Donation Resources

Our goal is to collaborate with your team to support patients and their families through the end-of-life process and to honor the choice of those who wish to be donors. Our hope is that you will feel confident that you have the resources and support available to you to recognize, refer and support potential donors. Our commitment to you is that we will be available to answer questions, offer support and facilitate donation conversations 24/7. The resources listed here are intended as reference materials for hospital staff and medical professionals. If you have a patient who meets the clinical trigger, are providing support to families who are considering withdrawing care or are asking questions about donation, or if you have additional questions not answered here, please call the 24-hour donor referral line at 1-800-344-8916.

Please note, this information is intended for medical professionals. If you have reached this page in error, please return to the home page

Recognizing the Clinical Trigger

Regulatory agencies and individual hospital policies require ALL patient deaths and imminent deaths to be referred to the Pacific Northwest Transplant Bank (PNTB) in a timely manner for assessment of donation potential. This requirement ensures that all patients and their families are afforded the opportunity to donate organs, eyes and tissues if they choose and are medically suitable. Because compliance is monitored closely and reported to regulatory agencies, PNTB has collaborated with hospitals in Oregon, SW Washington and Western Idaho to define a clinical trigger to help hospital staff identify and refer all potential donor patients in a timely manner (ideally within 1 hour of a patient meeting one of the criteria below).

Call the PNTB Referral Line 1-800-344-8916 if you are caring for a patient that meets any of the following criteria:

  1. A severely brain injured, ventilator-dependent patient with either :
    1. Clinical findings consistent with a Glasgow Coma Score of less than or equal to 5, and/or
    2. A plan to discontinue mechanical or pharmacological support for end of life
  2. A patient who has had comfort care measures ordered
  3. A patient who is made DNR, and death is expected within this hospitalization
  4. If a patient’s family is considering withdrawing support, end of life care options, or has asked about donation specifically
  5. At time of death, even if that patient has been previously referred***
  6. Prior to the mention or ANY conversation about donation
*** call needs to be made within one hour after death

Making the Referral

WHY THE EARLY REFERRAL? For most hospital staff, calling the donor referral line to report a patient who meets the clinical trigger is a routine part of their patient care and best practice philosophy. The early referral ensures that best practices are in place if and when donation becomes appropriate. Early referrals can:

  • Prevent withdrawal of care prior to determination of patient’s wishes and potential opportunity for organ donation
  • Provide for OPO and hospital collaboration for adequate physiological support of a donor patient
  • Allow for OPO and hospital partnership to support the wishes of both a patient and a family
  • Prevent deceleration of support prior to declaration of death
  • Prevent inadvertent or inappropriate timing of conversations with families or delivery of the wrong information (i.e., donor designation, medical suitability)
  • Allow OPO staff to share best practices in the management of catastrophically brain injured patients with physicians and nursing staff
  • Allow OPO staff to support hospital staff in delivery of grim prognosis to families and ensure that only trained requestors approach a family about donation
  •  Allow OPO staff sufficient time to adequately prepare and set the framework for positive outcomes for patients, families and hospital staff
MAKING THE (EARLY) REFERRAL Identify if your patient meets one or more criteria of the clinical trigger (donation should not be mentioned to the family at this point)
  1. A severely brain injured, ventilator-dependent patient with either :
    1. Clinical findings consistent with a Glasgow Coma Score of less than or equal to 5, and/or
    2. A plan to discontinue mechanical or pharmacological support for end of life
  2. A patient who has had comfort care measures ordered
  3. A patient who is made DNR, and death is expected within this hospitalization
  4. If a patient’s family is considering withdrawing support, end of life care options, or has asked about donation specifically
  5. At time of death, even if that patient has been previously referred
Call the donor referral line: 1-800-344-8916 (donation should not be mentioned to the family at this point)

When making the initial referral call, you will be asked to provide the following:

  1. Your name, hospital name, unit, call-back number
  2. Patient name, age, date of birth, gender, race, medical record
  3. Whether the patient has ever been on a ventilator; if not currently, date and time of extubation
  4. Cause of death or admitting diagnosis including any known medical history
*It may be helpful to have the patient’s chart available when you call

If a patient meets initial criteria for organ donation (under the age of 80, currently ventilated with a severe neurological injury) (donation should not be mentioned to the family at this point)

  1. A clinical coordinator from PNTB will call you back (within 10 minutes of your call to the referral line) to further assess the patient. Below you will find a list of example questions that you may be asked in this phone conversation. It is important to have the patient's chart easily accessible and to be available to have a 5-10 minute phone conversation with the PNTB coordinator. Please refer to the Donor Referral Worksheet for additional details about the information PNTB will need to assess your patient.
    1. What is the patient’s neurological status?
    2. What are the current vital signs, labs, current medications?
    3. What is the past medical history?
    4. Is there a plan for brain death testing?
    5. What is the current plan of care?
    6. What is the family understanding of the events/grim prognosis?
    7. Has donation been mentioned?
    8. A patient’s designation as a donor will be confirmed in this conversation. PNTB staff has access to the state registries and will inform you if your patient has established legal authorization for donation. This legal choice may be made through the DMV (on a driver’s license or state ID card), an advanced directive, living will or donor card. In the event that your patient is a designated donor, PNTB will fax you a copy of the Document of Gift. This is legal documentation authorizing an individual’s consent for donation and should be included as a permanent part of the medical record.Document of Gift example

      For more detailed information about state laws regarding donor designation, please refer to Regulatory and Compliance: donor designation

    9. If we cannot determine a patient’s potential for organ donation during this initial conversation with you, it is our policy to make onsite visits to further investigate medical compatibility for organ donation. If your hospital is located in the Portland/Metropolitan area, we will be onsite within one hour. For hospitals outside of that area, we will be onsite as quickly as possible. (If your hospital is located outside the Portland/Metro area, we may follow the patient over the phone for a day or more until we are able to make an onsite visit.)
When PNTB staff arrive onsite (donation should not be mentioned to the family at this point)
  1. Upon our arrival to your unit, PNTB staff will conduct a more thorough chart review and talk with you in additional detail in order to make a determination of medical potential for organ donation based on the patient’s history and current condition.
  2. If the patient is not medically suitable for organ donation, we will ask that you call the referral line again after the patient expires. If the patient has medical potential to be an organ donor, we will ask to “huddle” with the entire care team, including the physician. In our initial huddle we will confirm with all hospital staff that this patient is a potential donor and outline the anticipated plan of care including medical support of patient, family understanding of patient’s prognosis and appropriate timing for discussion of end of life/donation with the patient’s family.
  3.  Depending on many factors including the prognosis of the patient and the family’s understanding of the circumstances,  if appropriate we may stay onsite to work with the family, and begin donor management. In many cases however, we will continue to follow a patient over a series of days, checking in with the bedside RN each shift, and potentially making onsite visits every few days.
When is it appropriate to talk to a family about donation

Many healthcare providers find that working with grieving families who are facing the loss of a loved one is often the most challenging part of their job. Delivering a grim prognosis or explaining death is never easy, and it is natural to want to cushion the “bad news” with something positive that could offer hope and future health to others. While it may be tempting to couple bad news with information about donation, we know after years of experience and national best practices that talking about donation in the wrong setting or at the wrong time can lead to disastrous consequences for families, hospital staff and potential recipients.

Supporting families through the initial trauma of losing their loved one is our top priority, and our staff is specially trained to be able to have detailed and meaningful conversations about donation. Every family is different, and every donation case is unique. We will work closely with you and rely on your guidance to determine the most appropriate timing to have the donation conversation with a family. Some general guidelines to remember for grieving families:

  • Families experiencing crisis are experiencing psychological trauma. As a result, they have a more limited ability to understand, comprehend, retain information and problem solve. “Dose” a family slowly with information about their loved one’s prognosis and remember that they will likely need to be given the same information several times.
  • Current research suggests that the most important elements of delivering bad news to patients or their families involves the following components: conversation timing, honesty and openness, appropriate attitude, clarity of message, privacy, sympathy and instilling confidence that any questions can and will be answered.
  • We are working with people who are experiencing a traumatic personal tragedy. It is important to remember that how they would “normally” think, or “normally” act may not be possible because for many, stress caused by crisis can suppress abilities to function rationally. While they may “normally” accept donation, their everyday thinking patterns may be compromised. Nothing in their current environment or state of function is “normal.”
  • Families need time to accept that their loved one is not going to survive. More importantly, they need to feel confident that their loved one has, and continues to receive the best medical care with the most opportunity for survival. It is critical that the medical care of patients and potential opportunities for donation are separated in conversations with families.
  • Donation should not be discussed with families without the presence of a trained requestor. Currently, PNTB is the trained requestor for organ donation in all hospitals in the state of Oregon. Not only does this distinction visually represent a separation between medical care and donation options, it ensures families have access to have all information about their opportunities and/or decisions for organ donation. We will partner with hospital staff to have donation conversations with a family when the time is appropriate.
What Should I Say If…
  1. A family has already told me they don’t want donation?
    •  “I certainly respect your feelings. There are some decisions you can make with hospital staff and some you can’t. It is our hospital’s policy that donation is one of the conversations we need you to have directly with the donation agency. While unfortunately I can’t inform the agency of your choice, I can help facilitate that conversation and make sure all of your questions and concerns are addressed.”
  2. A family asks me why someone will be contacting them in the next couple of hours?
    • “Every family in our state has the opportunity to talk directly with a representative from a donation agency about eye and tissue donation. We are committed to ensuring that you have the most accurate information so you can make/support the best choices for your loved one. The donation agencies have a lot of information that we don’t have, and are experts in guiding families through this process. I can assure you they are respectful and equally committed to supporting your loved one and your family. I encourage you to talk with them.”
  3. A family wants their loved one to be a donor, but they aren’t medically suitable?
    • “Our hospital is very supportive of donation, and we are appreciative of your thoughtfulness of others during this time. We have talked with our donation partners who have reviewed (patient’s name) medical history and considered every possible donation option. Unfortunately, because of (exclusion reason), (patient’s name) is not a candidate for donation. I would be happy to get a representative from the donation agency on the phone to talk with you if you have more questions?”
  4. A family asks me about donation before I have called the referral line?
    • Stay focused on the present - coordinators from donation agencies are always available to support families and address questions. More important than knowing donation options, your job is to ensure families feel confident that their loved one is getting the best possible medical care and given the best chance for surviving their injury.
    • If a patient is on life support but is not brain dead (or if test results are pending):  “Right now, we are focused on doing everything we can to offer your loved one the best possible outcome for survival. Before we can know more, we need to wait and see what these tests will show us. We will contact our partners at the donation agency and make sure you have every opportunity to get all of your questions answered.”
    • If a patient is on ventilatory support and test results have confirmed death:  “Our hospital supports donation and we want to make sure all of your questions are answered. We partner with an organization called PNTB - they are the experts in organ donation. I’ll give them a call so I can connect you with them right now to talk to you about donation options.”
    • CALL THE DONOR REFERRAL LINE!!! We are happy to talk to any family - no matter what time!
  5. A family wants to withdraw support now and I haven’t called the referral line, OR the patient is a candidate for donation and there are no coordinators currently onsite?
    • “There are some policies and standards of care that must be completed before we can move forward with withdrawing ventilator support. I will mobilize our support team who will meet with you and talk about this process. We want to make sure that you are informed of all of your options, so you can be as comfortable as possible as you heal in the weeks, months, and years to come. Our team will help with this and should arrive in ____ minutes.”
      • Call the referral line and we will evaluate for donation potential and donor designation
      • Avoid last minute situations by referring when you suspect families may be getting close to electing to withdraw support
  6. A family is in the room when a patient becomes unstable or we are doing brain death testing and asks what is going on?
    • It is important to be honest, but also recognize family’s limited understanding during crisis. “(Patient’s name) blood pressure has dropped and we need to stabilize it see what’s going on.” OR “We suspect that despite all of our best efforts, (patient’s name) brain may be dying. We need to perform some tests and keep his body stable until we’re able to determine exactly what has happened.”
      • Supporting a patient allows time for the family to accept brain death or non survivable injuries and make decisions without pressure - regardless of donation outcomes
      • Remember, brain death testing is diagnostic, and its purpose is not solely for organ donation
      • It is NOT FAIR to talk to a family about donation in this situation!
  7. A family asks me what will happen if s/he is declared brain dead?
    • "If brain death is declared, there will be some additional conversations you will need to have. If and when the time is appropriate, I will introduce you to colleagues who will talk you through the next steps."
  8. A patient is a registered donor and the family has brought up donation?
    • “(Patient’s name) designated their wish to be an organ and tissue donor. I would like to introduce you to (Donation Agency Representative name) who is here to work with you to fulfill their wishes. S/he will answer all of your questions and support you through this process.”
    • For Eye and Tissue donors only: “(Patient’s name) designated their choice to be a tissue and eye donor through the (DMV, donor registry). A coordinator for the donation agency is going to work with you to fulfill their wishes and answer all of your questions. I could connect you with them by phone now, or if you would prefer, I can have them call you after you are at home and more settled in.”
    • **Remember to call the donor referral line BEFORE this conversation, so you know if your patient is registered or not!
  9. A patient is not a registered donor and I need to get contact information for family to give to the donation agency?
    • “There are a lot of things to think about at this time, and we are committed to supporting you through all of your decisions. I can help you think about an autopsy, and provide some options for funeral homes. I also would like to get a phone number where you can be reached in the next 1-2 hours if there are additional things to cover after we have finished our conversations.”

Determining Brain Death

Brain death accounts for less than one percent of all deaths in the United States, and can be quite confusing for families confronting an unexpected loss of a loved one. It is not unusual for families to question a brain death declaration: although ventilators are artificial, basic logic suggests that a beating heart, a chest rising and falling with each breath and warm skin indicate life. However, we now know that there is no resuscitative strategy that will revive a brain that has been deprived of blood and oxygen and whose cells have died. Brain death is a legal, clinical and measurable condition.

The Determination of Death Act (1980) defines brain death as the “irreversible cessation of all functions of the entire brain, including the brain stem.” In order for donation coordinators from PNTB to manage organ donation, a patient must be declared dead. While PNTB donation coordinators are available to offer guidelines to hospital staff testing for brain death, brain death is not and cannot be declared by donation coordinators. Brain death should not be declared using any arbitrary or subjective judgments and must be declared in accordance with hospital policies, medical standards, and national best practices. Below you will find general guidelines for determining brain death. These are only guidelines, and are suggested with the understanding that every clinical situation is different and may require other and/or additional methods of evaluation. If you have questions, please refer to your hospital policy and physician practice. Additionally, the Brain Death Checklist outlines the minimum diagnostic criteria necessary for diagnosing brain death.

NEUROLOGY 2010 Determining Brain Death in Adults

Critical Care Medicine; 2011 Pediatric Brain Death Guidelines

Ventilator self-cycling may falsely suggest patient effort during brain death determination

Brain death: assessment, controversy, and confounding factors

Declaration of Brain Death Checklist

  1. Presence of a severe neurological injury
  2. Absence of the following confounding factors:
    1. Temperature < 36 C
    2. Severe hypotension (SBP <100 as appropriate for patient's age)
    3. Drug intoxication or effects (barbiturates, opiates, neuromuscular blocking agents, etc.)
    4. High cervical spinal cord injuries
    5. Severe electrolyte, acid-base and/or endocrine disturbances
  3. Clinical exam which conclusively excludes the following reflexes:
    1. Spontaneous respirations
    2. Bilateral motor responses (excluding spinal reflexes)
    3. Corneal reflex
    4. Cough and gag reflexes
    5. Negative doll’s eyes
    6. No response to ice calorics
  4. Apnea Challenge Test
    1. Normalize patient’s PaCO2 and confirm with ABG
    2. Hyperoxygenate with 100% O2 for 10 minutes
    3. Remove patient from vent and deliver 6-10 L of O2 via ET-tube
    4. Observe for respiratory effort for 6-10 minutes (if patient becomes hemodynamically unstable, draw ABG and resume ventilation)
    5. After 6-10 minutes of apnea, draw ABG BEFORE placing patient back on vent
    6. If PaCO2 is >60 mmHg and no respiratory effort is exhibited, the test is positive for apnea which indicates lack of brain steam function and is confirmatory for the diagnosis of brain death
  5. Should steps 1-4 not provide adequate criteria for diagnosis of brain death, other confirmatory tests such as cerebral perfusion scan, cerebral angiogram, and EEG can also be used to confirm brain death.
Suggested Guidelines for Caring for the Catastrophically Brain Injured Patient (CBIGs)

The following are guidelines intended to preserve the option of donation and are commonly referred to as Catastrophic Brain Injury Guidelines (CBIGs). These guidelines are to help guide the care of the potential organ donor, while preventing harm should a patient survive their injuries. They are meant as care recommendations before death has been formally declared, and before the donation coordinator takes over medical management of the donor patient. **All patient care management will be dictated by the hospital physician/care provider unless or until the patient has legally been declared brain dead AND disclosure or authorization for organ donation has occurred.**

  1. Management Goals:
    1. Normalize hemodynamic status
      1. Optimize fluid balance:
        1. Continue maintenance IV fluid infusion
        2. Consider fluid bolus (crystalloid or colloid) for hypotension
        3. Blood product replacement as indicated by hospital policy
      2. For hypotension unresponsive to fluid bolus:
        1. Consider vasopressor support to maintain either a MAP > 60 or a SBP >90mmHg (7 years-adult), >80mmHg (6 months-2 years), >60 (0-6 months)
        2. Preferred drugs for organ preservation:
          1. Dopamine 0-20mcg/kg/min
          2. Neosynephrine 0-200 mcg/min (adult), 0.1-0.5 mcg/kg/min (pediatrics)
    2. Optimize oxygenation/ventilation
      1. Maintain oxygen saturation >95%
        1. Adjust FiO2 to keep PaO2 >90
        2. Use physiologic PEEP (+5cm H2O)
      2. Normalize pH (7.35-7.45)
        1. Normalize pCO2 (~40mmHg)
        2. Administer buffers (e.g. sodium bicarbonate) as indicated
      3. Prevent pulmonary edema/pneumonia
        1. Pulmonary toilet/suction/reposition q 1-2 hrs
        2. Follow daily chest x-rays
    3. Treat coagulopathy
      1. Maintain normothermia (core temperature 36.5-37.5°C)
      2. Monitor CBC and coagulation panel daily
      3. Blood product/factor replacement as indicated by hospital policy
    4. Treat neuro-endocrine disturbances
      1. Diabetes insipidus (urine specific gravity <1.005 and sustained polyuria)
        1. Consider treatment of hypernatremia (Na>155)
        2. Preferred drugs for organ preservation:
          1. DDAVP 0.5-1 mcg IV, repeat dose Q2h as indicated
          2. Vasopressin continuous IV infusion 0.5-5 U/h (adult), 0.5-1 milli-U/kg/hr (pediatrics)
      2. Impaired glucose tolerance
        1. Utilize hospital insulin therapy protocol to treat hyperglycemia
    5. Monitor and treat electrolyte abnormalities
      1. Monitor electrolytes daily
      2. Utilize hospital electrolyte replacement protocol
    6. Treat infection
      1. Broad-spectrum antibiotic coverage for clinical indications of infection

Goals of Donor Management

Donor management will begin when brain death has been declared and authorization or donor designation for organ donation has been obtained. A PNTB Donation Coordinator will be onsite and will work closely with you to begin donor management.

PNTBs donor management goals are fairly similar to goals that are already in place for any critically ill patient and are meant to optimize and maintain organ function. They are as follows:

-MAP 60-100 (IVF first, followed by vasopressor support if needed)

-CVP 4-10 (preventing pulmonary edema and also treating DI)

-EF >50% (on minimal to no vasopressor support, enabling us to evaluate true heart function without artificial support)

-pH 7.3-7.55 (treat acidosis with ventilator changes or bicarbonate administration)

-P:F ratio >300 (CPT, Albuterol, bronchoscopy, recruitment maneuvers)

-Na 135-155 (proper fluid resuscitation)

-PO4 >1.5 (electrolyte replacements)

-Glucose <150 (insulin infusion)

-UOP 0.5-3 ml/kg/hr (treating hypovolemia, rhabdomyolysis, DI)

In addition to these goals, maintaining normovolemia, normothermia, pulmonary toileting, preventing any electrolyte imbalance, preventing aspiration, treating infections, treating coagulopathy, and preventing cardiac arrest are all best practices when caring for a potential organ donor.

**Donor management does not occur in patients who have been determined to be suitable candidates for donation after circulatory death (DCD).  In these circumstances a PNTB coordinator will work with the attending physician for appropriate orders to properly evaluate and maintain the patient’s organs.

Operating Room Resources

PNTB’s donation coordinators will work closely with your operating room scheduler to schedule a time for surgical recovery of organs. PNTB coordinators arrange for transplant surgeons from a transplant center to perform the organ recovery; however, we utilize hospital staff for the circulator, scrub nurse and anesthesiologist positions.

Multiple organ recovery can take anywhere from 3-6 or more hours to complete. PNTB coordinators will assist you with setting up your surgical suite in preparation for organ recovery, and will be available to answer any questions prior to bringing the patient to the operating room. Click on the PDFs below for specific information on operating room set up for organ donation, and anesthesia guidelines for organ donation.

OR Room Set Up

Anesthesia Guidelines

Forms

  • Donor Referral Worksheet This form lists most of the information you will need to report when making an eye/tissue referral, and can help you organize the information prior to placing the call. However, in many cases Lions VisionGift will still need to obtain additional information to judge medical suitability for donation.