• Organ transplantation continues to improve every year. This success has led to the situation in which the demand for organs is greater than the supply.⁴ From January 2009-January 2010, patients received 2,198 transplants. As of April 2010, there were 107,173 people on the waiting list.

• In 1968, the Uniform Anatomical Gift Act was created by the National Conference of Commissioners on Uniform State Laws. This document established a uniform Donor Card as a legal document for anyone 18 years or older to legally donate organs upon death.

• In 1980, the Uniform Determination of Death Act was passed into law; this act states that death may be declared with the cessation of circulatory and respiratory functions or with irreversible cessation of all functions of the entire brain, including the brain stem.

• In 1984, the National Organ Transplant Act established a nationwide computer registry operated by the United Network for Organ Sharing and authorized the funding of regional organ procurement organizations.

• As of 1998, every death or imminent death in a U.S. hospital must be reported to an organ procurement agency to meet the federal rules of the U.S. Department of Health and Human Services.⁸

• In 2005, the Organ Donation and Recovery Improvement Act provided additional funding for individuals making living donations, funded research to increase public awareness of the donation process, and funded programs to increase hospital donation activities.

• The two types of donors are heart-beating and non–heart-beating donors.

• Heart-beating donation occurs when an individual has sustained a devastating intracranial catastrophe that results in the death of all neurologic functioning, including the brain stem. After two independent neurologic examinations are passed, an individual is declared legally dead and can be considered for potential organ donation. These patients are the single largest source of transplantable organs.¹⁰

• Donation after cardiac death or non–heart-beating donation can be considered after a number of devastating illnesses or injuries that can be classified on the basis of the Maastricht classification.^1,2 Donation after cardiac death is a decision that can be made for a patient having life-sustaining therapy withdrawn. The patient is assessed to determine if he or she is a potential organ donor, and the family is approached for consent by an independent team of healthcare providers (not the recovery team of healthcare providers). After the family has consented and said their final goodbyes, the withdrawal of life-sustaining therapy process occurs. After a predefined period of asystole, usually 2 to 5 minutes, the patient is pronounced dead by an independent physician and the organ recovery process is initiated (see Procedures 135 and 137).

• The Joint Commission has a set of standards specific to organ procurement and hospital policies and procedures and their relationship to the regional Organ Procurement Organization (OPO).^5,6

• Various legal documents (i.e., advance directives, wills, and driver licenses) direct all those involved as to the wishes of the individual to donate. Most OPOs recognize the obligation to maximize the recovery of organs for the benefit of those recipients awaiting life-saving transplantation; however, the implementation of this process should be accomplished in a respectful manner that honors the donor’s wishes. This process must include an approach that provides continuing support and care for the family while guiding them toward an understanding of their loved one’s wishes.⁷

• The patient remains in the critical care unit while the organs to be donated are evaluated and suitable candidates are determined through regional and national registries.

• If the potential donor has a do not resuscitate (DNR) order in place and the family has given consent to donate organs, the DNR is revoked with the knowledge and consent of the family. Thus, if a cardiac arrest occurs, advanced cardiac life support (ACLS) is initiated. If resuscitation attempts fail and recovery teams are available, the recovery process takes place as soon as possible.

• Costs incurred are the responsibility of the regional OPO.

• Early referral to the local OPO is of prime importance. Two common recognition points are a Glasgow Coma Scale score of 5 or less and the absence of two or more brain stem reflexes, which are indicative of a poor outcome in at least 70% of the patients.³

• “First mention” and “decoupling” are two important concepts related to early referral and early intervention.