_____________ Supporting Organ and Tissue Donation in Clinical Settings: The Pennsylvania Requirement
ORGAN VIABILITY AND COLD ISCHEMIC TIME Organs have different tolerances for ischemia. Approximate maximum cold ischemic times are [13]:
• A Glasgow Coma Scale (GCS) score ≤5 • Patients on mechanical ventilation with suspected or confirmed brain death • Any patient in whom • WLST is being considered It is important to be aware of family members’ responsive- ness toward the situation to determine if they are considering WLST. Signs that a family may be accepting the non-survivable nature of an injury include but are not limited to [11]: • Decision not to resuscitate (DNR) • Decision not to escalate interventions • Asking about WLST without indicating timing • Asking what it looks like to WLST • Asking about what happens next • Asking for permission for, or waiting for, additional people to come say goodbye • Discussing funeral arrangements • Talking about the person in the past tense • Bringing up donation Other indications may include statements such as, “they wouldn’t want to live this way,” or “we don’t want them to suffer/be in pain anymore.” The Joint Commission, CMS, and Association of Organ Procurement Organizations all emphasize that the threshold for referral should be low and that clinicians should call the OPO early—not only after death has been declared. THE ROLE OF THE OPO AFTER REFERRAL Once referral is made, the OPO assumes the coordinating role. Key steps include [12]: • Medical suitability review: The OPO’s medical director reviews the patient’s medical and social history to assess donor suitability. • Brain death evaluation support: OPO coordinators can assist clinical teams with the logistics of brain death evaluation, though the declaration itself must be made by physicians independent of the transplant team. • Authorization: Trained family support coordinators approach the next of kin (in cases where the patient has not registered as a donor) or confirm authorization per the patient’s documented wishes. • Donor management: If donation proceeds, the OPO assumes co-management of the donor, working alongside the ICU team to optimize organ function. • Procurement coordination: Surgical teams from recipient transplant centers travel to the donor hospital to recover organs, which are then transported and transplanted on a time-sensitive basis.
• Heart: 4 to 6 hours • Lungs: 4 to 6 hours • Liver: 8 to 12 hours
• Pancreas: 12 to 18 hours • Kidneys: 24 to 36 hours
These windows dictate the urgency of procurement and trans- port logistics. Clinicians managing a potential organ donor should understand that time is a critical variable affecting outcomes for recipients.
DETERMINING DEATH AND FAMILY COMMUNICATION Two distinct legal and physiological standards govern the decla- ration of death in the context of organ donation. A thorough understanding of both is essential for nurses and physicians. NEUROLOGICAL CRITERIA FOR DEATH (BRAIN DEATH) Brain death/death by neurological criteria (BD/DNC), defined as the complete and irreversible cessation of all brain function, including the brainstem, is recognized as legal death in all 50 U.S. states and the District of Columbia [14]. Brain death is not a coma, a vegetative state, or a minimally conscious state; it is death. The clinical determination of BD/DNC requires [15; 16; 17]: • An established etiology sufficient to cause irreversible neurological injury • An observation period of 24 hours in patients 2 years of age or older after hypoxic ischemic brain injury • In adults, exclusion of confounders: ‒ Core temperature >36°C ‒ Systolic blood pressure >100 mm Hg ‒ Mean arterial pressure ≥75 mm Hg (Only the mean arterial pressure goal is applicable on venoarterial extracorporeal membrane oxygenation) ‒ Absence of CNS-depressant drugs/exclude pharmacologic paralysis ‒ Absence of metabolic derangements that could mimic brain death • Neurological examination demonstrating absent brainstem reflexes: No pupillary response to light, absent corneal reflexes, absent oculocephalic reflexes, absent oculovestibular responses, absent gag and cough reflexes
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