Supporting Organ and Tissue Donation in Clinical Settings: The Pennsylvania Requirement _ ____________
• Neuroimaging: Consistent with the mechanism and severity of brain injury • Apnea testing: Absence of spontaneous respiratory effort at a PaCO ₂ ≥60 mm Hg (20 mm Hg above baseline) after at least one test for adults after neurological exam and two tests for pediatric patients (one after each neurological exam) Ancillary testing (EEG, cerebral angiography, nuclear perfu- sion scan, transcranial Doppler ultrasound) may be used when clinical examination/apnea testing cannot be completed or when there is an inability to correct metabolic derangements adequately, but the neurologic examination(s)/apnea test(s) are consistent with BD/DNC [17]. The patient’s family should be allowed to be present during the neurologic examination and apnea test; however, they should be informed about the potential for spinal reflexes (e.g., Lazarus sign) and the fact that these movements do not indicate brain function. In Pennsylvania, institutional brain death protocols, which must comply with the 2023 American Academy of Neurology guidelines, govern the exact procedural requirements [16; 17]. The AAN has created an interactive algorithm to help clini- cians integrate the guidelines into practice; this tool is available online at https://www.aan.com/Guidelines/BDDNC. Brain death must be declared by a physician (or, in some institutions, an advanced practice provider per institutional credentialing) who is not a member of the transplant team and who has no conflict of interest regarding donation. In Pennsylvania, two physician declarations are not legally required, but many institutions require it by policy. DECLARATION OF DEATH BY CIRCULATORY CRITERIA In DCD cases, death is declared following cardiac death—the irreversible cessation of circulatory and respiratory function. The “hands-off” period (typically 2 to 5 minutes per institu- tional protocol, most commonly 5 minutes) must elapse after cessation of cardiac activity before death is declared, to prevent auto-resuscitation [18]. The Society of Critical Care Medicine and other professional societies have published guidelines regarding the ethical and procedural standards for DCD [19].
to process this information should the OPO family support coordinator introduce the topic of donation. In many cases, this means two separate meetings, often with a short interval in between. Communicating Brain Death to Families For many families, the concept of brain death is profoundly counterintuitive. Their loved one appears to be breathing (via the ventilator), may feel warm to the touch, and may have a heartbeat. Physicians and nurses are often responsible for gently but clearly addressing this disconnect. Effective com- munication strategies include: • Use concrete, plain-language explanations: “The brain has stopped working completely and permanently. The machine is doing all the breathing.” “Your loved one’s body cannot breathe on its own at all.” • Avoid euphemisms like “brain dead” without explanation; instead, affirm: “This is legal death; he has died.” • Invite questions and allow silence. Do not rush the family toward any decision. • Avoid prematurely discussing organ donation. The family needs to come to terms with the death of their loved one first. CARING FOR FAMILIES The hours surrounding a patient’s death — and particularly the donation conversation — represent some of the most emo- tionally intense moments a clinical team will witness. How nurses and physicians engage with families during this time has lasting consequences for the family’s grief experience and for donation outcomes. CULTURAL AND RELIGIOUS CONSIDERATIONS Pennsylvania’s population is ethnically and religiously diverse, and perspectives on donation, death, and the body vary sig- nificantly across communities. All major religious traditions in the United States, including Catholicism, Islam, Judaism, Protestantism, Hinduism, and Buddhism, either support organ donation or leave it to individual conscience [23; 24]. However, cultural beliefs, independent of formal religious doctrine, may create hesitation or concern. Effective culturally sensitive care includes: • Asking, not assuming: Directly inquire about any cultural or religious considerations the family would like respected. • Involving spiritual care: Chaplains and spiritual
COMMUNICATING WITH FAMILIES: THE DECOUPLING PRINCIPLE
Research and best practice consistently support the principle of decoupling (i.e., separating the notification of death or the discussion of withdrawal of life support from the request for donation). When families receive both conversations simultaneously, authorization rates decline and family distress increases [20; 21]. The practical application of decoupling means a physician and/or nurse should first meet with the family to explain the patient’s neurological status, the meaning of brain death, and what it means for the patient’s prognosis, before any mention of donation. Only after the family has had adequate time
care specialists can be invaluable mediators between clinical teams and families navigating faith-based concerns.
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