Tissue and Organ Donation

Function

Tissue and organ donation is of tremendous benefit to living patients as it functions to help the living. One individual's tissue and organ donation can impact numerous lives. While the majority of the public is in favor of organ donation, individuals often fail to include this decision in their living wills. Further, while many states allow drivers to register as organ donors on their driver licenses, few complete the required form. The consequence is a tremendous tissue and organ shortage leading to long wait times on transplant lists that in many instances result in premature deaths of viable patients that could have lived longer lives with the benefit of tissue and organ transplants.

Issues of Concern

Care during the organ donation process is multi-faceted and begins with the optimization of the donor following the determination of death using neurologic or circulatory criteria. This process means optimizing cardiopulmonary status via hemodynamic and ventilatory support. Expeditious organ/tissue procurement is the recommendation because, soon after death, inflammatory mediators begin to invade solid organs leading to increased organ immunogenicity. [6] While being cautious, from procurement to placement, every step must be done quickly and efficiently to assure the best outcomes.

Healthcare Provider and Team Role

Some health professionals have cultural, ethical, or religious beliefs that preclude their willingness to participate in the donation or receipt of tissues or organs. It is important to respect individuals' personal belief systems; however, personal beliefs should not interfere with the patient's right to self-determination. The primary commitment is to the patient and family. However, certain healthcare professionals may not wish to become involved in the organ and tissue donation process or to participate in campaigns to increase donations in their community and/or facility. This decision should be respected as a personal choice. For those that want to help, the role can be as simple as helping patients make the decision to donate prior to death.

Tissue and organ removal teams' main concerns revolve around permission, removal, and rapid transfer of organs and tissues. [1][7] Challenges often involve failure to identify eligible donors, death not officially declared within a specific timeframe, or absence of an appropriate recipient. 

Tissue and organ placement teams made concerns include the suitability of the tissue or organ, maintaining the viability of the tissue and organ, and rapid transplantation. Permission issues may stem from the denial of organ donation from a potential donor, donor’s family, or other judicial officers. [8][9]

Health professional's responsibilities in tissue and organ donation vary with their role. Some providers work with the families of donors, others with the families of recipients. Some may be responsible for performing surgery and managing the patient. In addition, there is often an administrative team that works with organ procurement organizations. While health professionals should help educate patients on the benefits of organ donation, specific responsibilities of team members include:

• Organ donation public and provider education [10]
• Organ donor identification [11]
• Coordination of tissue and organ donation
• Support of donor and recipient families which includes understanding cultural, psychological, and religious issues
• Administration management and interaction with organ procurement organizations

Individuals that would like to become involved in tissue and organ donation can do the following steps: 

1. Education by becoming familiar and involved with local organ procurement programs
2. Complete continuing education in regards to organ donation procurement and placement and provide staff and colleague education
3. Develop the skills to work with the organ procurement coordinator at your institution

Providers should be aware of the following in regards to tissue and organ procurement and placement:

• The first priority is to save the patients life, not harvest tissue or organs; organ donation is not permission to give up or withdraw care
• Most religions support tissue and organ donation
• There is no cost to the family for tissue or organ donation
• Matching of the donor to the recipient usually involves a computerized matching system that considers: recipients condition, blood type, wait time, and location; the financial situation of the recipient is not a factor

Tissue and Organ Selection and Processing

Members of the healthcare team should have a clear understanding of the issues involved in tissue and organ donation as this will improve outcomes. Organ donation starts with confirmation of clinical brain death, usually by a neurosurgeon or neurologist.  It should be remembered that a coma is not brain death. In general, this is based on accepted medical standards:

1. Irreversible cessation of brain functions, including the brain stem [12][13][14]
2. Irreversible cessation of circulatory and respiratory functions

Other considerations for death may include family or patient has signed an advanced directive to withdraw life support.

When a prospective donor is near death or has died, the organ procurement coordinator should be notified and informed of the patient's identification number, name, age, past medical history, cause or anticipated cause of death, family contact information, and any other pertinent information. the organ procurement coordinator determines if the patient is a potential donor and should arrive at the hospital within 90 minutes if the patient is a suitable candidate. All deceased patients may be considered for organ donation. The coordinator, if the patient is acceptable, will then speak with the family and gain further information.

If the evaluation rules in donation, the organ procurement coordinator will complete the following:

• Arrange for additional tests
• Arrange for social work and clergy support
• Search the state registry to determine if prior consent has been given on the patient's driver's license
• If possible, the living will of the patient will be located and evaluated. If there is no predetermined consent, the coordinator will contact the spouse, certified domestic partner, adult child, parent, adult sibling, legal guardian, or any other person authorized to make decisions.
• Until a determination of donation is finalized, the coordinator will assure the patient is maintained on artificial life support.
• The coordinator procurement coordinator contacts the medical examiner and Organ Procurement and national database Transplantation Network (OPTN) to initiate a search for potential matching recipients.
• Donor is matched with the recipient based on tissue type, blood type, weight, height, wait time, severity of illness, and distance. The system generates a matching recipient list by tissue/organ type for contact use by the coordinator.
• The first match for each tissue/organ becomes the prime transplant candidate for contact.
• The transplant surgeon makes the final decision based on recipient health, suitability of tissue or organ, and the availability of the recipient with local patients receiving preference.
• The receiving coordinator conducts consent and matching in a manner similar to organ donation.
• The donor body is placed in the morgue with saline-soaked gauze covering the eyes and is not released to the funeral home until all potential harvesting is completed.
• Recovery of tissue is performed by recovery surgeons either in the same hospital or at another location.

Tissue and Organ Recovery and Transplantation

Tissues that may be recovered and transplanted include blood vessels, bone, cartilage, corneas, heart valves, skin, and tendons. Organs that may be recovered and transplanted include the heart, intestine, kidney, liver, lung, and pancreas. Steps in the process include:

1. Appropriate consents from the family
2. Rapid scheduling of the organ recovery surgical team by the organ procurement coordinator
3. Preparation of an ice-cold preservation solution used to flush each organ removed
4. Surgical removal using standard surgical incisions in a sterile operative environment
5. Organs removed first and placed in sterile containers and packed icy slush which cools but does not freeze (kidneys are placed on a perfusion machine the pumps preservation fluid through the organ during transport)
6. Following organ removal, tissues are recovered
7. Any incisions made are surgically closed
8. Due to rapid loss of viability of organs and tissues, rapid ground or air transport is arranged by the organ procurement coordinator
9. The organ procurement coordinator contacts the funeral director for removal of the body
10. The recipient transplant team of the donor organ or tissue, as well as the recipient, is made ready to receive and complete the transplant

Non-living Donors

Following donor optimization, standard organ removal in the operating room is as follows: heart and lungs first, followed by hepatectomy, pancreatectomy, and bilateral nephrectomies. [15] Subsequent organ cooling to 4 degrees C considerably reduces warm ischemia damage to organs; however, it does not completely arrest cellular processes. Therefore, a thorough organ washout technique, along with selecting appropriate preservation solutions, is critical to organ viability leading to decreased immune reaction and formation of oxygen-free radicals upon reperfusion. [16]

Living Donors

There are two types of living tissue and organ donation.

1. Directed donation - donor names a specific tissue or organ recipient
2. Non-directed donation - donor does not name a specific tissue or organ recipient

While living donation reduces transplant wait times, it has its own set of challenges. The kidney and liver are commonly living donor donations. Less commonly intestines, lung, or pancreas segments are transplanted. 

Considerations should be given to cost and potential complications. Living donation requires informed consent due to potential complications. Some are specific to the organ donated. Complications include:

General

• Abdominal internal bleeding
• Allergic reactions to anesthesia
• Blood clots
• Blood loss
• Death
• Depression
• Infection
• Organ dysfunction
• Pain
• Pneumonia
• Wound infection

Kidney 

• Bowel obstruction
• Damaged kidney function require dialysis or transplantation
• Hernia
• Hypertension

Liver

• Bile leakage
• Bowel obstruction
• Damaged liver function requiring medical therapy or transplantation
• Hernia

Barriers and Misunderstands Concerning Tissue and Organ Donation

Health professionals should be educated in tissue and organ donation and be prepared to provide families with accurate information while dispelling misunderstandings. [17]

Barriers

There are numerous barriers to organ donation and recovery. Health professionals and institutions should provide an experienced team to make the process of tissue and organ donation as efficient as possible while minimizing the emotional impact on donor families. The team often consists of a nurse, a social worker or pastor, and a clinical provider. If the institution provides positive moral and social support, the donation for the family usually proves to be a rewarding experience.

There is a potential cost of living donation. While insurance may cover the surgery and follow-up care, any long-term complications may not necessarily be covered. Uncovered costs include lost wages, particularly if there are long-term complications of surgery. [18][19][18]

Misunderstandings

Many clinicians and families may have misunderstandings in regards to tissue and organ donation. Examples include a belief that there is an age limit, when in fact there is no age limit on organ donation. Others are concerned it may be a religious violation when in reality few religions prohibit tissue and organ donation. Others are concerned that an open casket may not be possible when this typically is not an issue. Some believe that the health of the donor may prohibit donation, in reality, few medical conditions affect tissue or organ donation. For some donor families, they believe there is a cost associated when no fees are levied. Some even believe the organs are sold, in reality, organs are matched via a computer database which does not consider the financial status of potential recipients. Patients may not agree to donate because they believe health professionals will be less apt to save them in an emergency, when in fact saving their life is the top priority, and tissue and organ donation is not considered. [17]

Clinical Significance

Following successful transplantation into a host, the mainstay of long-term care is a combination of lifelong close monitoring and appropriate immunosuppression. [20][21][22] Patients must come to realize that there will never come a time in their lives when close monitoring is no longer necessary. Additionally, clinicians must understand current standard practices in caring for these patients as well as accept upcoming innovations such as monitoring patients for donor-specific antibodies as a marker of immunologic risk. [23][24] Furthermore, non-invasive markers found in blood and urine are now beginning to replace biopsies in assessing for immunologic injury. [25][26]

Organ donation is vital to patients, yet there is a large deficiency of those willing to donate coupled with a long list of individuals needing tissue and organ donation. By becoming educated regarding the issues and concerns, hopefully, more patients will successfully be encouraged to give the gift of life.

Enhancing Healthcare Team Outcomes

For a successful tissue/organ transplantation to occur, it requires an extraordinary amount of teamwork from all aspects of the healthcare system. Preoperatively, nurses are required to provide close monitoring of hemodynamic parameters outlined in current standard practices and offer interventions as necessary. Intraoperatively, it is known that various specialties of medicine participate in the operation, requiring extensive and clear communication for surgical success. Finally, allied health professionals play a critical role in maximizing the organ recipient’s return to normal function postoperatively, leading to a happy and healthy life.

Nursing, Allied Health, and Interprofessional Team Interventions

Communication is a useful tool that is imperative to positive patient outcomes as it relates to organ transplantation. Research participants recognize that nurses are at the center of communication, seeing as they spend the most time at the bedside amongst all healthcare providers. [27] As such, they become the most powerful means of communicating compliance and good practices to patients during their life-long journey of close monitoring, which involves close screening of infections, organ rejection, and malignancies.