Currently more than 100,000 patients are on the organ transplant list in the US alone. Many patients die each year without receiving a life saving organ. Increasing organ donation rates will improve this situation and will save many lives.

One of the biggest sources for organ donation are the patients with severe traumatic brain injuries who progress to brain death. Even after the patient is pronounced brain dead there is often a delay in time until organ procurement takes palce. Obtaining consent for organ donation from the family is one of the biggest obstacles towards a successful donation.

Does it matter how soon the organs are taken after the patient is declared brain dead? Does it decrease the viability of organs and reduce the number of organs harvested if the waiting time is prolonged?

Currently there is no maximum established waiting time from the onset of brain death to when a successful donation is possible. A study published in the June issue of the Trauma Journal attempts to answer those questions. The study was conducted in Southern California.

The authors of this study found no decrease in the proportion of organ procurement with a longer waiting time. Indeed, according to this publication, a successful organ donation is possible even more than 60 hours after brain death.

Furthermore, the rate of heart and pancreas procurement increased with a longer delay after the diagnosis of brain death was made. The exact reasons for this finding are unclear. The authors suggested that many more patients were hemodynamically stable for organ procurement with a longer time delay.

These findings are supported by previous studies. It was shown that the graft viability might improve after kidney donation with a longer time allowed to pass after the brain death. Better hemodynamic status and attenuated inflammatory response with longer waiting times were attributed to a better kidney graft function in the recipient.

Of course, better organ procurement rates do not guarantee better organ graft survival in the recipient over time. The findings of this study are encouraging, nevertheless. So far there is no established maximum time between the diagnosis of brain death and organ donation. After all, sooner or later is better than never at all.

Just a few days after I had posted a blog about the importance of organ donation and the barriers towards obtaining the consent for donation from the patient’s family, I found myself in a room full of strangers talking about withdrawing life support from their loved one.

The patient was a previously healthy female in her late thirties who was involved in a horrendous car accident. She sustained a severe head injury and remained unresponsive. The CT scan of her brain on day 4 showed extensive cerebral edema and developing infarcts. The prognosis for her neurological recovery was dismal at that point.

From an organ donation standpoint she was a perfect donor – previously healthy and young patient with an isolated head injury.

The family already knew that things were bad. I explained once again what was happening and why their loved one was not going to recover. It seemed like the family had already made up their minds and was considering withdrawal of care.

When I asked about organ donation, the answer was “No we do not want that”. I had to paraphrase the question and asked if the patient would have wanted this if she new that this is going to happen. There was a silence in the room for a few seconds and then one the family members said that she had never put an organ donor sticker on her driver’s license. As I mentioned before, the lack of knowledge about the patient’s own wishes regarding organ donation is one of the barriers towards a successful consent for donation.

I started explaining why organ donation is important and why they should consider it. As I was doing it, I felt uneasy and conflicted. I just told the family that their loved one is not going to get better and now I am trying to get her organs.

I remember some time ago in a similar circumstance, a family member started yelling at me: “You just want to take her organs, that’s why you doing this…”

I have to acknowledge that it almost creates a conflict of interest for the treating physician to approach the family about organ donation. The studies have shown that the success rate for obtaining consent for donation is, actually, higher when somebody independent from the healthcare team approaches the family.

I realize that feeling conflicted about being the treating physician and requesting consent for donation did not allow me to be more persistent with my request. Eventually, I had to acknowledge that the patient was not going to be an organ donor.

This is a very unfortunate situation. One life is lost in a horrible accident, yet we have failed to improve or even save the lives of many other people. Even knowing the barriers for obtaining the consent, I was not able to overcome them.

Organ donation is a very complicated and involved process. The essential part of this process is organ procurement or the process of taking organs out of the organ donor body.

According to the “Dead Donor Rule” the donor should be declared dead prior to organ donation rather than dying as a result of donation. Otherwise, it would be unethical or even criminal to harvest the organs.

How do you define death for organ donation?

The patient may be pronounced brain dead prior to donation. This means that no brain activity or measurable blood flow to the brain can be detected. The diagnosis of brain death is usually made on clinical grounds with an optional confirmatory test like a nuclear medicine brain perfusion scan.

If the patient is not brain dead, donation is still possible via a “Donation after Cardiac Death” (DCD) protocol. The essence of this approach is for the patient to be pronounced dead based on the cessation of circulatory and respiratory functions, assuming that brain death is imminent after that.

In the real world if DCD is pursued, the patient would be taken to the Operating Room where life support will be removed. The physician will have to document the cessation of the respiratory function and mechanical asystole (lack of heart contractions) for 2 to 5 minutes depending on the Hospital protocol.

Mechanical asystole means a lack of heart contractions and circulation. The patient still might have electrical activity in the heart. Lack of heart contractions associated with the electrical activity (pulsless electrical activity) is sufficient to declare death.

Lack of cardiac contractility is documented by the absence of Doppler flow over the arteries, absence of blood flow through the aortic valve on a cardiac ECHO, or by documenting the lack of circulation by an invasive arterial cannula.

The usual sequence of events, once the life support is removed, is respiratory arrest leading to cardiovascular collapse. The lack of breathing and circulation should be observed for at least 2 to 5 minutes before organs should be taken. This is necessary to assure that an “auto-resuscitation” or spontaneous return of vital functions does not occur.

This is a somewhat superficial and simplified review of the declaring dead process for organ donation. Educating the public about organ donation, death and organ procurement is an essential step to improve the rate of consent for organ donation.

There are more than 100,000 people on a transplant waiting list in the US alone. Each year, only about a quarter of these patients will receive life saving transplants because of the significant shortage of organ donors. Thousands of patients on the transplant list die every year without a chance to receive an organ. The gap between the number of patients awaiting transplant and the number of organs available continues to widen.

Obtaining family consent for organ donation is a crucial rate-limiting step towards successful donation. The lack of understanding of the organ donation and organ procurement process by the families’ of the potential organ donors is one of the barriers.

A study conducted in Texas and published in the Journal of Trauma indicates that only 57% of families consent for organ donation. There were several specific barriers towards giving consent for donation identified by this study:

#1 Ethnicity
Hispanic families were four times less likely to give consent for donation. African-American families were seven times more likely to decline donation. During the past 20 years, African Americans and Hispanics represent only 12% and 11% of organ donors. Lack of understanding of brain death and the organ donation process were considered the likely explanation by the authors of this study. Specific approaches focusing on minority groups might improve the donation rates among minorities.

#2 Age and cause of death of the patient.
Older age (aged 50 years or older) and a medical cause of death of the potential organ donor were independent predictors for the failure to consent for organ donation by the family. The authors of this study indicated that the families of older patients would likely consider organ donation to be out of the realm of possibility. Many families were also unaware of the patient’s previous wishes and attitudes towards organ donation. It was found in the previous studies that the knowledge of a patient’s preference to donate increased the likelihood of donating by seven times. Efforts to improve donor designation, including the DMV organ donor program, might improve organ donation rates.

#3 Circumstances surrounding the request for consent
It was found that the sooner the family is approached about organ donation the higher the chances of obtaining the consent. Also, being approached by a member of the OPO (organ procurement organization) team, rather than by an independent member of the healthcare team also increased the rate of donation. Some large medical centers only allow specially trained individuals to approach the family about organ donation.

In conclusion, the rates of organ donation remain suboptimal. Identifying and eliminating barriers for successful organ donation will save thousands of lives every year.

Deciding to become an organ donor is a very good thing to do. There is a huge shortage of organs available for transplant and close to 100,000 patients are on a waiting list to receive them. I can only encourage you to consider becoming an organ donor.

I often see patients in the Intensive Care Unit with severe and irreversible brain damage. Most of those patients could have become organ donors. Many patients had even expressed their desire to become an organ donor prior to becoming disabled. Few of them actually donate their organs. Why is this happening?

Often, it becomes a family decision to proceed with organ donation. The lack of understanding of the basic procedures involved in organ donation and organ harvesting can lead the family to decline it. I have seen, on a multiple occasions, family changing their minds in the last moment.

Patients become organ donors in two cases: if the patient is pronounced brain dead or if the patient is suffering from a severe and irreversible condition with no meaningful chance for recovery (usually severe brain damage from trauma, bleed or stroke). In both cases, the patient should be considered a suitable donor based on the overall picture of health.

If the patient is pronounced brain dead based on clinical criteria and a confirmatory test, his or her organs could be taken immediately. It takes some time, though, to run all the necessary tests on the organ donor. Matching the donor with the organ recipients will likely delay this process as well. And, finally, depending on the location of the hospital, allow some time for the transplant team to get in there. All in all, it might take 8 to 18 hours before the organs could be harvested. This is considered to be a more “straightforward” process.

If the patient is not brain dead, the process could take even longer. At this point the donation is possible per the DONATION AFTER CARDIAC DEATH (DCD) PROTOCOL.
In this case, the donor becomes a non-heart beating donor. What it means is that the patient will be taken to the operating room where life support is going to be removed. If the patient is pronounced dead (no spontaneous breathing or heart beat) within a short period of time (usually 2 hours) his or her organs will be taken for donation. Often, it takes some time for the patient to become “ready”. It is not unusual to wait up to several days for the neurological damage to progress so that there is a higher chance of the patient dying within two hours so that the organs could be taken. It is often hard for the family to wait up to several days after they decided to withdraw care. In my experience, the need to wait and the uncertainty of the process often make the family change their mind.

The physician overseeing the process of organ donation is allowed to administer pain medications to keep the patient comfortable. The line between keeping somebody comfortable and facilitating death is somewhat blurry, though. A transplant surgeon from California was charged with accelerating the death of a patient to harvest his organs by administering high doses of Morphine. The physician was later acquitted of felony charges.

In conclusion, the process of organ harvesting is a very involved and even lengthy process. A better understanding on the part of the family might improve our chances of providing more organs for the patients in need.

Following guidelines, rules and protocols is a must when you are taking care of the ICU patients. Yet, invariably, family’s wishes and concerns will change the way you treat your patients, even the sickest ones. Medical care doesn’t stop even after you pronounce the patient brain dead (see image above). If the family is interested in organ donation you have to “keep the body going” so that somebody can get a “second chance” by getting those organs. The one question that always comes up when dealing with a potential organ donor – are we being aggressive enough in “recruiting” eligible organ donors? Are we taking away somebody’s hopes for better life or even survival when taking “No” for an answer?