The donation process begins one of two ways. You can make a decision while you are alive by registering to be an organ, eye and tissue donor or your family will decide for you if donation becomes an option.
Medical professionals do everything possible to save a patient’s life.
The Organ Procurement Organization (OPO)
In 1984, the National Organ Transplant Act (NOTA) was signed into law creating the National Organ Procurement and Transplantation Network (OPTN) for matching donor organs to waiting recipients. The OPTN includes all OPOs and transplant centers and is managed by the United Network for Organ Sharing (UNOS). The OPTN standardized the process through which organs are donated and shared across the country.
Organ procurement organizations (OPOs) are nonprofit, government-certified agencies that facilitate organ donation. Many also facilitate tissue and eye recovery services. OPOs operate in designated service areas; these service areas may cover whole states or just parts of a state. Carolina Donor Services is the largest OPO that serves the state of NC. Carolina Donor Services serves 7.2 million people in 77 counties of North Carolina and Danville, Virginia.
OPOs are the link between the organ donor, transplant center and the recipient. When organs are donated, the OPO in that area attempts to place the organs with the best recipients following a list through the UNOS database. Organs are matched with potential recipients based on blood type, medical urgency, geographical location and time waiting on the list.
Highly specialized clinical specialists provide these major services:
- Assist hospitals with procedures and education on donation
- Receive all organ and tissue donor referrals
- Evaluate potential donors for organ, tissue, and eye suitability
- Discuss authorization for donation with families
- Medically manage the donor for organ preservation
- Coordinate surgical organ and tissue recovery
- Allocate organs
- Arrange transportation of organs to transplant centers
- Assist with importing/procuring of organs from outside of the service area (another state)
- Provide professional education for nurses, physicians and other healthcare professionals
- Provide public education to increase public awareness of the need for organ donation
- Provide public policy advice and assist in public policy formulation
- OPO personnel are available 24 hours a day, 365 days a year to assist physicians, nurses and families as needed.
The Referral Process
It is important to know that there are national standards and both federal and local laws that govern how and when a medical professional can make an official determination of death. Hospitals and emergency medical professionals will make every effort to save a patient’s life regardless of their status as a registered donor. Federal regulations require hospitals to notify their organ procurement organization (OPO) of all patients who have died or whose death is imminent. OPO staff review the potential donor’s medical condition and history to determine his or her eligibility for donation. The OPO will typically search the donor registry to determine if the patient is a registered donor. The OPO and hospital staff collaborate to ensure the family is cared for and offered the appropriate donation options.
Two Types of Deceased Organ Donation
There are two sets of criteria which can be used to determine when a patient has clinically and legally died: death determined using circulatory criteria and death determined using neurologic criteria. When talking about organ and tissue donation we refer to death as either Circulatory Death or Brain Death.
Donation after Circulatory Death
Donation after Circulatory Death (DCD) is organ donation from a patient who has died by means of cardiac arrest. These patients are ventilator-dependent to live but are not brain dead. Once the heart has stopped beating and the patient is no longer breathing, the patient is declared dead by a medical professional not affiliated with organ transplantation. The organ donation process takes place soon after death is declared. If cardiac arrest doesn’t happen in a certain amount of time, donation doesn’t take place.
DCD donation increases the number of organs available for transplant and is a source of donation that can help to alleviate the shortage of organs. It also allows more people who wish to donate the ability to do so. DCD donors most often donate kidneys and, in less common circumstances, liver, pancreas, lungs and heart.
Donation after Brain Death
Brain death is rare and occurs in approximately 1 out of every 100 hospital deaths. Brain death is the irreversible and complete cessation of all brain function including the brain stem. Brain death is final and finite; it is not the same thing as being in a coma or persistent vegetative state. It is clinical and legal death. With brain death, no blood is flowing through the brain or brain stem and the patient has stopped responding to outside stimuli. An extensive, controlled clinical exam is performed to determine brain death. A physician carefully reviews the medical history and performs a series of physical exams and tests to determine if the brain is no longer working. The standard tests for brain death show if the person:
- Cannot breathe without the ventilator
- Has no pupil response to light
- Has no response to pain
- Has no gag or cough reflexes
The ventilator provides oxygen to the organs keeping the organs viable until the organs are donated.
Brain death can be confusing:
A brain dead person on a ventilator can feel warm to the touch and can look "alive". The heart is still beating and it may seem that the patient is breathing, but a brain dead patient cannot breathe, the ventilator is pushing oxygen into the lungs making the person's chest rise and fall.
Are coma and brain death the same thing?
No. Coma is a decrease in brain function and there is a chance a person may regain consciousness. Brain death is the irreversible cessation of all brain function. There is no chance of recovery with brain death.
If the patient is medically eligible for organ donation, family support coordinators go to the hospital to meet with the doctors and the patient care team. They are carefully trained to work with families experiencing a wide range of emotions after a loved one’s death, and to meet with family members at the appropriate and most sensitive time to discuss donation as part of what will come next:
- If the patient has registered as a donor, through the online registry and/or the DMV registry, they explain first-person authorization and the donation process to family members, answer questions and provide additional support that the family may need.
- If the patient has not registered as a donor, they offer the option of donation to the family and request their authorization.
- If the family is not at the hospital and has no plans to come to the hospital, the Family Support Coordinator may talk with them over the phone.
They ask the family of authorized donors for current medical information about the potential donor. This review of the patient’s medical/social history involves questions much like those asked of a potential blood donor. Additionally, tests are conducted to determine which organs are suitable for transplant. Medical information about the donor is sent to the United Network for Organ Sharing (UNOS) for matching with potential recipients.
All potential tissue donor families are approached over the phone, during which time an authorization and current medical/social history questionnaire is completed.
Organ donor management is a complex and highly-specialized area of health care. The process begins with an Organ Donation Coordinator’s evaluation of a potential organ donor, assessing function of all organs and insuring medical suitability.
Improving organ function to maximize the gift of transplantable organs is vital. Even a single organ that is made available for transplant can save a life. This makes donor management and organ optimization of the utmost importance as staff focuses on keeping the patient stable, organs functioning and able to be transplanted.
The donor is kept on ventilation while all necessary tests and procedures are completed which may include electrolyte replacement, blood replacement, advanced imagery and diagnostic procedures. Once all procedures and medications necessary to assist with organ function are completed, medical management of the donor is continued while the donor is scheduled for surgery to recover organs.
Under contract with the U.S. Department of Health and Human Services’ Health Services & Resources Administration (HRSA), the United Network for Organ Sharing (UNOS) maintains a centralized computer network called UNet. Transplant professionals can access this computer network 24 hours a day, seven days a week. Generally, organs are offered first to the sickest patients within the same region. If there are no eligible recipients in that region, the organs will be offered to candidates in other regions. UNet electronically links all transplant hospitals and organ procurement organizations in a secure, real-time environment.
Matching Donated Organs with Transplant Candidates
When a deceased organ donor is identified, an organ donor coordinator from an OPO accesses the UNet system and enters all the necessary medical information about the donor. The system uses this information to match the medical characteristics of the candidates waiting with those of the donor. The system then generates a ranked list of patients who are suitable to receive each organ. This list is called a “match run.”
Factors affecting ranking may include:
- Degree of medical urgency (for heart, liver, lung and intestines)
- Tissue match
- Blood type
- Length of time on the waiting list
- Immune status
- Distance between the potential recipient and the donor
The organ is offered to the transplant center which has the first person on the list. The transplant team considers the organ for the patient. When the transplant team is offered an organ, it bases its acceptance or refusal of the organ based on the needs of the patient at the time using various medical criteria. When a patient is selected, he or she must be available, healthy enough to undergo major surgery and willing to be transplanted immediately. If the organ is refused for any reason by the patient or by the patient’s doctor, the transplant center of the next patient on the list is contacted. The process continues until the organ is accepted. Once all the organs are allocated, surgery is scheduled and the organ recovery takes place. The entire process can take up to 24- 36 hours. Following the recovery process, an open-casket funeral can be held. Organs are recovered in a dignified surgical environment and the body is carefully restored.
Tissue donation is more common than organ donation. Tissue recovery takes place at either the donor hospital or in a recovery suite at the OPO.
A single tissue donor can touch the lives of up to 50 people as the donated tissues are used in a variety of procedures that can save lives, repair limbs, relieve pain or enhance a patient’s quality of life. The following is a list of the types of tissue that can be donated along with recipient benefits.
- Heart valves may be used to replace valves that have been damaged or no longer function properly.
- Recovered veins may be used for aneurysm repair by strengthening the vessel walls. Those same veins may also be used for patch grafts during heart valve replacement surgeries. Veins may be used for multiple and repeat coronary artery bypass surgeries, to restore blood flow below the knee and as a vascular access for long-term hemodialysis patients.
- Skin may be used to treat burn patients. These grafts assist the patient in fighting off infections as well as giving the patient’s own skin time to heal. The derma skin may be used in reconstructive surgeries for women who have undergone mastectomies due to breast cancer. The skin may also be used in certain oral surgeries, gynecologic-obstetric surgeries, and orthopedic surgeries.
- Bone grafts may be used in numerous surgical procedures, such as replacement for bone deficits for victims of cancer, trauma, and other conditions, which require bone to facilitate recovery. In some cases, the graft means the difference between amputation of a limb or maintaining the ability to walk.
- Soft tissues such as tendons, ligaments, and fascia may be used for corrective knee and ankle surgeries, gynecologic-obstetric surgeries and many other reconstructive surgeries.
Once the tissue donation process is complete, the donor’s appearance is restored and prepared for transport to the funeral home. Just as in organ recovery, an open-casket funeral can be held. Tissues are recovered using dignified surgical procedures.