Organ Donation after Brain Death

[Nccity2002, MSN, RN]

Hi There,

I am interested in finding out what is the practice of other facilities/states in regard to how much time is given to families to make a decision in regard to organ donation, once a patient is legally declared brain dead. I work in a busy trauma ICU, and in the last three months it seems we are having more situations where brain dead patients (and I mean, legally declared by two MD's, physical exams, and in some case cerebral angiograms), are being kept for long period of times in an ICU bed (twelve days, the longest one, after the patient was declared!!). All those situations involved difficult families dynamics and plain old difficult families; and in many of those situations, they kept changing their minds when they felt that their demands were not being met, such as sponsoring four family members from Mexico...after the hospital already sponsored three other relatives.

My undestanding is that insurance/ medicare stop paying for care once a patient is legally declared, I had worked in community/county hospitals where once declared, family are given 48 hrs to make a decision...but my current facility is a teaching hospital. I think my facility is trying to meet the family emotional needs...but from a practical standpoint, what is the practice in other places??

Thanks!!

[Sun0408, ASN, RN]

In my Trauma ICU it is pt/family based. We do not declare brain death with two MD's, it must be with a blood flow study. If there is no blood flow to the brain, the pt is declared and removed from life support with in hours if they are NOT a donor. The decision is usually made for donation before brain death is declared; however, the donation can not take place until the pt has progressed to brain death. Most of the time, the pt dies before brain death/donation can happen. We try our best to keep them alive( per family wishes) for donation but sometimes death works faster than our meds can help.. Or the family decided against donation and removes the pt from life support before brain death happens..

I know there is much more to this but this is the cliff notes. Just got home from a very long shift

[Esme12, ASN, BSN, RN]

The difference here is that you are in a teaching facility and I'll bet they do transplants. They have patients sitting in the building that need organs and they can control the donor's care much more effectively once brain death has been declared. Once brain death has been declared the patient is dead, legally, thoroughly dead.....so you are right insurance companies do not pay. The organ bank and facilities share the cost of the care of the donor. I this case the hospital itself which is partially covered in the transplant itself.....or in grants or the transplant charges/costs itself......or classify the costs as losses, a write off so to speak.

Also, there is no travel time for the organs to arrive at the recipient's location. When the donor is in the community setting the care costs are minimally recovered. The transplant teams have little to NO control over the care of the donor and you have to count in travel time of the removed organ to get to the recipient.....so time limits will be VERY different.

I think you new facility being a teaching facility are not only trying to appease the families but they are trying to save several lives that are physically near by. I will tell you I have dealt with families that definitely vacillate more than others due to cultural beliefs and they can be very trying and time consuming to deal with......but I am sure your facility is just trying to save several lives with one tragic death and have the skill and know how to accomplish this goal.

I know it seems ridiculous to you in the length of time they are allowing these families to vacillate.....but I'll bet they know what they are doing. Peace :paw:

[BelgianRN]

In Belgium everyone is presumed an organ donor unless they signed an official declaration they don't want to. In theory we can harvest their organs regardless of the family wishes, but in practice it is asked to the family if they object (I think it is done in almost all centers in the country). If they object then care is withdrawn immediately. At most there is a 12 - 24 hour waiting period for family members to come over and say their goodbyes.

But I have to say we rarely get refusals from family members if their loved one hasn't made an official refusal himself/herself. Brain death is declared by three MD's one of which has to be a neurologist/neurosurgeon. And out of formality we'll do a 4-vessel angiography of the brain but by law that isn't required.

Most refusals come from the non-christian religions, generally the jewish and muslim patients (we have huge communities of both in my city). But we have a rabi and an imam that explain to these patients and/or their family that it isn't against their religious beliefs to participate in organ donation. The only religious problems come from the Buddhists because they are not allowed to participate, but they are a minority in our city and naturally their wishes get respected.

[Nccity2002, MSN, RN]

In my Trauma ICU it is pt/family based. We do not declare brain death with two MD's, it must be with a blood flow study. If there is no blood flow to the brain, the pt is declared and removed from life support with in hours if they are NOT a donor. The decision is usually made for donation before brain death is declared; however, the donation can not take place until the pt has progressed to brain death. Most of the time, the pt dies before brain death/donation can happen. We try our best to keep them alive( per family wishes) for donation but sometimes death works faster than our meds can help.. Or the family decided against donation and removes the pt from life support before brain death happens..

I know there is much more to this but this is the cliff notes. Just got home from a very long shift

Hi Sun0408,

Thanks for you input, and hope you got some sleep!!

We are very pro-active in identifying and preserving potential organ donors. We have an "organ perfusion protocol" which allow us to implement interventions (such as pressors and aggresive ventilation management) to maintain major organs perfused, when a patient is deemed a potential donor. The nurse can initiate the protocol in collaboration with the medical team. The problem is that sometimes, we are so good at stibilizing these potential donors that it is harder for families to accept the fact that their loved one is really gone (all they see is that their loved one is pink and warm to touch....), therefore making it more difficult for them to make a decision, one way or the other.

[Nccity2002, MSN, RN]

Hi Esme,

Thanks for you insight in the process.

We actually only do kidnesy and livers; but I had not been aware of any inpatients receiving organs from one of our donors....usually the organs are shipped out, to other places. I think you are right, for once, a hospital is trying to do the right thing by empowering families and I am proud to work at such a facility...still, sometimes, I wonder if we may be overdoing it, especially when we bend over backward to meet/accomodate them and it never seem to be enough.

[Nccity2002, MSN, RN]

In Belgium everyone is presumed an organ donor unless they signed an official declaration they don't want to. In theory we can harvest their organs regardless of the family wishes, but in practice it is asked to the family if they object (I think it is done in almost all centers in the country). If they object then care is withdrawn immediately. At most there is a 12 - 24 hour waiting period for family members to come over and say their goodbyes.

But I have to say we rarely get refusals from family members if their loved one hasn't made an official refusal himself/herself. Brain death is declared by three MD's one of which has to be a neurologist/neurosurgeon. And out of formality we'll do a 4-vessel angiography of the brain but by law that isn't required.

Most refusals come from the non-christian religions, generally the jewish and muslim patients (we have huge communities of both in my city). But we have a rabi and an imam that explain to these patients and/or their family that it isn't against their religious beliefs to participate in organ donation. The only religious problems come from the Buddhists because they are not allowed to participate, but they are a minority in our city and naturally their wishes get respected.

Hi BelgianRN,

What you just described is what I am mostly used to. In California, if someone indicates(via DMV records) that they wish to become an organ donor, legally, the organ procurement organization in CA (One Legacy) has the legal right to procure the organs without family authorization...althought they usually try to respect the family wishes, therefore they rarely enforce it (I had only witnessed one case where they actually persue it). As you mentioned, I often find it very helpful when religion is weighted in the decision process and there is someone of religious authority who is able to provide guidance as to what is acceptable when it come to organ donation.

Thanks for your reply!!

[ckh23, BSN, RN]

Our facility gets the ethics committee involved immediately. The organ procurement team should have already approached the family about donation before hand. We give about 24 hours for family members to come if they are coming from far away. After that it is explained to the family the patient will be taken off the vent regardless of donation or not.