called.
Referral to Transplant Network 1(800) 55-DONOR
Health Care Team Discusses Brain Death exam with Family	Bedside nurse or physician refers patient to the Transplant Network at 1-800-553-6667 as a potential organ/tissue donor A Transplant Network Coordinator will travel to the hospital and: notify attending physician of presence on unit to evaluate patient for preliminary organ donor medical suitability discuss case/plan of care with hospital staff Healthcare team explains results of brain death exam, and answers family questions. Healthcare team listens for cues that family realizes and acknowledges the death of their loved one. Some families may understand and acknowledge the death of their loved one prior to confirmatory brain death exams
Request Donation in Appropriate Setting	Donation options should not be mentioned prior to the family verbalizing a clear understanding of brain death. Attending physician/nurse introduces Transplant Network Coordinator: "This is _____, s/he often works with families in your situation to help you make some final decisions." A Transplant Network Coordinator and attending physician/nurse introduce options of organ and tissue donation to the family
Introduce Options of Donation to Family	The Transplant Network Coordinator provides family with information about donation options in a private setting Family is given time to consider donation options and make an informed decision. Any decision the family makes will be supported.
Support Family/Answer Questions	A Transplant Network Coordinator and hospital staff discuss next steps with the family for either: organ/tissue donation, obtain legally informed consent and medical/social history or for withdrawal of support Family is given the opportunity to spend time with their loved one prior to the withdrawal of support.

    Weblink: http://www.transweb.org/qa/asktw/answers/answers9509/braindeath.html

California Brain Death Statute
In 1974, the California legislature passed laws addressing brain death:

(AB 3560 and HSC 7180) Determination of Death - A person shall be pronounced dead if it is determined by a physician that the person has suffered a total and irreversible cessation of brain function. There shall be independent confirmation of the death by another licensed physician. Such physicians may not participate in or have any contingent interest in organ transplantation that may follow. Likewise, members of the transplant team cannot be involved in the diagnosis of brain death.

Please note that Nevada Law requires confirmation of brain death by one licensed physician.

Guidelines for Determination of Brain Death
The following guidelines are offered to assist the physician in determining brain death. Currently, accepted clinical criteria for determination of brain death include:

• Total unresponsiveness
• Pupils are fixed and dilated.
• Absence of corneal reflexes and ocular movement.
• No gag or cough reflex.
• No spontaneous movements, response to painful stimuli, or posturing.
• Occasionally, spinal reflexes may remain intact. However, this does not contraindicate brain death criteria.
• Absence of spontaneous respirations.
• Exclusions:
  The diagnosis of brain death depends upon the exclusion of two conditions: hypothermia (temperature below 90 degrees Fahrenheit) and central nervous system depressants such as barbiturates.

Brain death is a clinical diagnosis. Although brain death can be established by clinical criteria alone, confirmatory tests may be used to support the clinical diagnosis. These studies are not required by law, but may be required by the attending physician or by hospital policy. Confirmatory tests include:

• EEG
  An EEG should not be obtained to confirm brain death unless the clinical criteria for the diagnosis have already been met.
• Cerebral Flow Studies
  Absence of cerebral circulation is diagnostic of brain death. Cerebral flow studies should be considered when there is a possibility of drug effect or uncertainty regarding the nature of the intracranial lesion. Again, this is for confirmatory purposes and is not a required procedure for the determination of brain death.

After the pronouncement of death, the respirator and all other supportive measures are continued, to allow optimum perfusion of the organs until the organ procurement is completed.
   
Report on National Consensus Conference on Donation After Cardiac Death (PDF)

OPTIMAL REFERRAL AND FAMILY REQUEST PROCESS FORORGAN AND TISSUE DONATION FOLLOWING CARDIAC DEATH  

Support Family/Answer Questions	Patient admitted with a severe, nonrecoverable, neurological injury Transplant Network notified...(as above) No mention of organ donation Attending physician informs family that patient has a severe, nonrecoverable, neurological injury or system failure with ventilator dependence Hospital staff provides family with support and answers their questions
Referral to Transplant Network 1(800)55-DONOR	Bedside nurse refers patient to the Transplant Network at 1-800-553-6667 as a potential organ/tissue donor A Transplant Network Coordinator will travel to the hospital and: notify attending physician of presence on unit to evaluate patient for donation suitability obtain permission from attending physician to evaluate patient's ventilatory dependence: assess patient's weaning parameters discuss with attending physician which donation options can be offered to the family Family, in consultation with the Health Care Team, makes the decision to withdraw support from the patient. No mention of organ donation
Family and Health Care Team Decide to Withdraw Support
Introduce Options of Donation to Family	Donation options should not be mentioned prior to the family making withdrawal of support decisions Attending physician/nurse introduces Transplant Network Coordinator: "This is _____, s/he often works with families in your situation to help you make some final decisions." A Transplant Network Coordinator and attending physician/nurse introduce options of organ and tissue donation to the family
Request Donation in Appropriate Setting	The Transplant Network Coordinator provides family with information about donation options in a private setting Family is given time to consider donation options and make an informed decision. Any decision the family makes will be supported.
Support Family/ Answer Questions	A Transplant Network Coordinator and hospital staff discuss next steps with the family for either: organ/tissue donation, obtain legally informed consent and medical/social history or for withdrawal of support Family is given the opportunity to spend time with their loved one prior to the withdrawal of support.

   

1. Question: How do people become organ donors?
   Answer: There are living donors and deceased donors. A living donor may donate one of a set of paired organs (such as a kidney) or a portion of an organ (example: liver) to a family member or close friend. Naturally, living donors retain ample organ function and continue to live normally.
   
   Deceased donors and/or their families have consented to organ donation. These patients must be artificially supported in an intensive care unit where death is determined either by a loss of all brain function (so-called "brain death") or by absence of a heartbeat.
    
2. Question: What is organ donation after cardiac death?
   Answer: An organ donor after cardiac death is a donor of organs after death is determined by an absence of heartbeat. These patients have severe terminal brain injuries but have not progressed to brain death. Patients must meet certain medical criteria and families must have already decided to discontinue medical support. Support is withdrawn in the operating room, the patient is declared cardiac dead, and organs are recovered.
   
   In contrast, most organ donation in the U.S. occurs after the determination of death by the absence of brain function, that is, after an individual is declared brain dead.
   
   Patients who are brain dead have cardiorespiratory function maintained artificially by a mechanical ventilator. Organs continue to function because the circulation of oxygenated blood is continued artificially.
   
   In either circumstance, whether declared dead by an absence of brain function (brain dead), or declared dead by the absence of heartbeat (donation after cardiac death), organs may be recovered for transplantation after death, if the family gives permission for donation.
    
3. Question: Is organ donation after cardiac death a new procedure?
   Answer: No. Although this issue has recently captured media attention, this is not a new procedure. Until the concept of death by absence of brain function (brain death), was accepted by society in the 1970's the only opportunity for organ donation was to recover organs for transplantation after cardiac death.
   
   However, the clear majority of deceased donations are from donors who are determined to be brain dead.
   
   Of the 5,983 deceased donors in the U.S. in 2000, only 114 (2%) were donors after cardiac death.
    
4. Question: Why would a hospital wish to offer organ donation after cardiac death?
   Answer: Organ donation after cardiac death gives individuals and families who wish to donate an opportunity to make an anatomical gift. In other words, their wishes regarding donation can be fulfilled.
    
5. Question: Are organs ever removed before a patient is dead?
   Answer: No. All deceased organ donors have been declared dead either by brain death criteria or cardiorespiratory criteria. Surgical recovery of organs occurs only after declaration of death and with explicit informed consent of the donor and/or donor's family.
    
6. Question: Who makes treatment decisions, including a decision to withdraw artificial support, on patients who will become donors?
   Answer: Patients and their families, in collaboration with their health care providers, decide if and when to withdraw artificial support. Decisions to withdraw artificial support are made independent of whether or not the person becomes a donor. The California Transplant Donor Network is never involved in decisions to withdraw treatment.
   
   There is a deliberate and clear separation between the medical team that treats the patient until death and the organ recovery team that removes and preserves the organs after death. The California Transplant Donor Network and the organ recovery team do not make medical decisions for patients prior to death.
    
7. Question: Who is involved in the declaration of death?
   Answer: Death is declared by doctors not affiliated with organ recovery or transplantation. The hospital physicians are not involved with organ recovery or transplant, and are responsible for determining when death has occurred and making the official declaration of death.

  Tissue banks are separate entities from the California Transplant Donor Network although all organizations work to support family decisions regarding donation. Each hospital has the responsibility of referring all hospital deaths to CTDN. Below is a description of the steps that normally take place from the donor referral through recovery and follow up.

The hospital staff identifies the potential donor (all deaths) and calls the California Transplant Donor Network (CTDN) at 1-800-55-DONOR. If the potential donor is a candidate for organ donation (heart beating) a Transplant Coordinator from CTDN will evaluate the case, go to the hospital, and to talk with the family about donation.

If the patient is already cardiac dead (no heartbeat), the call will be referred to the Tissue Bank Coordinator (TBC). The TBC will contact the hospital staff person familiar with the potential donor to obtain further information and determine medical suitability. If the potential donor is medically suitable the TBC will request the name and phone number of the next of kin.

Prior to contacting the next of kin, the TBC will call the Medical Examiner/Coroner to obtain permission to proceed with tissue donation and any special instructions. If consent has been obtained from the next of kin and the additional medical/social history is acceptable, the TBC calls the responsible hospital staff to arrange for a tissue recovery time. When multi-tissue donation is planned, the use of an operating room may be requested. However, the tissue recovery usually takes place in the morgue, the funeral home or the Coroner's office. The other possibility is that the tissue recovery follows the recovery of organs in the operating room.

For a multi-tissue donor, a team of technicians will perform the tissue recovery. The team provides all of their own sterile surgical supplies and materials. The surgical recovery time for a multi-tissue donor, including reconstruction and clean-up, averages four to five hours. (This recovery is done after organ recovery if the patient was also an organ donor.) The Tissue Bank team will coordinate transportation of the body to the morgue and will notify the funeral home and the Coroner, if necessary, at the end of the case. Any paperwork required by the hospital or other agencies will also be completed. The Tissue Bank bears the responsibility for any charges related to the tissue donation, including operating room charges if applicable.

Following tissue recovery, thank you letters are sent to the donor family and the hospital staff who participated in the referral. Basic recipient information is given in the case of corneal donors. Other tissues may remain in quarantine for up to three months, pending further testing and processing.

Transplantable Tissues
• Heart Valves
• Corneas/Sclera
• Bone Grafts
• Connective Tissue
• Middle Ear Tissues
• Skin Grafts
• Saphenous/Femoral Veins
    Management Guidelines (PDF)
    Goal of Organ Donation Breakthrough Collaborative
"Committed to saving or enhancing thousands of lives a year by spreading known best practices to the nation's largest hospitals, to achieve organ donation rates of 75% or higher in these hospitals." Health and Human Services Secretary Tommy Thompson & Key National Leaders

What is the collaborative?
200 hospitals have been identified as having the most organ donor potential in the United States. Within these 200 hospitals 14 hospitals have already achieved donation rates of 75% or better. Hospitals were invited by their OPO to join the collaborative to collectively share best practices. This project strives to increase donation rates within these hospitals to 75%, thereby saving hundreds more people through organ transplantation. Our goal at the Transplant Network is to take what we learn through this process and spread the changes throughout our service area.

FOCUS:

• Create/Enhance the Culture of Accountability for results within the Hospital
• Make the donation process a part of the everyday hospital culture
• Become "part" of the hospital instead of "from the outside"
• Hospital makes suggestions for changes instead of OPO "telling them what to do"
• "Success" is increasing conversion rates
• Tailor the interventions to the hospital identified needs.

HOW (four over arching strategies):

• Unrelenting focus on change, improvement and results
• Rapid, early referral and linkage
• Integrated donation process management
• Aggressive pursuit of every donation opportunity

For more information:
http://www.organdonationnow.org
First things First (PDF)
Breakthrough Collaborative: Best Practices Final report (PDF)
    Hospitals may and should disclose Private Health Information (PHI) to CTDN (privacy rule 45 CFR 164.512)

A covered entity (hospital) may use or disclose PHI to OPO's or other entities engaged in the procurement, banking or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.

Procurement and banking activities are not considered health care and the organizations that perform such activities are not considered health care providers for the purposes of this rule.
     
Brain Death
Legislation
Organ Donation
Tissue Donation
  California Brain Death Statute
In 1974, the California legislature passed laws addressing brain death:

(AB 3560 and HSC 7180) Determination of Death - A person shall be pronounced dead if it is determined by a physician that the person has suffered a total and irreversible cessation of brain function. There shall be independent confirmation of the death by another licensed physician. Such physicians may not participate in or have any contingent interest in organ transplantation that may follow. Likewise, members of the transplant team cannot be involved in the diagnosis of brain death.

Guidelines for Determination of Brain Death
The following guidelines are offered to assist the physician in determining brain death. Currently, accepted clinical criteria for determination of brain death include:

• Total unresponsiveness
• Pupils are fixed and dilated.
• Absence of corneal reflexes and ocular movement.
• No gag or cough reflex.
• No spontaneous movements, response to painful stimuli, or posturing.
• Occasionally, spinal reflexes may remain intact. However, this does not contraindicate brain death criteria.
• Absence of spontaneous respirations.
• Exclusions:
  The diagnosis of brain death depends upon the exclusion of two conditions: hypothermia (temperature below 90 degrees Fahrenheit) and central nervous system depressants such as barbiturates.

Brain death is a clinical diagnosis. Although brain death can be established by clinical criteria alone, confirmatory tests may be used to support the clinical diagnosis. These studies are not required by law, but may be required by the attending physician or by hospital policy. Confirmatory tests include:

• EEG
  An EEG should not be obtained to confirm brain death unless the clinical criteria for the diagnosis have already been met.
• Cerebral Flow Studies
  Absence of cerebral circulation is diagnostic of brain death. Cerebral flow studies should be considered when there is a possibility of drug effect or uncertainty regarding the nature of the intracranial lesion. Again, this is for confirmatory purposes and is not a required procedure for the determination of brain death.

After the pronouncement of death, the respirator and all other supportive measures are continued, to allow optimum perfusion of the organs until the organ procurement is completed
    California Health and Safety Code 7150 (PDF)
California Health and Safety Code 7155.7 (PDF)
California Health and Safety Code 7180/7181/7182 (PDF)
    DONOR IDENTIFICATION
Potential organ donors are previously healthy individuals who have suffered irreversible brain death. {Patients with catastrophic brain insults who do not meet Brain Death criteria may be considered for organ donation after cardiac death (arrest).} The following are examples of fatalities which commonly result in an acceptable organ donor:

• Head trauma -- car accidents, gunshot wounds, blunt head trauma
   
• Cerebral vascular accidents -- subarachnoid or intracerebral hemorrhage
   
• Primary brain tumors
   
• Cerebral anoxia -- drug overdose, aspiration, cardiac resuscitation, smoke inhalation, drowning, hanging

The recovery of vital organs which include heart, heart-lung, lungs, kidneys, liver, pancreas and small bowel requires a donor with an intact heartbeat and effective perfusion and oxygenation. The recovery of tissues which include eyes, bone, skin, cartilage, heart valves and veins does not require a heart beating donor. A patient that is dead on arrival (DOA) can be an acceptable tissue donor.

The California Transplant Donor Network encourages health professionals to refer all potential donors. Each donor will be evaluated on an individual basis as to his/her acceptability.
    Tissue banks are separate entities from the California Transplant Donor Network although all organizations work to support family decisions regarding donation. Each hospital has the responsibility of referring all hospital deaths to CTDN. Below is a description of the steps that normally take place from the donor referral through recovery and follow up.

The hospital staff identifies the potential donor (all deaths) and calls the California Transplant Donor Network (CTDN) at 1-800-55-DONOR. If the potential donor is a candidate for organ donation (heart beating) a Transplant Coordinator from CTDN will evaluate the case, go to the hospital, and to talk with the family about donation.

If the patient is already cardiac dead (no heartbeat), the call will be referred to the Tissue Bank Coordinator (TBC). The TBC will contact the hospital staff person familiar with the potential donor to obtain further information and determine medical suitability. If the potential donor is medically suitable the TBC will request the name and phone number of the next of kin.

Prior to contacting the next of kin, the TBC will call the Medical Examiner/Coroner to obtain permission to proceed with tissue donation and any special instructions. If consent has been obtained from the next of kin and the additional medical/social history is acceptable, the TBC calls the responsible hospital staff to arrange for a tissue recovery time. When multi-tissue donation is planned, the use of an operating room may be requested. However, the tissue recovery usually takes place in the morgue, the funeral home or the Coroner's office. The other possibility is that the tissue recovery follows the recovery of organs in the operating room.

For a multi-tissue donor, a team of technicians will perform the tissue recovery. The team provides all of their own sterile surgical supplies and materials. The surgical recovery time for a multi-tissue donor, including reconstruction and clean-up, averages four to five hours. (This recovery is done after organ recovery if the patient was also an organ donor.) The Tissue Bank team will coordinate transportation of the body to the morgue and will notify the funeral home and the Coroner, if necessary, at the end of the case. Any paperwork required by the hospital or other agencies will also be completed. The Tissue Bank bears the responsibility for any charges related to the tissue donation, including operating room charges if applicable.

Following tissue recovery, thank you letters are sent to the donor family and the hospital staff who participated in the referral. Basic recipient information is given in the case of corneal donors. Other tissues may remain in quarantine for up to three months, pending further testing and processing.

Transplantable Tissues
• Heart Valves
• Corneas/Sclera
• Bone Grafts
• Connective Tissue
• Middle Ear Tissues
• Skin Grafts
• Saphenous/Femoral Veins
     
General MOU (PDF)
JCAHO Standard LD1 (PDF)
JCAHO White Paper on Organ Donation (PDF)
     
CTDN APHA Abstract(PDF)
Joint APHA Abstract(PDF)
The Growing Use of Donation After Cardiac Death Donors: An Expert Interview With Howard M. Nathan (PDF)
Success in Reapproaching Families(PDF)
Bridging The Gap Between Family And Requestor (NATCO) (PDF)
Bridging The Gap Between Family And Requestor (AOPO) (PDF)
Coroner Roles In Transplantation (PDF)
The Medical Examiner's Role in Organ and Tissue Recovery (PDF)
The Diagnosis of Brain Death (PDF)
Does my Religion Approve of Organ Donation (PDF)
Needs of Families of Patients with Severe Brain Injury (PDF)
Nursing is Key to Successful Request for Organ Donation (PDF)
Message from HHS Secretary Tommy Thompson (PDF)
Recommendations of ACOT (PDF)