Handle organ procurement delicately with families

OPOs educate public, help hospitals  

One of the most difficult encounters for medical staff is simultaneously informing a family of the death of a loved one and bringing up the idea of donating organs and tissues. Staff awareness of resources to coordinate organ procurement — and the staff’s attitude toward organ procurement — can make a big difference in an area’s organ procurement rate.

An important resource at this critical time is the area Organ Procurement Organization (OPO). OPOs are nonprofit agencies overseen by the federal government, and each OPO is assigned to a specific territory. When a donor becomes available and the OPO in that area is notified, the OPO recovers the organs and coordinates allocation of the organs or tissues to qualified patients.

But despite being a vital link in the transplantation process, the role of OPOs is not always clear to hospital staff, some studies indicate. According to the Joint Commission on Accreditation of Health-care Organizations (JCAHO), many health care organizations experience problems during JCAHO surveys because staff are unsure about organ procurement guidelines, such as the time frame in which the OPO needs to be notified about an "imminent death." Because organs must be recovered quickly for successful transplantation in another patient, the OPO must be involved in a timely fashion or the organ may no longer be useful.

The primary function of OPOs is to coordinate the procurement and allocation of organs and tissues by evaluating potential donors, discussing donation with family members, and arranging for the surgical removal of donated organs. They also serve as educational resources by providing public awareness campaigns and education to clinicians and the general public to encourage organ donation.

Educating hospital staff can mean the difference between a family agreeing to donate tissue and organs, and rejecting the idea. A study published in 2001 in the Journal of the American Medical Association found that the time spent with an OPO coordinator was a strong factor in families’ decisions to donate. The authors of the study concluded that the role of hospital staff should be limited to involving OPO staff early in the process and working under their direction to optimize the donation request, taking advantage of the experience of the OPO staff who are better prepared to work with the family than the hospital staff might be.

Hospital staff awareness of when to notify an OPO of a potential donor is key as well. Hospitals must notify OPOs of pending death rather than waiting until the patient dies. The OPO determines the medical qualifications for donation, and if the initial determination is positive, sends procurement staff to the hospital to evaluate the patient and to discuss donation with the patient’s family.

Even though OPO staff are responsible for direct contact with the donor’s family about making a donation, the hospital staff’s attitude toward donation can be a critical influence. One health care system surveyed its staff to gauge understanding of the donation process, and found that potentially disruptive misconceptions abounded. After implementing an inservice program to educate staff, the hospitals in the system saw a marked increase in their donation rates.

OPOs say that while facilitywide education is desired, staff in trauma and emergency departments need focused training because the likelihood of staff in those departments being involved in donor situations is highest. While legal requirements vary from state to state (some states mandate that an OPO make the first request to families of potential donors), involving a hospital chaplain or family minister can help ease fears about the process.

Health care and organ procurement professionals agree that public education is critical because making a decision on organ donation is more easily made before the need arises. If an informed decision is reached and the future donor shares his or her wishes with family, the burden is removed from the family at a time of crisis.

Researchers from the University of Buffalo’s School of Social Work recently published a study in the journal Death Studies that showed public education on organ and tissue donations, when delivered at the middle school and high school levels, promoted family discussions about donations and ensured that accurate information on organ donation and end-of-life choices was conveyed. High school participants in the study reported that they felt "very prepared" or "somewhat prepared" to make those choices after participating in a program on organ donation.

The issue of expressed consent is a critical element of organ donation that must be emphasized to anyone involved in organ procurement.

According to the U.S. Department of Health and Human Services (HHS) "The Organ Donation Breakthrough Collaborative: Best Practices Final Report," (available at www.organdonor.gov/bestpractice.htm), potential donor families are typically thrust into these circumstances in shock and in great need. An integrated OPO and hospital approach to meeting the wide range of needs of potential donor families is also more likely to result in an informed decision to donate.

Preparing the family for imminent death contributes to informed decision making and successful organ donation, the HHS report states. Further, during the consent process, OPO staff, often have hospital staff present to help answer questions from family members about brain death and organ donation. In the event that families initially refuse to donate, OPO staff will seek to determine whether the family is denying the request to donate at all, or is denying the request at that time for another reason, which may justify approaching the family again later.

A common misconception is that a signed donor card or driver’s license is all that is necessary to carry out a person’s wish to be a donor. Because there is no national donor registry, individual donors must share their decision with their families, and the families must give consent. Based on studies indicating success of school-based public education on organ donation, HHS created Decision: Donation — A School Program That Gives the Gift of Life, a model instructional package for high schools that emphasizes the importance of organ and tissue donation and the need for teenagers to make an informed decision about whether to be a donor and share their donation wishes with their families.

Further reading

• The Organ Donation Breakthrough Collaborative, U.S. Department of Health and Human Services. www.organdonor.gov. Information on best practices, as well as regional OPO assignments and the Decision-Donation High School Program.

• Waldrop DP, Tamburlin JA, Thompson SJ, et al. Life and death decisions: Using school-based health education to facilitate family discussion about organ and tissue donation. Death Studies 2004; 28:643-657.