Organ and Tissue Donation

Organ donation is the process of taking healthy organs and tissues from one person and transplanting them into another person (MedlinePlus, n.d.). Most organs and tissues are taken from deceased donors, but occasionally, they are taken when the donor is alive. The first successful organ transplant was a kidney donated by a man to his identical twin in Boston, Massachusetts, in 1954. The first simultaneous kidney/pancreas transplant was done in 1966. In 1967, the first liver transplant was performed, and in 1981, the first heart and lung transplants were done (United Network for Organ Sharing [UNOS], 2022). According to UNOS (2023b), the United States exceeded 42,800 transplants in 2022 and reached 1 million total transplants on September 9, 2022.

Every individual has the right to become an organ donor. Individuals under 18 years of age need permission from a parent or guardian if they want to be a donor. Organs are donated by a deceased person who gave permission before death; the family of a deceased patient may offer their loved one's organs or tissues, or a living person may act as a living donor. Organ donation can potentially save the lives of individuals with end-stage organ failure. In addition, organ and tissue transplants can potentially restore health and function to many individuals.

As of February 1, 2023, there are 103,924 people in need of a lifesaving transplant, with the most needed organ being a kidney (UNOS, 2023a). Every day, 20 people die waiting for a transplant. One person may save eight lives through the donation of vital organs. In addition, one person can affect and improve the lives of 50 or more people by donating organs and tissues (UNOS, 2023b).

Organ donation is a very personal and challenging decision for many to make. One may donate their organs to help others or save someone's life, help a loved one, or improve one's sense of worth. When families decide to donate a loved one's organs, they may feel their loved one is helping others, or their loved one is living on through others.

Reasons individuals or families of individuals would not want to donate organs or tissues include:

• The fear that future or present medical care will be limited in order to get the organs from the individual who has agreed to donate.
• The fear of the procedure of harvesting the organs.
• Fear of pain (deceased donors are brain-dead and feel no pain).
• Cost concerns (there is no direct cost to the family who donates).
• Religious concerns – most religions do not discourage organ/tissue donation (if there is a concern, encourage the potential donor/family to talk to a clergy member).

Lastly, the fear of the health care provider not wanting to interfere with a grieving family after their loved one has died or has been declared brain dead is another barrier to organ donation. Bringing in an Organ Procurement Organization (OPO) will help ensure that the family of a loved one is approached in a sensitive manner.

John T. is a 35-year-old white male treated for hypertension for three years with lisinopril. He is married and is the sole provider for his wife and four children. Upon a routine annual checkup, he is noted to have elevated creatinine and potassium levels. He is admitted to the hospital, and further evaluation shows he has polycystic kidney disease.

What are the likely outcomes from this diagnosis and possible treatment options?

He is stabilized in the hospital but is told he will eventually need a kidney transplant or spend the rest of his life on dialysis.

What are the next steps to begin treatment?

Over the next two years, his kidney function slowly deteriorates to a point where his nephrologist officially decides to place him on the kidney transplant list. He undergoes fistula placement for impending dialysis and starts dialysis four months later.

Because he needs to keep working to support his family, John does overnight dialysis three days a week, where he goes to a center to receive dialysis while he sleeps. During the week, he works six 8-hour day shifts. He finally received his kidney transplant after four years on the transplant list.

Discussion of Outcomes

Now that he has received his transplant, he will need close follow-up, continue to be on lifelong medications, and needs to take care of his health as he is at an increased risk for infections and complications.

Strengths & Weaknesses

If he had continued on dialysis, it might have prolonged his life, but it may have also stopped working at some point. Although there are risks with a transplant, this was the best long-term option for allowing him to continue supporting his family and living a somewhat normal life.

Organ transplantation is when a donated organ is surgically transferred to another person. Organ transplant typically occurs due to end-stage organ failure, possibly due to multiple disease states (see Table 1).

When the physician determines a transplant is necessary, a referral is made to a transplant program. The patient should be encouraged to obtain a copy of Partnering with Your Transplant Team, a free handbook from the U.S. Department of Health. It provides the patient and family with information about the process, including an overview of the transplant process and how the patient can best navigate the system (UNOS, 2023b).

After a transplant is decided on, an OPO helps with the process. The OPO has two major roles. It works to coordinate the donation process when an organ becomes available and works to increase the number of registered donors. There are 56 OPOs in the United States. The OPO is a critical component of the donation process, with personnel always available to help.

Specifically, the OPO will evaluate the potential donor, contact the Organ Procurement and Transplantation Network (OPTN), run a match list, work with family members, and arrange to transport and recover donated organs. All OPOs are certified by the Centers for Medicare and Medicaid Services and must be members of the OPTN. In addition to the OPO, multiple organizations are involved in the transplant process. These include the transplant hospital, the OPTN, and UNOS. Every transplant hospital in America is an OPTN member and must have a transplant surgeon and a physician with training/experience in the type of organ that is transplanted.

The OPTN is a unified transplant network created in 1984. The network is non-profit, operated privately, and under federal contract. The organization works to increase the supply of donated organs and increase the effectiveness and efficacy of organ donation.

UNOS manages the transplant system in the United States. It is a private non-profit organization with multiple responsibilities (see Table 2).

After the patient has selected a transplant program, an evaluation is set up to determine if the patient is a candidate and to provide help with finances. The transplant coordinator works with the recipient and is involved in the testing, evaluation, and getting the patient on the national waiting list. If the transplant team determines that the patient is a candidate, they are listed on the OPTN national list of all individuals awaiting a transplant.

Patients need to understand the financial commitment to the transplant process. Working with insurance companies in advance is important to ensure full transparency related to costs. Most recent numbers show heart transplants cost over $1.3 million, while kidney transplants are over $400,000 (National Foundation for Transplants, 2022). Donating organs does not cost the patient's family or estate anything postmortem.

Once on the national list, wait times are variable, and patients need to be educated about average wait times for their organs. The longest wait time is for kidney transplantation, averaging 3.6 years, with 3,000 new kidney patients added monthly (National Kidney Foundation, 2022). Patients should be encouraged to care for themselves while waiting for a transplant. They should be instructed to maintain doctor appointments, take all medications, exercise (as appropriate), eat healthily, and not smoke, drink alcohol, or do illegal drugs. Patients must always be prepared with adequate transportation if they are notified that an organ is available.

Donors can be deceased or living. Deceased donors have to be declared brain dead, which happens when the brain is completely and irreversibly non-functional and is caused by insufficient blood/oxygen supply, causing the brain cells to die (UNOS, 2019).

When an individual dies, the OPO determines if the patient is suitable to donate. Donors are often victims of injuries (brain trauma), have catastrophic strokes, or suffer an aneurysm. Some conditions rule out donation, such as human immunodeficiency virus (HIV), other infectious diseases, many active cancers, or organs damaged by trauma or lack of perfusion.

A living donor will give an organ or part of an organ. Organs may include a kidney or a part of the liver, pancreas, lung, or intestine. Living donors cannot have HIV, hepatitis, an array of other infections, cancer, uncontrolled high blood pressure, or diabetes.

All deceased donors are screened for HIV at the time of brain death. Living donors are screened sometime before the transplant. Because there is a chance that the donor may have contracted HIV in the interim, repeat testing must occur as close to the date of transplant as possible but no longer than seven days prior. Living donors should be educated to avoid behaviors associated with an increased risk of acquiring HIV infection before transplant surgery.

Kidney

A kidney transplant may be needed when kidneys stop working from diabetes, hypertension, genetic disease, cancer, or other injuries. Kidneys can be transplanted from a living or deceased donor. After a transplant, patients will begin anti-rejection medications, sit up within one day, avoid lifting or driving, and shower daily (UNOS, n.d.).

Heart

A heart transplant requires a deceased donor and is matched by blood type and body size. The transplant is usually done to combat heart failure. Like other transplants, anti-rejection medications are necessary, and regular follow-ups will occur (American Heart Association [AHA], 2021).

Liver

A liver for transplant can be provided by a deceased or living donor. Only a portion of the liver is taken if a living donor is used, as the liver can regenerate itself. The transplant is done after end-stage liver disease occurs. After a transplant, liver function tests will frequently occur, along with at least five days in the hospital. Medications and frequent follow-ups are needed (Mayo Clinic, 2022c).

Lungs

A lung transplant, which can be performed on one or both lungs, typically occurs from a deceased donor. However, a healthy individual might be able to donate a lobe. The transplant usually occurs due to diseases such as COPD, cystic fibrosis, pulmonary hypertension, or heart disease affecting the lungs. After a transplant, medications are started, and pulmonary function tests, bloodwork, and bronchoscopies may be performed to see how the transplant is functioning (Johns Hopkins Medicine, 2023).

Pancreas

A pancreas transplant occurs from a deceased donor and is sometimes done with a kidney transplant, often lessening the risk of rejection. The old pancreas remains in the recipient's body. The transplant often occurs for uncontrolled type 1 diabetes (Johns Hopkins Medicine, 2019).

Intestines

Intestinal transplant is one of the rarest transplants, with the Cleveland Clinic only completing seventeen in 2021. The small intestine is typically transplanted, often related to intestinal failure (Cleveland Clinic, n.d.).

Cornea

Also known as keratoplasty, a cornea transplant can help restore vision, reduce pain, or improve appearance. It is harvested from a deceased donor. After the surgery, patients must take their medications as scheduled, wear eye protection to keep the eye from being damaged, lie flat on their back (at times), and follow up closely with their physician (Mayo Clinic, 2022b).

Bone Marrow

Bone marrow transplants can be done from one's own cells (autologous) or a donor (allogeneic). It may treat both cancerous and non-cancerous hematologic disorders. Stem cells are collected from blood or bone marrow and are infused into the patient. After a transplant, it may take weeks before the blood cells return to normal ranges. These individuals are closely monitored with routine bloodwork due to being at risk for infection and complications (Mayo Clinic, 2022a).

There are continued postop measures aimed at ensuring the transplant is successful. The transplant recipient must take medications, have follow-up appointments, and live a healthy lifestyle. One of the biggest tasks is to take anti-rejection medication to prevent the body from rejecting the transplanted organ. Finding the right dose after surgery often takes time, as transplant surgeons may have to adjust dosages or change medications frequently (Transplant Living, 2022).

A 28-year-old male arrives in the emergency department after suffering a closed head injury from a motor vehicle accident. His wife and mother were in the emergency department shortly after he arrived as they were traveling in a car behind him when he was in the accident. The paramedics intubated him in the field. Upon arrival at the emergency department, he was hypotensive and had an elevated heart rate. His left pupil was 8 mm and minimally reactive, and his right pupil was 5 mm and nonreactive. When turning the head to both sides, there was no eye movement. No movement was noted when ice water was injected into both ear canals. The corneal reflex in both eyes was absent.

The computed tomography head scan showed a large subdural hematoma left-to-right shift. The patient was deemed not to be a surgical candidate by the neurosurgeon. He was treated medically in intensive care with hyperventilation while monitoring to see if the injury would be reversible.

After four hours, there was no clinical improvement in the patient. The patient is continued on respiratory support.

What might these signs indicate? What is his prognosis?

The next morning, there was no clinical improvement. The neurologist who examined the patient recommended a cerebral perfusion scan because he had a Glasgow Coma Scale score of 3, no purposeful movement, no cough or gag reflex, no spontaneous respirations, and fixed and dilated pupils.

The perfusion scan showed no blood flow to the brain. Based on this and the physical exam, the neurologist determined that the patient was brain dead. A referral was made to the OPO. During this process, the average blood pressure was 98/56 mmHg, with an average heart rate of 103 beats per minute. The patient was noted to have a stable creatinine level, blood urea nitrogen level, and liver function tests.

The organ recovery coordinator evaluated the patient and determined that the patient was a candidate for organ donation but was concerned with the clinical picture. The attending physician increased the intravenous fluids to help maintain blood pressure and reduce organ hypoperfusion risk.

The family was made aware that the patient was brain dead. The physician who had the conversation with the family discussed organ donation but did not push the issue because the family was very upset about losing their loved one.

What would the next steps be to discuss organ donation appropriately?

The physician spoke to the transplant coordinator from the OPO and suggested that she talk to the family. The coordinator, who has special training in grief counseling, counseled the family. She worked with the family and helped them accept that their loved one was brain dead. After a while, the family was open to organ donation. After working with the coordinator, the family agreed to donate all tissues and organs.

Strengths & Weaknesses

Although organ donation is not an easy topic to discuss and can be very difficult for family members, understanding a loved one's wishes in advance would help bridge this gap. Healthcare professionals must know the appropriate, tactful manner of starting these discussions and when to refer to necessary team members for further evaluation.

Although the organ donation process is often difficult for families, nurses should be able to provide support and education. The support may include knowing the transplant and donation process and who can be contacted for specific questions. It also includes determining which patients might be eligible organ donors and quickly referring them to the local OPOs. The nurse must continue caring for the organ donor and ensure organ preservation while supporting the family (Karaman & Akyolcu, 2019). When their patient becomes a possible organ donor, the nurse must maintain high ethical standards and adhere to the American Nurses Association's Code of Ethics, including advocating for the patient's safety and maintaining compassion and respect (Hunt & Murphy, 2020).

Many people die every year needing a transplant. It is essential to understand the importance of becoming an organ donor as there is a severe shortage of organs, with many individuals awaiting transplants. Nurses have key roles in helping others understand organ and tissue donation. Healthcare professionals must be able to provide accurate information about organ donation, including dispelling myths surrounding organ donation, encouraging others to get involved in the donation process, and possibly becoming organ donors. Lastly, nurses should understand organ rejection and the steps required to reduce the risk of rejection.

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