Non-Heart-Beating Organ Transplantation Medical and Ethical Issues in Procurement (1997) / Chapter Skim
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5 Survey of Organ Procurement Organization and Transplant Program Policies
5 Survey of Organ Procurement Organization and Transplant Program Policies
Pages 33-44
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From page 33... ...
According to UNOS, its role is "to establish a national Organ Procurement and Transplantation Network under the Public Health and Safety Act, in order to improve the effectiveness of the nation's renal and extrarenal organ procurement, distribution, and transplantation systems by increasing the availability of, and access to, donor organs for patients w~th~~end-stage organ failure; to develop, implement, and maintain quality assurance activities; and to systematically gather and analyze data and regularly publish the results of the national experience in organ procurement" (UNOS Articles of Incorporation)
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From page 34... ...
According to UNOS data, 20 donor hospitals and OPOs recovered organs from NHBDs in 1996, and 36 recovered organs from NHBDs from 1993 to 1996. PROTOCOL STATISTICS All of the OPOs responded to the IOM request for a copy of their NHBD protocols, either by mail or via phone interview.
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From page 35... ...
Many of the OPOs without NHBD protocols expressed an interest in learning more about the issues surrounding NHBD procedures and hearing the findings of this report. The IOM received a total of 29 NHBD protocols from various OPOs (25 approved, 4 in draft form or in the approval process)
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From page 36... ...
One protocol states that the "OPO representative will discuss the possibility of procurement with the attending physician to ensure that the physician agrees with termination of support on medical grounds" before the decision to terminate support is made. Many OPO protocols outline the tests and procedures for determining donor suitability.
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From page 37... ...
One protocol allows donation only if the interest in organ donation is initiated by the family of the patient: "NHBD will never be offered as an option for any patient by a member of the health care team transplant team OPO etc.... NHBD can only be discussed if an unprompted family member brings up organ donation as an important priority of the patient as his/her 'last wish.' If the family discusses the issue prior to a level-of-care decision being made NHBD will never be considered as an option." This contrasts with another protocol that allows the possibility that families may inquire about organ donation before deciding to withdraw life support and permits OPO personnel to inform them that a decision to withdraw support should not be influenced by any considerations of or: an donation.
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From page 38... ...
The point at which the procurement team inserts femoral arterial cannulas in anticipation of in situ organ flushing and preservation after death is of particular interest. Half of the OPO protocols allow the transplant surgeon to insert femoral arterial cannulas before the withdrawal of life support.
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From page 39... ...
Of the 29 OPO protocols reviewed, as noted in Table 5.1, 15 specify using, heparin or the combination of heparin and phentolamine at some point during, the death and donation process. Five OPOs administer heparin prior to termination of life support.
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From page 40... ...
Other medications used in various protocols include Thorazine, Verapamil, mannitol, cephalosporin, penicillin, insulin, trifluoperazine, and SoluMedrol and other steroids "to reduce ischemic damage." WITHDRAWAL OF LIFE SUPPORT AND DECLARATION OF DEATH Withdrawal of life support and declaration of death in controlled NHBDs differ among OPO protocols. In order to avoid conflicts of interest, all protocols explicitly require that the physician who declares death must not be affiliated in any way with the OPO, recovery team, or transplant team.
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From page 41... ...
One OPO withdraws support and declares death, continues chest compressions to circulate heparin and phentolamine, and then inserts catheters for cold perfusion before procuring organs. Another OPO performs this sequence in reverse: it inserts cannulas, withdraws support, administers phentolamine and heparin, and then declares death before procuring organs.
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From page 42... ...
One OPO representative stated, "My surgeon and I have taken training for pump perfusion for kidneys, and we have recovered organs from heart-beating, brain-dead patients who arrested in the OR. We gave them heparin and cardiac massage until we could get the organs out." These patients-brain-dead donors who arrest unexpectedly before organ procurement fall into the uncontrolled NHBD category (Maastricht cate;,ory IV)
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From page 43... ...
Regardless of whether or not cannulation and cooling take place prior to consent, each OPO protocol for uncontrolled NHBDs prohibits actual organ procurement without family consent. Another procedure sometimes used during uncontrolled NHBD procurement that deserves consideration is the use of CPR after the patient has been pronounced dead.
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From page 44... ...
A consensus on these issues, expressed in more standardized and detailed protocols would help to avoid conflicts of interest, safeguard quality care for donors and promote procurement of viable organs. The great variation found in OPO protocols and the increasingly urgent demand for more organs suggest the value of a discussion of NHBD programs in the United States with the objective of a more effective use of the costly Organ Procurement and Transplantation Network.
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