More than 100,000 people are in need of a life-saving organ transplant at any given time, according to the United Network for Organ Sharing.1 “Organ donation is a social good and should be supported by sound policies that protect and support donors through the process,” says Leslie M. Whetstine, PhD, professor of philosophy at Walsh University.
Surgeons have mastered anastomosis, immunosuppression is managed through the use of effective medications, and an organ matching system ensures timely and fair allocation.
“The biggest obstacles to organ transplantation are no longer technical in nature,” says Whetstine, bioethicist at Aultman Healthcare Delivery System. “The primary hurdle in the modern era is the scarcity of organs.”
At the hospital level, changes can be made that facilitate successful organ donation. At the Northeast Georgia Medical Center, a multidisciplinary team significantly increased the organ referrals rate and expanded the list of donors and organs transplanted. “Key stakeholders from the organization’s trauma program and the organ procurement organization [OPO] identified opportunities to improve the overall knowledge and processes surrounding organ and tissue donation,” reports Jesse Gibson, MBA, BSN, RN, TCRN, the organization’s trauma program director.
The overarching goal: Create a culture that values organ donation as a standard of care for patients and families. A multidisciplinary team worked with the organization’s donation advisory committee:
• The group updated internal policies related to end-of-life care;
• The group educated physicians, nurses, and advanced practice providers on the importance of involving trained requesters;
• The OPO hospital development liaison shared current data in many forums throughout the organization. “This helped support the necessity of the actions,” Gibson says;
• The group committed to raise awareness of organ and tissue donation, both in the organization and in the community.
Whenever a family authorizes organ donation, the hospital raises a “Donate Life” flag. Staff line the hallways to honor the donor and family on their way from the ICU to the OR. “Staff from all departments pay respect and show gratitude for the unselfish act of donation,” Gibson says.
The hospital hosts a dinner event to bring donor families and the clinical care groups together to remember and celebrate the donors. Some key results of the initiative:
• The number of organ referrals has increased from 169 in 2015 to 320 in 2021;
• There were 31 organ donors in 2021 vs. 22 during a previous three-year period;
• 102 organs were donated in 2021 vs. 16 in 2015.
“No one action led to the improved numbers observed by the organization,” Gibson reports. “The overall approach resulted in increased engagement and commitment.”
If no one raises the possibility of organ donation, the opportunity is lost forever. “One major concern is that the opportunity for organ and tissue donation will be missed, depriving families of the chance to save lives,” says Teisha Campbell, the OPO’s hospital development liaison.
The OPO provides a 24/7 donor referral line for the hospital staff to contact when patients meet clinical triggers for organ and tissue donation. Designated requestors are staff who are specially trained to approach families, when appropriate, to talk about organ donation. Families were approached about donation 90% of the time in 2021 vs. 52% of the time in 2015.
Northeast Georgia Medical Center operates an ethics committee, with an ethicist on staff. “Ethicists are typically involved in acute instances, where more urgent attention is required,” Gibson says. In those cases, the clinical team works with the palliative medicine team to initiate engagement by ethicists. The team also contacts the hospital’s legal and risk management departments. “Fortunately, there are laws in the state that support a donor’s wishes if he or she has signed up to be a donor,” Gibson notes. “This mitigates ambiguity and helps ensure wishes are fulfilled in these unfortunate situations.”
Sometimes, ethicists become involved in a case due to confusion over what the patient would want. Some patients registered as organ donors with the department of motor vehicles, but the patient’s advance directive does not mention organ donation. The advance directive might indicate the patient does not want clinicians to continue mechanical ventilation past a specific point. Yet to preserve organs in an optimal state, a patient needs to be kept on a ventilator to progress to brain death or post-brain death.
“One thing ethicists can do is be aware of how advance directive forms address, or do not address, organ donation,” says Lois Shepherd, JD, professor of biomedical ethics at the Center for Health Humanities and Ethics at the University of Virginia.
If an existing advance directive and the desire to donate organs are in conflict, ethicists work with the appropriate decision-makers. Ethicists determine, to the extent possible, how the patient would have wished that conflict to be resolved. “It is preferable for there to be a more proactive approach, where instead of contributing to confusion in this regard, advance directive forms help to clarify the patient’s priorities,” Shepherd observes.
Ethicists “would have to be very careful” about promoting conversations about organ donation during rounds, Shepherd cautions. “It is important that while the patient is living, the focus is on the patient: the patient’s health, comfort, and wishes,” Shepherd emphasizes.
Any conflict of interest between pursuing the best outcome for a patient and making decisions that facilitate organ donation raises ethical concerns. For example, if a patient might be a good candidate for donation after cardiac death, any discussion about organ donation would be deferred until a decision has been made to withdraw life support. “Those caring for the patient do not, as a rule, take part in discussions about organ donation,” Shepherd adds.
Clinicians should not be perceived as compromising quality of care because of an interest in securing organs. “Clinicians don’t actually do this, but it’s bad optics for them to talk about organ donation,” explains Brendan Parent, JD, director of transplant ethics and policy research at the NYU Grossman School of Medicine.
Technically, conversations about donation fall under the purview of OPOs. “But sometimes, OPOs don’t move quickly enough,” Parent argues. “We should start carefully breaching this firewall, and have clinicians initiate this conversation in thoughtful ways.”
An individual’s organ donation wishes should be part of their holistic care plan, according to Parent. Ethicists could provide education to clinicians on this point. “But it requires a specific understanding of the nuances around trust in organ donation, and the relationships with OPOs, and with the transplant team,” Parent explains. A culture of trust between the patient community, clinical care providers, the transplant program, and the OPO is necessary. “This takes years to build — and one bad case to break,” Parent warns.
REFERENCES
1. United Network for Organ Sharing. UNOS research and data analytics for OPOs.
2. Gibson JE, Campbell T, Gibson K, et al. Collaborative approach to organ donation in a level II trauma center. AACN Adv Crit Care 2023;34:88-94.
An individual’s organ donation wishes should be part of their holistic care plan. Ethicists could provide education to clinicians on this point. A culture of trust between the patient community, clinical care providers, the transplant program, and the organ procurement organization is necessary. This takes years to build — and one bad case to break.
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