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The Organ Donation Process

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  1. The Organ Transplant System
  2. The Organ Donation Process
  3. Presumed Consent

The Organ Transplant System

The Organ Transplant system is one of the most analyzed and regulated aspect of medical care today because it depends on the altruism and trust of the public.

In 1984, the National Organ Transplant Act established the Organ Procurement and Transplant Network (OPTN), a national organ sharing system to guarantee, among other things, fairness in the allocation of organs for transplant. The OPTN is operated by the nonprofit organization United Network for Organ Sharing (UNOS). UNOS maintains a central computer network containing the names of all patients waiting for kidney, heart, liver, lung, intestine, pancreas and multiple-organ transplants. The UNOS “Organ Center” is staffed 24 hours a day to respond to requests to list patients, change status of patients, and help coordinate the placement of organs.

Patients experiencing organ failure are evaluated by a transplant physician at a hospital where transplants are performed. If the patient is deemed to be a suitable for a transplant s/he is registered with the UNOS Organ center, where a centralized computer network links all organ procurement organizations (OPOs) and transplant centers. Staffed 24 hours a day throughout the year, the Organ Center assists with the matching, transporting, and sharing of organs throughout the U.S.

When donor organs are become available the local OPO typically accesses the UNOS computerized organ matching system, enters information about the donor organs, and runs the match program

For each organ that becomes available, the computer program generates a list of potential recipients ranked according to objective criteria (i.e. blood type, tissue type, size of the organ, medical urgency of the patient, time on the waiting list, and distance between donor and recipient).

After printing the list of potential recipients, the procurement coordinator contacts the transplant surgeon caring for the top-ranked patient (i.e. patient whose organ characteristics best match the donor organ and whose time on the waiting list, urgency status, and distance from the donor organ adhere to allocation policy) to offer the organ. Depending on various factors, such as the donor’s medical history and the current health of the potential recipient, the transplant surgeon determines if the organ is suitable for the patient. If the organ is turned down, the next listed individual’s transplant center is contacted, and so on, until the organ is placed.

Once the organ is accepted for a potential recipient, transportation arrangements are made for the surgical teams to come to the donor hospital and surgery is scheduled.

The general principles that guide the waiting list are the patient’s medical urgency, blood, tissue and size match with the donor, time on the waiting list and proximity to the donor. Under certain circumstance, special allowances are made for children. For example, children under age 11 who need kidneys are automatically assigned additional points. Factors such as a patient’s income, celebrity status, and race or ethnic background play no role in determining allocation of organs.

Although it is called a ‘list’ there is no ranking patients until there is a specific organ available, because each donor’s blood type, size and genetic characteristics are different. Therefore, when a donor is entered into the national computer system, the patients that match that donor, and therefore the “list,” is different each time.

The other major guiding principal in organ allocation is: local patients first. With the exception of perfectly matched kidneys and the most urgent liver patients, first priority goes to patients at transplant hospitals located in the region served by the OPO. Local transplants decreases the logistical complication’s thereby increasing the chances of a successful donation. Next in priority are patients in areas served by nearby OPOs; and finally, only if no patients in these communities can use the organ, it is offered to patients elsewhere in the U.S.

The Organ Procurement Organizations

The Organ Procurement Organization is an a not-for-profit organization responsible for identification and care of organ donors, organ retrieval, organ preservation, transportation, and data follow up regarding  cadaveric organ donors; OPO staff work with donor families, and educate medical staff and the general public about organ donation. There are currently fifty-eight OPO’s operating in the United States covering every state.  Larger states are covered by more than 1 OPO

The local OPO is responsible for:

-approaching families about the option of donation when they have lost a loved one

-evaluating the medical suitability of potential donors

-coordinating the recovery, preservation, and transportation of organs donated for transplantation

-educating the public about the critical need for organ donation

The Organ Donation Process

Trauma Scene: An individual may suffer an injury to the head from an accident, suffer an aneurysm in the brain, or may have been involved in an event that has caused lack of oxygen to the brain.

Transport: A team of paramedics and emergency medical technicians (EMT) begin life-saving efforts at the scene. They communicate with emergency room doctors during transport to the hospital.

Hospital: Emergency room doctors and nurses have advanced life-support equipment ready when the ambulance or helicopter arrives. They evaluate injuries and continue life-saving measures including ventilator support (mechanical breathing), IV fluid, blood replacement, and medications. An operation may be needed to help in life-saving efforts. The patient is then transferred to the intensive care unit.

ICU: Tests are performed of the brain to determine the damage caused by the accident or other event. Tests may show continued brain activity and blood flow through the brain. If tests show no blood flow through the brain, more tests are conducted to determine if the brain has died. Death is declared at the time brain death is determined.  Click here to learn more about Brain Death.

Brain DeathAfter brain death is declared and explained to the family, a local transplant coordinators meets with the family about donation. If the family consents the coordinator begins the process of relaying critical information to the physicians whose patients will receive the organs and to coordinate the arrival of the transplant surgeons who will remove the organs.

The Transplant: Timing is critical as one of several technicians working with the transplant surgeons readies organ preservation fluids. These fluids will help ensure that the organs remain in good condition from the time they leave the donor’s body to the moment they are transplanted into the recipients. Situated along the sides of the operating room are sterile tables, bowls, towels and plastic bags where recovered organs are brought for a visual inspection and then packed into sterile ice and placed into coolers for transport.

Post-Transplant: The local organ procurement organization often facilitates communication between the transplant recipients and the donor’s family.

Presumed Consent

Currently America and Israel work on an ‘Opt In’ system, meaning anyone who wants to be an organ donor should opt into the system by registering for an organ donor card. The weaknesses of this system are that some people might want to opt in but they are too lackadaisical or forgetful to get around to doing it. Moreover, family members may override the card and ask for the organs not to be recovered.

A system that has been touted as very successful in Europe is called ‘Opt Out.’ This means it is presumed that all citizens have given consent to donate their organs except in cases where they have called up a national register to opt out of the system. Supposedly, this system has produced very high donation rates in Europe. But has it?

Spain is routinely cited as a successful example of presumed consent. But most of the growth in donation rates there happened well after the passage of presumed consent legislation.  Spain’s success is attributed to effective management of the transplant system, not a simple legal rule. Some countries, notably Austria, do have “true” presumed consent, with no provision for kin veto. But they do not outperform countries like the U.S. by any great margin. So why does presumed consent not work in Austria?

Even if presumed consent were to increase organ donation in certain countries in Europe it would not necessarily increase organ donation in Israel and America. Israelis and Americans are, in general, suspicious of the medical establishment and are afraid that organs will be recovered by over-eager surgeons before the patient is actually dead. With presumed consent, a citizen would have to trust that the transplant network in charge of the opt out registry truly has no record of the person opting out. With the opt in system currently in place, there is no need to trust the transplant network because the organ donor card is found in the possession of the donor whose intentions are clear and explicit.

Other resources:

The New York Organ Donor Network

    United Network for Organ Sharing