New Jersey Organ & Tissue Donation

Transcription

1 New Jersey Organ & Tissue Donation Contact Hours: 1.0 First Published: May 7, 2013 Course Expires: May 7, 2016 Copyright 2013 by RN.com All Rights Reserved Reproduction and distribution of these materials is prohibited without the express written authorization of RN.com

2 Acknowledgements RN.com acknowledges the valuable contributions of Nadine Salmon, MSN, BSN, IBCLC is the Clinical Content Specialist for RN.com. She is a South African trained Registered Nurse, Midwife and International Board Certified Lactation Consultant. Nadine obtained an MSN at Grand Canyon University, with an emphasis on Nursing Leadership. Her clinical background is in Labor & Delivery and Postpartum nursing, and she has also worked in Medical Surgical Nursing and Home Health. Nadine has work experience in three countries, including the United States, the United Kingdom and South Africa. She worked for the international nurse division of American Mobile Healthcare, prior to joining the Education Team at RN.com. Nadine is a nurse planner for RN.com and is responsible for all clinical aspects of course development. She updates course content to current standards, and develops new course materials for RN.com. Conflict of Interest and Commercial Support RN.com strives to present content in a fair and unbiased manner at all times, and has a full and fair disclosure policy that requires course faculty to declare any real or apparent commercial affiliation related to the content of this presentation. Note: Conflict of interest is defined by ANCC as a situation in which an individual has an opportunity to affect educational content about products or services of a commercial interest with which he/she has a financial relationship. The author of this course does not have any conflict of interest to declare. The planners of the educational activity have no conflicts of interest to disclose. There is no commercial support being used for this course.

3 New Jersey Board of Nursing CE Requirements By February 7, 2014, the New Jersey Board of Nursing will require every registered professional nurse to have completed a one hour continuing education course that covers organ and tissue donation and recovery designed to address clinical aspects of the donation and recovery process. A registered professional nurse who completed a course that included a section on organ and tissue donation and recovery during his or her initial nursing education need not complete the continuing education course required above. Purpose The purpose of this course is to educate registered nurses in the fundamental aspects of organ and tissue donation to meet the New Jersey Board of Nursing state requirement for continuing education in organ donation. Learning Objectives After successful completion of this course, you will be able to: 1. Discuss the gap between the number of organs donated and the number of people waiting for transplants. 2. Describe the organ donation process. 3. Name the various agencies involved in organ transplantation. 4. Recall the role of the transplant coordinator and the bedside nurse in organ/tissue donation. 5. Review ethical considerations in organ/tissue donation.

4 Glossary Allocation: The process of determining how organs are distributed. Allocation includes the system of policies and guidelines which ensure that organs are distributed in an equitable, ethical, and medically sound manner. Allograft: An allograft is a transplant of an organ or tissue that comes from another person of the same species. Anti-Rejection Immunosuppressive Drugs: Medications that reduce or prevent the body's ability to reject a transplanted organ or tissue. Antibody: A protein substance made by the body's immune system to attack a foreign substance. Since antibodies attack transplanted organs, transplant patients must take powerful drugs to reduce the body's attack on the transplanted organ. Antigen: A foreign substance, such as a transplanted organ or tissue that triggers the body to reject it. Brain Death: Occurs when the brain is totally and irreversibly non-functional. Brain death is caused by not enough blood supply of oxygen which causes the brain cells to die. Cadaveric Donors: Also called non-living or deceased donors, are those who donate their organs or tissue after they have died. Candidate: A patient who has been placed on the national waiting list for solid organ transplantation. Cardiac Death: Occurs when a person's heart stops and cannot be resuscitated. Just like brain death, there is no recovery from cardiac death. Cold Ischemia Time: The time an organ is without blood circulation and is kept cold, from the time the organ is removed from the donor to the time it is transplanted into the recipient. In surgery, the time between the chilling of a tissue, organ, or body part after its blood supply has been reduced or cut off and the time it is warmed by having its blood supply restored. This can occur while the organ is still in the body or after it is removed from the body if the organ is to be used for transplantation. Cross-Matching: A blood test performed before a transplant to find out if the specific donor organ to be transplanted is likely to be rejected by the prospective recipient. If the test is positive, the donor and recipient are "incompatible" and the transplant is unlikely to be performed with an organ from that donor.

5 Glossary Cyclosporine: Used as an immunosuppresive agent to suppress the body's immune response thereby preventing organ rejection. Deceased Donor: A person who has been declared dead and whose organs and/or tissues have been donated for transplantation. Designated Requestor: Defined in the Centers for Medicare and Medicaid Conditions of Participation as an individual who has completed a course offered or approved by the organ procurement organization (OPO) and designed in conjunction with the tissue and eye bank community in the methodology for approaching potential donor families and requesting organ donation. The interpretation of this rule allows for some degree of flexibility. Donation: The act of giving organ(s), tissue(s), or blood to someone else without compensation. Domino Transplant: Although it does not happen often, a domino transplant occurs when patient A needs lungs, but the best treatment is to give that patient a heart and lung combination. Since patient A's heart was good, it can be transplanted into patient B who needs only a heart. Donor Designation: Documentation of an individual s decision to donate organs, eyes, and/or tissues after death usually designated on a driver s license or through a state donor registry. Donor Registries: A confidential electronic database in which individuals can enter and store their wish to be an organ and tissue donor. Most registries are for a single state, but a few serve more than one state. Most registries have enrollment capacity through the motor vehicle offices and many also have online registry portals. Because registry information is accessible on a 24/7 basis to authorized procurement personnel, it is the safest and quickest way to determine if a deceased individual wanted to be a donor. First Person Consent Legislation: State laws ensuring legal authority to proceed with organ procurement without consent from the family based on a legal indication of the deceased's consent for donation, such as on a driver's license or other official document. Graft Survival: The length of time an organ functions successfully after being transplanted. Histocompatibility: The examination of antigens to determine if a donor organ will "match" and be compatible with a potential recipient's system. This routine test is often called tissue-typing and helps identify the most suitable recipient for a donated organ.

6 Glossary Human Leukocyte Antigens (HLA): A genetically determined series of markers (molecules) located on human white blood cells (leukocytes) and on tissues that are inherited from both biological parents. HLA matching is important for compatibility between donor and recipient. Living Donor: A person who donates an organ or tissue while alive. Lymphocytotoxic Crossmatch Test: Detects antibodies in the recipient that react with donor HLA antigens prior to transplantation. These tests are used primarily for transplant candidates to assess the suitability of a potential donor. A positive lymphocytotoxic cross-match identifies antibodies responsible for hyperacute rejection of kidney grafts and is a clear contraindication to transplantation. Match: The degree of compatibility or likeness between a donor and a recipient. Match Run: The list that is generated when an organ donor's information is entered into the national waiting list computer system to identify potential recipients. National Organ Transplant Act (NOTA): Passed by Congress in 1984, NOTA initiated the development of a national system of organ sharing and a scientific registry to collect and report transplant data. It also outlawed the sale of human organs in the United States. Organ Donation: To give an organ or a part of an organ to be transplanted into another person. Organ donation can occur with a deceased donor who can give kidneys, pancreas, liver, lungs, heart, intestinal organs, and with a live donor who can give a kidney or a portion of the liver, lung, or intestine. Organ Preservation: Methods used to maintain the quality of organs between removal from the donor and transplantation into recipient. These methods include preservation solutions, pumps, and cold storage. Preservation times can vary from 2 to 48 hours depending on the type of organ being preserved. Organ Procurement and Transplantation Network (OPTN): The Organ Procurement and Transplantation Network (OPTN) is a group of organizations that improve the effectiveness of the nation's organ procurement, donation, and transplantation system by increasing the availability of and access to donor organs for patients with end-stage organ failure. The OPTN is administered by the United Network for Organ Sharing (UNOS) under contract to the U.S. Department of Health and Human Services. Organ Procurement Organizations (OPO): Local organizations throughout the U.S. designated by the Centers for Medicare and Medicaid Services (CMS) who are responsible for increasing the number of registered donors in their service areas, and for coordinating the donation process when actual donors become available.

7 Glossary Procurement: The surgical procedure of removing an organ, corneas, or other tissue(s) from a donor. Procurement Coordinator: Staff member of the OPO, typically a nurse, paramedic or other medically trained individual who is responsible for evaluating potential donors, discussing donation with family members, medically managing the donor prior to the recovery of organs and tissues and arranging for the donation process (removal and transport of donated organs). Recipient: This is the patient receiving the donated organ or tissue. Recovery: Is the process of removing organs and tissues from the donor. Rejection (Acute and Chronic): The body's way of protecting itself against a foreign invader such as infectious germs. The body sees the transplanted organ or tissue as a foreign invader and attempts to destroy it. Acute rejection happens very quickly; chronic rejection is the slow failure of a donated organ to function. Required Request: A law passed in 1986 requiring hospitals to have a policy in place requiring all families of suitable donors to be asked to give consent to their loved one's organs and tissues to be used for transplant. This law is expected to increase the number of donated organs and tissues for transplantation by giving more people the opportunity to donate. Requester: A healthcare professional who discusses organ donation with surviving family members of a potential donor in order to obtain their consent for donation to occur. Scientific Registry of Transplant Recipients (SRTR): The purpose of the SRTR is to provide evaluation of clinical information about donors, transplant candidates and recipients, as well as patient and graft survival rates. Tissue Typing: A procedure in which the tissues of a prospective donor and recipient are tested to identify the human leukocyte antigens (HLA). Transplantation: The transfer of cells (e.g. stem cells), tissue, or organs from one person to another. Transplantation, Allogenic (Allograft): Transplantation between genetically different members of the same species (not identical twins).

8 Glossary Transplantation, Autologous: Receiving a transplant of one's own cell or tissues. This type of transplantation can be used to repair or replace damaged tissue. For example, autologous bone marrow transplantation permits the use of strong cancer therapies that can damage bone marrow. Bone marrow is removed prior to treatment and once the treatment is completed marrow that has not been affected by the therapy is transplanted back into the patient. Transplant Coordinator: A transplant center staff member responsible for managing the care and progress of potential transplant recipients before, during, and after the transplantation. Transplant Recipient: A person who has received a tissue or organ transplant. United Network for Organ Sharing (UNOS): Is a private, non-profit membership organization that coordinates the national matching system, the OPTN, under contract to the U.S. Department of Health and Human Services. Xenograft: An organ or tissue transplanted into a human from a non-human animal.

9 Introduction Organ donation is the surgical process of providing one or more organs to be used for transplantation into another person (United States Department of Health & Human Services [USDHHS], 2013). Organ donors can be deceased or living. Organ donation begins with a person who recognizes an opportunity to help others, enrolls in a state donor registry, and shares the decision to be a donor with family members and friends. The culmination of the process occurs when the person donates an organ and saves or enhances the lives of as many as eight people who need an organ transplant (USDDHS, 2013). The Shortage of Organs and Tissues Although 95% of the national U.S. population indicates support for donation, a far smaller percentage actually makes the decision to be organ and tissue donors. As a result of this, more than 74,186 people nationally have died waiting for organ or tissue transplantation. Since 1997, 2,470 New Jersey residents have died because life-saving organs were not available to them for transplant (New Jersey Legislature, 2008). Organ donations may include liver, kidney, pancreas, heart, lung, and intestine. Tissue donations may include bone, tendons, cartilage, ligaments, skin, corneas, and heart valves. One tissue donor can enhance the lives of more than 50 people (USDHHS, 2013).

10 Demand versus Supply The need for organs far exceeds the availability of donated organs. According to the USDHHS (2013), there are currently more than 116,500 candidates waiting for an organ donation. The demand for kidneys is especially high due to medical advances in dialysis. An additional limitation in supply is the fact that tissue donation must be initiated within 24 hours of death. Unlike organs, tissue can be processed and stored for an extended period of time for use in severe burn treatment, ligament repair, bone replacement, and other reconstructive procedures. The Problem of Organ Donation in New Jersey New Jersey lags behind most other states in terms of organ donors. Although more than 42% of U.S. drivers are registered organ donors, only 31% of New Jersey drivers are registered, ranking it 41 out of 50 states (New Jersey News, 2012). The state of New Jersey moved to digital licenses a few years ago, which helped increase the numbers of registered organ donors, but state officials still hope to raise New Jersey s ranking. Other changes to the state s Motor Vehicle Commission s website make it easier for drivers to register. Identifying Potential Donors Beginning five years after the effective date of 2008, no New Jersey driver s license or personal identification card will be issued or renewed unless the applicant first addresses the issue of organ donation. This does not apply to applicants for provisional licenses or personal identification cards who are under the age of 18.

11 NJ Life Registry The portal will require a resident who has not registered as an organ donor, and who seeks a driver s license or identification card, to either register as an organ donor through the Donate Life NJ Registry or review information about the life-saving potential of organ and tissue donation. Did You Know? You may express your wish to donate your organs and tissues for transplant by designating the words "Organ Donor" to appear on your NJ driver license or non-driver identification card. This designation is for individuals 18 or older. Test Yourself The state of New Jersey has tried to increase organ and tissue donations is by: A. Simplifying the donor registration process when applying for or renewing a New Jersey driving license. B. Mandating NJ drivers to either register as an organ donor through the Donate Life NJ Registry or review information about the life-saving potential of organ and tissue donation. C. Both of the above. All of the above are correct. The state of New Jersey moved to digital licenses a few years ago, which helped increase the numbers of registered organ donors, but state officials are still hoping to raise New Jersey s ranking. Other changes to the state s Motor Vehicle Commission s website make it easier for drivers to register. Beginning five years after the effective date of 2008, no New Jersey driver s license or personal identification card will be issued or renewed unless the applicant first addresses the issue of organ donation. This does not apply to applicants for provisional licenses or personal identification cards who are under the age of 18. The portal will require a resident who has not registered as an organ donor, and who seeks a driver s license or identification card, to either register as an organ donor through the Donate Life NJ Registry or review information about the life-saving potential of organ and tissue donation.

12 The Organ Donation Process: The Donor The process of donation begins when a person indicates their consent to be a donor by enrolling in their state's donor registry. Most often this happens when obtaining or renewing a driver's license. Most people also inform their family they want to be a donor so their family member can support their decision when needed. Signing up to be a donor usually takes place many years before donation becomes a possibility. At some point in time, a potential donor may be admitted to a hospital because of illness or accident. Most donors are victims of severe head trauma, a brain aneurysm, or stroke. If all possible lifesaving efforts fail, a physician will determine if brain death has occurred. This is usually done by a neurosurgeon or neurologist in compliance with accepted medical practice and state law. The certification of death must be made by an attending physician who is in no way affiliated with the organ procurement organization (OPO). In compliance with federal regulations, a hospital notifies its local OPO of every patient that has died or is nearing death. The hospital provides the OPO with information about the deceased to confirm his or her potential to be a donor. If the patient is a potential candidate for donation, an OPO representative immediately travels to the hospital. The OPO representative will also search the state's donor registry to see if the deceased had enrolled as a donor. If so, that will serve as legal consent. If the deceased had not registered and there was no other legal consent for donation such as a driver's license indicator, the OPO will seek consent from the next of kin. When consent is obtained, medical evaluation will continue, including obtaining the deceased's complete medical and social history from the family.

13 Test Yourself All hospitals are required to notify the local organ procurement organization (OPO) of every patient that has died or is nearing death, and provide the OPO with information about the deceased to confirm his or her potential to be a donor. Is this a violation of HIPAA Privacy Rules? A. Yes B. No The correct answer is no. The Privacy Rule allows covered health care providers to share protected health information for treatment purposes without patient authorization, as long as they use reasonable safeguards when doing so (USDHHS, 2013b). Suitability to Donate as a Living Donor Each potential living donor is evaluated to determine suitability to donate. The evaluation includes both the possible psychological response and physical response to the donation process. This is done to ensure that no adverse outcome, physical, psychological, or emotional, will occur before, during, or following the donation. The decision to be a living donor must be weighed carefully as to the benefits versus the risks for both the donor and the recipient. Often, the recipient has very little risk because the transplant will be life saving. However, the healthy donor does face the risk of an unnecessary major surgical procedure and recovery.

14 Living Donors: Additional Risks Living donors may also face other risks. For example, a small percentage of patients have had problems maintaining life, disability, or medical insurance coverage at the same level and rate as previously. And, there can be financial concerns due to possible delays in returning to work because of unforeseen medical problems. Note! Generally, living donors should be physically fit, in good health, between the ages of 18 and 60, and should not have or have had diabetes, cancer, high blood pressure, kidney disease, or heart disease (USDHHS, 2013). The Decision to Donate The decision to be a living donor is a very personal one and the potential donor must consider the possibility of adverse health effects that could follow donation. In some cases, the decision also may take into consideration the lifesaving potential for a loved one who may be the transplant recipient. Because all of the effects, especially the long term effects, to the donor are not known at this time, the Federal government does not actively encourage anyone to be a living donor. The Federal government does recognize the wonderful benefit that this gift of life provides to the patient awaiting a transplant and has several ongoing programs to study, support, and protect the living donors who do choose to provide this gift.

15 Matching Donors with Recipients If the deceased's evaluation does not rule out donation, the OPO contacts the Organ Procurement and Transplantation Network (OPTN) to begin the search for matching recipients. The OPTN operates the national database of all patients in the U.S. waiting for a transplant. It is operated by the United Network for Organ Sharing (UNOS) under contract to the U.S. Department of Health and Human Services. Characteristics to Match A computer program matches donor organs with recipients based on certain characteristics. These include blood type, tissue type, height, and weight. The length of time the patient has been waiting, the severity of the patient's illness, and the distance between the donor's and the recipient's hospitals also figure into who is the best match for a specific organ. The list does not reference race, gender, income, or social status. The OPTN computer system stores the matching information for all waiting patients and the OPO representative enters the same information for the donor. Finding a Match A list of patients (by organ type) who match the donor is generated. Each organ is offered to the first patient on the computer match list. The transplant surgeon may determine that the organ is medically suitable for that patient or may refuse the organ for a number of reasons, such as if the patient is too sick to be transplanted or the patient cannot be reached in time.

16 Most organs (75%) go to local patients. The others are shared with patients in other regions of the country. Other Agencies Involved in the Organ Transplantation Process Other important organizations involved in the organ transplantation process include: United Network for Organ Sharing (UNOS): This agency is a private, non-profit organization that manages the U.S. transplant system under contract with the federal government. This organization manages the national transplant waiting list to match donors and recipients on a 24/7, 365-day basis, maintains a nation-wide database containing all organ transplant data for all transplants occurring in the United States, and monitors all organ matches to ensure organ allocation policies are followed. The agency also provides assistance to patients and families, educates for transplant professionals regarding their roles in the transplantation process, and educates the public on the importance of organ donation. Organ Procurement and Transplantation Network (OPTN): This network is a non-profit, private-sector entity whose members include all U.S. transplant centers, all organ procurement organizations, all histocompatibility laboratories, medical and scientific organizations, and members of the general public. The OPTN is governed by a Board of Directors and is operated by UNOS. Transplant Centers: Numbering more than 250 across the United States, transplant centers are entities within hospital facilities that operate organ transplant programs. They must be members of the OPTN and must meet strict professional standards. Histocompatibility Laboratories: As members of the OPTN, these labs are certified to perform human leukocyte antigen (HLA) typing to determine the compatibility between a donor's organ or tissue and that of a recipient. Histocompatibility antigens are genetically determined antigens found on the cell membranes of the cells of most tissues. These antigens are responsible for the processes of tissue rejection when organs or tissues from a different individual are grafted to a host recipient. Medical and Scientific Organizations: Also members of the OPTN, medical and scientific organizations include such agencies as the Eye Bank Association of America and the American Society of Transplant Surgeons.

17 Test Yourself The name of the organization that operates the national database of all patients in the U.S. waiting for a transplant is the: A. Organ Procurement Organization (OPO) B. United States National Transplant Organization (USNTO) C. Organ Procurement and Transplantation Network (OPTN) The correct answer is the Organ Procurement and Transplantation Network (OPTN). The OPTN operates the national database of all patients in the U.S. waiting for a transplant. It is operated by the United Network for Organ Sharing (UNOS) under contract to the U.S. Department of Health and Human Services. Maintaining the Donor At the hospital, the donor is maintained on artificial support and the condition of each organ is carefully monitored by the hospital medical staff and the OPO procurement coordinator. The OPO representative arranges the arrival and departure times of the transplant surgical teams. After the surgical team arrives, the donor is taken to the operating room where organs and tissues are recovered in the same sterile and careful way as in any surgery. Tissue recoveries such as bone, cornea, and skin occur after organ recoveries. All incisions are surgically closed and usually do not interfere with open-casket funerals. Time is of the essence. Organs must be transplanted very quickly as they can remain healthy only for short periods of time after removal from the donor. The OPO representative makes arrangements for the organs to get to the hospitals of the intended recipients.

18 The Organ Donation Process: The Recipient End-stage organ failure is the most common diagnosis for those awaiting an organ transplant. A patient with end-stage organ failure must receive a referral from the attending physician in order to be evaluated by a transplant program as a potential transplant candidate. The patient should then be encouraged to do as much research as possible to find a transplant hospital that meets their needs based on location, compatibility with insurance programs, financial arrangements, and support group availability. Once a transplant hospital of choice is selected, the patient can schedule an appointment for an evaluation. Creating a National Waiting List If the transplant team members determine that the patient is a suitable transplant candidate, they will add them to the OPTN national list of all people waiting for a transplant. The transplant team will contact the patient in writing about ten days after listing to inform the patient of the date and time that their name was added to the national list.

19 Note! A useful resource for transplant recipients is a free handbook, entitled "Partnering with Your Transplant Team." This handbook is available from the Health Resources and Services Administration (HRSA) and provides wait-listed patients, recipients, and their families a sound overview of the transplant system and suggestions for how to navigate it. Copies are available in English and Spanish and are free of charge. Obtain your copy from the HRSA Information Center: askHRSA or Waiting for a Donor Organ Waiting for a donor organ can be an extremely stressful time for the patient. However, there are several things the patient can be encouraged to focus on during the waiting time to best prepare for transplantation: 1. Financial planning: Transplantation involves costs before, during, and after the actual transplant surgery. Costs include laboratory tests, organ procurement, transplant surgeons and other operating room personnel, in-hospital stays, transportation to and from the transplant hospital for surgery and for checkups, rehabilitation, including physical or occupational therapy, and medications, including immunosuppressive or anti-rejection drugs which may cost up to $2,500 per month. The average cost of transplantation in 2008 ranged from $259,000 for a single kidney to over $1,200,000 for a heart-lung transplant (USDHHS, 2008). Health insurance may cover some or most of the costs, but insurance policies vary widely. 2. Taking care of their health: Patients should try to stay as healthy as possible by keeping scheduled appointments with physicians, following dietary and exercise guidelines and ensuring availability and transportation when contacted by the transplant coordinator. Organ Median National Waiting Time Organ Time (Days) Heart 113 Lungs 141 Liver 361 Kidney 1,219 Pancreas 260 Intestines 159 USDHHS (2013)

20 Contact Between Donors and Recipients Sometimes organ recipients want to thank the family of their donor. Sometimes donor families want to check on the health and well-being of the person who received an organ from their loved one. The possibility of this human contact lifts the process of donation and transplantation above the mechanics of medicine and surgery and makes it a true sharing of life, gratitude, and love. Transplant centers and OPOs are required by law to protect the confidentiality of donors and recipients. However, they can arrange for contact between the families when both sides agree. The process usually begins with a letter from the recipient to the donor family, sent in care of the transplant center. Organ and Tissue Donations from Living Donors While most solid organ and tissue donations occur after the donor has died, some organs and tissues can be donated while the donor is alive. The first successful transplant in the U.S. was

21 made possible by a living donor and took place in 1954, when one twin donated a kidney to his identical twin brother. As a result of the growing need for organs for transplantation, living donation has increased as an alternative to deceased donation, and about 6,000 living donations take place each year (USDHHS, 2013). Most living donations happen among family members or between close friends. Some living donations take place between people unknown to each other. Organs and Tissues for Donation Kidneys: Living individuals can donate one of the two kidneys and the remaining kidney provides the necessary function needed to remove waste from the body. Single kidney donation is the most frequent living donor procedure. Liver: A living donor can donate one of two lobes of their liver. This is possible because, just as skin cells grow new skin, liver cells in the remaining lobe of the liver grow or regenerate until the liver is almost its original size. This re-growth of the liver occurs in a short period of time in both the liver donor and liver recipient. Lungs: It is also possible for living donors to donate a lung or part of a lung. Although lungs do not regenerate, both the donated portion of the organ and the portion remaining with the donor are fully functioning. Heart: Surprisingly, it is also possible for a living person to donate a heart, but only if he or she is receiving a replacement heart. This occurs only when it is determined that someone with severe lung disease and a normally functioning heart would have a greater chance of survival if he or she received a combined heart and lung transplant. As a result, the heart-lung recipient's own heart, if it is in good condition, is then donated to an individual who needs only a heart transplant. Tissues: Tissues donated by living donors may include skin, bone, blood, marrow, blood stem cells, amnion, and umbilical cord blood. The amnion is donated after childbirth, skin can be donated after certain surgeries, such as abdominoplasties, and bone after knee and hip replacements. A healthy body can easily replace some tissues such as blood or bone marrow.

22 Types of Transplants There are four main types of transplants that may be performed, depending on the source of the organ or tissue and the location to which it will be transplanted: 1. Allogeneic transplant (also known as allograft): Is an organ or a tissue that is transplanted from a genetically non-identical donor to a human recipient. 2. Isogeneic transplant (also known as isograft or syngraft): Is an organ or a tissue that is transplanted from one identical twin to the other identical twin. 3. Autologous transplant (also known as autograft): Is tissue that is transplanted from another site in or on the body to another site in or on the body of the same individual. 4. Xenogeneic transplant (also known as xenograft): Is an organ or tissue that is transplanted from one species (animals) to another species (man).

23 Addressing Donation Professionally The nurse plays a vital role in the organ/tissue donation process, and can greatly influence the decision to donate an organ, as the manner in which donation is discussed can influence the ultimate decision. The family is naturally distressed about the sudden loss of a loved one and must be approached with the utmost dignity, concern, and sympathy. The person who approaches the family must have an unwavering commitment to the organ donation process. To promote the highest level of professionalism, federal regulations require that the person who approaches a family must be trained. These people are known as designated requestors. The designated requestor, most often an OPO staff member, collaborates closely with the healthcare team in this process. The nurse is an important member of the team and is often the healthcare professional that is most familiar with the patient and the family. Nurses usually establish close and trusting relationships with the family, and are thus in a good position to offer support and address the issue of organ or tissue donation with the family. For this reason OPO designated requestors often partner with nurses when addressing organ donation with a family. Studies show that the average authorization rate for donation increases significantly when the family is approached by a procurement coordinator, together with a member of the healthcare team (Rodrigues et al., 2006). It is important to allow the family to express their grief and verbalize an understanding of the patient s actual condition before beginning to discuss the donation process. Note! Nurses need to participate in the authorization process and reach out to grieving families in a sensitive, compassionate and sincere manner.

24 Test Yourself When approaching a family to discuss the possibility of organ donation, it is best if: A. The nurse approaches the family in private. B. The clergy is summoned to initiate discussions. C. A joint team consisting of a designated requestor, a representative of the healthcare team, and a member of clergy initiate discussions together. The correct answer is C. OPO designated requestors often partner with nurses when addressing organ donation with a family. Studies show that the average authorization rate for donation increases significantly when the family is approached by a procurement coordinator, together with a member of the healthcare team (Rodrigues et al., 2006). The Nurse as Educator, Facilitator, and Supporter The American Nurses Association (ANA) Code of Ethics for Nurses recognizes the role for nurses in providing care across the life continuum, including the provision of supportive care to the dying patient. Nursing has a long history of providing such care in hospitals, long term care facilities, hospices, and in the home.

25 Offering the option of an organ or tissue donation to the patient or family during the final stage of life is often an important factor in coping with the impending death and loss. Since professional nurses are involved in the final stages of the patient's life, the nurse needs to be an educator, facilitator, and supporter in the organ donation process (ANA, 2013). Another vitally important role of the nurse in the organ donation process is documentation. Ensure that the family s decision to donate or decline donation is thoroughly documented in the patient s medical chart. Legal Considerations In order to increase the rate of successful organ donation, the federal government, many states and the Joint Commission (TJC) have promulgated requirements promoting the opportunity for donation (ANA, 2013). The Omnibus Reconciliation Act (OBRA) of 1986 required that all hospitals receiving funding from Medicare and Medicaid have policies in place to identify potential organ donors and to inform families of the donation process. OBRA also requires that families are asked about donation when a member dies. Legal Considerations: The Nurse s Role There should be clear guidelines addressing the nurse's role in assisting the organ procurement team in offering the option of donation to the patient and family. If a facility requires a specially trained organ donation facilitator, training as a "designated requestor should be made more available to professional nurses. There should be a recognized and active role for professional nurses in the organ donation process (ANA, 2013). Note! Be familiar with the specific organ/tissue donation Policies & Procedures in your organization. Leadership and Education Healthcare professionals are taught the skills to deal with incurable diseases and medical and surgical emergencies, but often aren't taught about organ donation after a person succumbs to

26 those injuries or diseases. Every day, healthcare professionals must make phone calls informing family members that a loved one has died. Conversely, many people in this country are waiting for the call that will save their lives; they've been matched with a donor. Healthcare professionals have the responsibility to educate bereaved family members on the process and importance of organ donation during this critical window of time. Key leadership is needed within healthcare organizations to ensure policies and procedures are implemented that align with the legal and organizational framework of organ donation on local, state, and federal levels. Agencies Involved in the Organ Transplantation Process The organ/tissue transplantation process is a complex process that involves several different agencies. One important agency involved in the organ transplantation process is the Organ Procurement Organization (OPOs). There are currently 58 organ procurement organizations (OPOs) in the United States. OPOs are responsible for increasing the number of registered donors and coordinating the donation process when actual donors become available. When donors become available, OPOs evaluate the potential donors, check the deceased s state donor registry, discuss donation with family members, contact the Organ Procurement and Transplantation Network (OPTN), run a match list, and arrange for the recovery and transport of donated organs. They also provide bereavement support for donor families and volunteer opportunities for interested individuals. OPOs must be certified by the Centers for Medicare and Medicaid Services (CMS) and abide by CMS regulations. By federal law, all OPOs must be members of the Organ Procurement and Transplantation Network (OPTN). All OPOs are members of the Association of Organ Procurement Organizations. New Jersey OPOs

27 In the state of New Jersey there are two OPOs: 1. New Jersey Organ & Tissue Sharing Network (Northern and Central New Jersey) 2. Gift of Life Donor Program (Southern New Jersey) Note! OPOs are available 24 hours a day, 365 days a year to help physicians, nurses, and other healthcare professionals involved in donation. Ethical Considerations: The Dead Donor Rule The dead donor rule is an ethical norm that states that a person must be declared legally dead before any vital organs are removed. This implies that organ procurement cannot actually cause the death of the donor. There are many ethical and legal issues revolving around the question of what actually constitutes death. Ethical Considerations: Brain and Cardiac Death Brain death is defined as total cessation of all functions of the brain including cerebral and brain stem function. Sudden cardiac death is a sudden, unexpected death caused by loss of heart function (sudden cardiac arrest). Death after cardiac arrest may also occur after a brain-injured, ventilated patient with no hope of survival is disconnected from ventilatory support. Thus a person is pronounced dead when all electrical activity of the brain irreversibly ceases (brain death), or when the heart irreversibly stops beating (cardiac death). Ethical Considerations: Supporting the Family

28 Families of patients facing end-of-life decisions are understandably emotional, confused, angry and upset. They need to feel that any decision made will be in the best interests of their loved one. The family should not be pressured into doing anything they do not feel right about. The manner in which organ donation is brought up, as well as the timing of the discussion, is critical to ensuring a positive outcome. The best time to begin discussion about donation is after all possible avenues of treatment have been exhausted and the family understands the finality of the patient s condition. Ethical Considerations The setting in which discussions about donations take place is equally important. There should be privacy and minimal external noise. The family should be approached in a calm and respectable manner by a representative of the OPO, a member of clergy, and a representative from the healthcare team. The family should be encouraged to express their grief, and be reassured that the decision they come to will be in the best interests of their loved one, and in accordance with the deceased s wishes. Donation can be viewed positively as a gift of life to others and a tribute to the memory of the deceased donor. Barriers to Donation Although most people agree in theory to organ donation, there are several barriers and misconceptions about organ and tissue donation that ultimately prevent a potential donor from actually donating his or her organs or tissues. Some reasons that a potential donor or the family of a potential donor may decide against organ donation may include: The misconception that a registered donor may not receive the same level of care as a non-donor in an end-of-life situation. Fear of pain or disfigurement during or after tissue/organ removal. Concerns of incurring financial expenses related to the organ procurement. All of these concerns need to be addressed and the family can be reassured that all patients, irrespective of donor status will always receive the same level of care, and organ procurement is usually performed post-mortem, with minimal disfigurement. All costs associated with organ donations are covered by the recipient s insurance so there are no associated financial considerations for the donor or the donor s family.

29 Religious concerns also impact a decision to donate. Most major religions encourage organ and tissue donation and participation of a religious representative (clergy, rabbi or priest) in the decision-making process may be of benefit. Healthcare professionals may also harbor personal anxieties about end-of-life issues and the concept of organ donation, which may inadvertently impact a patient or family to not consider donation. Collaboration with a professional OPO co-coordinator can facilitate communication with the family and improve the chances of them agreeing to an organ donation. Healthcare professionals should also address their own concerns about donation to ensure that personal feelings do not influence patient outcomes. Discussion about personal concerns can be appropriately addressed with a trained donation advocates. Conclusion Organ and tissue donation is a gift of life. The nurse plays a pivotal role in supporting the patient and/or the family in making the decision to donate organs. An understanding of the organ donation process and familiarity with the roles and responsibilities of the various organ donation agencies is important for the nurse to understand. Unconditional support and understanding is critical to the grieving family s wellbeing, and sensitive and compassionate care from the nurse can make the organ donation process easier and more meaningful for a family. The state of New Jersey actively supports organ donation and promotes the education of the public in organ donation.

30 Resources United States Department of Health & Human Services: The United States Department of Health & Human Services offers a wealth of information for prospective donors, recipients, and healthcare professionals. DonateLife.net: Is a not-for-profit alliance of national organizations and state teams across the United States committed to increasing organ, eye, and tissue donation. The United Network for Organ Sharing (UNOS): Is a private, non-profit organization that manages the nation's organ transplant system under contract with the federal government. UNOS is involved in many aspects of the organ transplant and donation process. Organ Procurement & Transplantation Network (OPTN): Is the unified transplant network established by the United States Congress under the National Organ Transplant Act (NOTA) of The OPTN is a unique public-private partnership that links all of the professionals involved in the donation and transplantation system. Transplantliving.org: Is a service of UNOS that provides information for organ recipients and transplant patients.

31 References American Nurses Association [ANA], (2013). Professional Nursing Practice: End-of-life Care & Organ Donation. Retrieved March 19, 2013 from: Atwood,D., Uttley, R. & Ortega, D. (2012).Organ donor considerations. Nursing Management, 43 (6), P New Jersey Legislature (2008). Senate Bill 755: New Jersey Hero Act. Retrieved from: New Jersey News (2012). N.J. hopes to boost low organ donation numbers. Retrieved March 20, 2013 from: Organ Procurement and Transplantation Network [OPTN], (2013). Transplants by donor type. Data: View data reports. Retrieved online March 20, 2013 from: Organ Procurement and Transplantation Network Web site [OPTN], (2013b). About OPTN. Retrieved online March 20, 2013 from: Rodrigues, J., Cornell, D. & Howard R. (2006). Organ donation decision: comparison of donor and non-donor families. American Journal of J Transplantation, 6(1), p United Network for Organ Sharing [UNOS], (2013). Theological perspectives on organ and tissue donation. Retrieved online from: United Network for Organ Sharing [UNOS], (2013). Donation & Transplantation. Retrieved March 20, 2013 from:

32 U.S. Department of Health and Human Services [USDHHS], (2013). Organ and tissue donation and transplantation. Retrieved March 19, 2013 from: U.S. Department of Health and Human Services [USDHHS], (2013b). HIPAA Frequently Asked Questions for Providers and other covered entities. Retrieved March 18, 2013 from: Disclaimer This publication is intended solely for the educational use of healthcare professionals taking this course, for credit, from RN.com, in accordance with RN.com terms of use. It is designed to assist healthcare professionals, including nurses, in addressing many issues associated with healthcare. The guidance provided in this publication is general in nature, and is not designed to address any specific situation. As always, in assessing and responding to specific patient care situations, healthcare professionals must use their judgment, as well as follow the policies of their organization and any applicable law. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Healthcare organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Healthcare providers, hospitals and facilities that use this publication agree to defend and indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from RN.com. Participants are advised that the accredited status of RN.com does not imply endorsement by the provider or ANCC of any products/therapeutics mentioned in this course. The information in the course is for educational purposes only. There is no off label usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN.com. The use of trade names does not indicate any preference of one trade named agent or company over another. Trade names are provided to enhance recognition of agents described in the course. Note: All dosages given are for adults unless otherwise stated. The information on medications contained in this course is not meant to be prescriptive or all-encompassing. You are encouraged to consult with physicians and pharmacists about all medication issues for your patients.