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Policies,Clinical,UW Health Clinical,Administrative,Legally Driven Care

Organ and Tissue Donation (1.2.14)

Organ and Tissue Donation (1.2.14) - Policies, Clinical, UW Health Clinical, Administrative, Legally Driven Care

1.2.14


UW HEALTH CLINICAL POLICY 1
Policy Title: Organ and Tissue Donation
Policy Number: 1.2.14
Category: UW Health
Type: Inpatient
Effective Date: August 28, 2017

I. PURPOSE

To ensure timely notifications and appropriate requests for organ and tissue donations are made for deaths
or imminent deaths in compliance with state and federal law (Hospital Conditions of Participation for Organ,
Tissue and Eye Donation), applicable accreditation standards, and ethical practices. To ensure that all
patients who are considered for organ, tissue, and eye donation have been evaluated by UW Organ and
Tissue Donation (UW OTD), the Tissue Bank, and/or the Eye Bank, and to ensure all First-Person
Authorizations (FPA) for donation are honored.

II. DEFINITIONS

A. “Imminent death” is defined as a mechanically ventilated patient with a severe brain injury whom a physician
is evaluating for brain death or has a Glasgow Coma Score (GCS) of 5 or less or for whom a physician and
family are planning to withdraw life-sustaining therapies. Such criteria are referred to as the "clinical triggers"
for organ donation.
B. “Notification of UW OTD.” Imminent death requires timely notification to the UW OTD of this patient that has
met clinical triggers.
C. “Timely” is defined as notification to UW OTD within one (1) hour of meeting the criteria of imminent death
as defined above.
D. “Designated requestor” is an individual who has completed training in the methodology of offering the
patient, the legal next of kin (LNOK) of a patient the opportunity of donation, or informing families of a
patient’s first person authorization for donation during the donation consent process.
E. “Family” refers to the persons authorized to make the decisions being addressed, e.g., donation or
withdrawal of care.
F. “Donation after Brain Death” is a donation that occurs after determination of brain death. The legal definition
of brain death is the irreversible cessation of all functions of the entire brain, including the brain stem.
G. "Donation after Circulatory Death" (DCD), also denoted as “Donation After Circulatory Determination of
Death” (DCDD), is a donation that occurs after a terminal extubation and circulatory death is declared. This
is an opportunity for patients with a severe brain injury or experiencing their last illness who do not meet the
criteria for brain death.
H. “State of Wisconsin Donor Registry” is a first-person authorization registry that allows individuals to provide
their own authorization for the donation of their organs, tissue, and eyes.
I. “First person authorization” is documentation of the patient’s authorization for organ, tissue, and eye
donation. The valid methods of First Person Authorization may include: Driver License or Identification Card;
Will; Advance Directive/Healthcare Power of Attorney documentation; Witnessed Communication when
Terminally Ill; Donor Card or Record of Donation: and Donor Registry. If an authorization is made in a state
other than Wisconsin, and is valid in that state, it is a valid authorization in Wisconsin.
J. “Notification of Death.” All deaths are required to be reported to the Donor Referral Line” at 1-866-894-2676.

III. POLICY ELEMENTS

Patients and their families have a right to elect organ, tissue, and/or eye donation in the event of death. It is
the policy of UW Health to offer organ, tissue, and eye donation to all eligible families as an end-of-life
opportunity in a manner that is compassionate and reflects current best practices in donation requesting.
The UW OTD, Wisconsin Tissue Bank, and the Wisconsin Lion’s Eye Bank are the authority for determining
suitability for potential organ, tissue, or eye donation. The Donor Referral Line shall be notified of all deaths
and imminent deaths in a timely fashion. All patients who expire in a UW Health hospital shall have their
decision about organ, tissue, and eye donation documented on the Report of Death Flowsheet, which is part
of the electronic medical record. If the patient has indicated First Person Authorization for donation, the
record of authorization (see definitions section for methods) will be placed in the medical record. If
documentation of first person authorization is present, the Document of Anatomical Gift Authorization form is
not required.

IV. PROCEDURE



UW HEALTH CLINICAL POLICY 2
Policy Title: Organ and Tissue Donation
Policy Number: 1.2.14


A. Referral: Patient meets criteria outlined as Imminent Death.
i. When a patient's clinical status is consistent with the definition of imminent death, a member of the
healthcare team shall call the “Donor Referral Line” at 1-866-894-2676 within one hour of the
patient meeting clinical triggers.
a. The Donor Referral Line will request patient info to complete this referral.
b. Completion of this phone call will be documented in the EMR.
c. After notification UW OTD, tissue bank, or eye bank will communicate the first person
authorization status of the patient.
1. This consent status will be documented in the EMR progress note.
2. The FPA evidence will be entered into the EMR.
d. Appropriate efforts must be made to ascertain the existence of a POA for health care.
e. After notification, UW OTD, tissue bank, or eye bank will communicate the eligibility status
of the patient as an organ, tissue, or eye donor.
1. Patient suitability as a donor will be documented in the EMR progress note.
f. The nurse caring for the patient shall notify the faculty attending physician or a member of
the medical staff of referral to the Donor Referral Line, consent status, and donor
suitability.
ii. If the patient is not an eligible donor per UW OTD, tissue bank, or eye bank, a request for donation
should not be made. This should be documented on the Report of Death Flowsheet in Health Link.
B. Consent for organ, tissue, or eye donation
i. No member of the care team should initiate a discussion about donation with the patient and/or
family/next of kin (NOK) until the patient has been referred to the Donor Referral Line and a
recovery agency representative has affirmed a consent conversation should occur.
ii. Donation conversations should be facilitated with a Designated Requestor present.
iii. Per Wisconsin state statute 157.06 consent for donation shall be obtained from the highest priority
person in the following list who can be contacted and is able and willing to make the decision
whether to donate:
ξ Patient
ξ Health care agent or power of attorney and has authority to make an anatomical gift for
the patient
ξ Spouse
ξ Adult Children
ξ Parent
ξ Adult Sibling
ξ Adult Grandchild
ξ Grandparent
ξ Adult who exhibited special care or concern for the patient, except as a compensated
health care provider
ξ Legal Guardian
ξ Any other person who has authority to dispose of the body (i.e., coroner)
iv. If the patient does not have FPA, the Documentation of Anatomical Gift Authorization form must be
filled out completely by recovery agency staff or a designated requestor.
v. The Anatomical Gift Authorization form shall be placed in the patient's medical record.
vi. Documentation of a refusal shall be made on the Report of Death Flowsheet and a progress note in
Health Link with his/her own name and title, and the name and relationship of the person refusing
donation.
vii. If the patient is determined suitable for donation, and consent to donation is obtained, or the patient
has documented FPA, Hospital staff shall follow the direction of the appropriate recovering agency
(UW OTD, tissue bank, or eye bank).
C. Donation after Brain Death
i. According to the Uniform Determination of Death Act, brain death is defined as “an individual who
has sustained irreversible cessation of all functions of the entire brain, including the brain stem”.
ii. The physician-of-record or their designated representative is responsible for informing the family of
the patient's death. Record of death (date and time) shall be documented in the patient's record.
iii. After determination of brain death, management of the potential donor is conducted by UW OTD
following the Brain Death Order Set (Navigator).
iv. Only UW OTD may determine eligibility for donation after brain death.



UW HEALTH CLINICAL POLICY 3
Policy Title: Organ and Tissue Donation
Policy Number: 1.2.14

v. Optimal recovery of organs is achieved by maximizing collaboration among UW OTD and Hospital
staff. UW OTD coordinators can enter orders within the guidelines of the donor management
protocols.
vi. Recovery procedures will comply with standard OR procedures. Communication with the OR prior
to recovery will be completed by the Organ Procurement Coordinator (OPC) from UW OTD.
D. Donation after Circulatory Death (“DCD”)
i. Eligibility of a DCD Donor.
a. The patient must have suffered a brain injury, be experiencing his/her last illness (e.g.,
end stage musculoskeletal disease, end stage cardiopulmonary disease, and high spinal
cord injury) and a decision has been made that life-support is no longer beneficial to the
patient, such that the patient's death would be imminent, as determined by the patient's
primary health care team, subsequent to the removal of the ventilator and vasopressor
support.
b. A patient can be considered for DCD if the patient, family, or other decision-maker has
elected to withdraw life-sustaining treatment in agreement with the patient’s care team.
c. Only UW OTD can determine eligibility for DCD.
d. A candidate for DCD:
1. Does not meet the criteria for brain death.
2. The patient, family, or other decision-maker has chosen to withdraw mechanical
and medical support in agreement with the patient’s care team.
3. The family or the patient (if there if evidence of FPA) provides consent for
donation.
4. No medical or social contraindications to donation are present as determined by
UW OTD medical director or their designee.
5. Circulatory death is likely within a reasonable period (often within 120 minutes or
less) after the withdrawal of ventilator support.
6. Should circulatory death not occur within the designated time frame, efforts to
recover organs will not be pursued and a plan is made to return the patient to a
suitable unit and continue comfort care.
7. Discontinuing DCD organ donation efforts does not specifically preclude tissue
donation eligibility and processes.
e. The opportunity for organ donation should not be offered to the patient, family, or other
decision-maker until they have acknowledged that the patient has a non-recoverable injury
or illness as determined by the patient's physician and they have elected to withdraw life-
sustaining treatment.
ii. Consent for DCD Donation.
a. The consent discussion should include:
1. Disclosure of possible medication administration such as heparin, phentolamine
(Regitine), hydralazine, amphotericin B, n-acetylcysteine (Mucomyst), vitamin E,
ursodiol, and prednisone or other medications whose purpose is to improve
organ function.
2. The possibility of procedures prior to withdrawal of life-sustaining treatment
intended to facilitate optimal organ function such as femoral vascular access
under local anesthesia and bronchoscopy.
3. The possibility that cardio-respiratory arrest will not occur in a time frame that will
allow for organ donation.
A. The patient will remain under the care of the primary treating team and
will be returned to the appropriate nursing unit.
b. If those authorized to donate would like to proceed with DCD donation, the following
consent paperwork must be completed:
1. Method of FPA or Documentation of Anatomical Gift Authorization
2. UW OTD’s Donation After Circulatory Death (DCD) Consent Form
A. This form must be completed by a person authorized to make medical
decisions for the patient
B. This form includes consent for: administration of heparin, phentolamine
(Regitine), amphotericin B, n-acetylcysteine (Mucomyst), vitamin E,
ursodiol and prednisone, femoral artery and vein access under local
anesthetic, bronchoscopy, placement of arterial line, and conduct of a



UW HEALTH CLINICAL POLICY 4
Policy Title: Organ and Tissue Donation
Policy Number: 1.2.14

DCD tool.
iii. Management of a DCD Donor.
a. An order set, the DCD Donor Navigator is installed which guides the attending physician in
the management of the patient to optimize the recovery of transplantable organs.
b. UW OTD staff cannot write orders for patients being managed for DCD donation.

V. DCD RECOVERY PROCESS, INCLUDING END-OF-LIFE CARE AND PRONOUNCEMENT OF DEATH

A. An attending physician or senior fellow not affiliated with UW OTD or transplantation will prescribe end-of-life
medications including analgesics/pain medications and adjust ventilator settings according to their practice
and hospital policy.
B. An attending physician or senior fellow (under the direction of the patient’s attending or critical care
attending physician), is responsible for the discontinuation of life support and determining circulatory death.
i. The above physician will inform the procurement team of the extubation time and time cardiac
death is pronounced.
ii. Death is declared after the loss of effective circulatory function (absence of blood pressure by
arterial line monitoring, pulse, and cardiac sounds) and a five minute waiting period.
iii. Following the five minute wait period the physician must immediately document the date and time
of circulatory death.
C. Operating Room Withdrawal of Life-Sustaining Therapies and Declaration of Death
i. Once all the necessary documentation, coroner clearance, evaluation, and recovery arrangements
have been completed, and all members of the recovery team are present, the patient will be
transferred to the operating room.
ii. The process of DCD is to be considered as a continuation of the patient’s critical care unit
management until the declaration of death. Therefore, anesthesia providers (including
anesthesiologist and anesthetists), except when acting in the role of critical care physicians, are not
involved in the withdrawal of life-support, other pre-mortem care, or declaration of death.
iii. The same standards for monitoring the patient during the transport to the MRI/CAT scanner, etc.
are to be used in transporting the potential donor to the OR.
iv. The potential donor’s attending physician, critical care attending physician, or senior critical care
fellow under the direct supervision of the critical care attending physician will accompany the
potential donor to the OR and is responsible for the continuous ventilation of the potential donor.
v. Respiratory support should be provided by the potential donor’s current ventilator, other respiratory
support devices, or transport ventilator. These devices should be brought to the OR by a
respiratory therapist who will ensure the ventilator is appropriately set and connected to the patient.
vi. After arrival to the operating room, an active time-out will be conducted to confirm correct patient,
procedure, position and availability of any special equipment needed according to UWHC policy
#8.48, Operative, Invasive, and Other Procedures.
vii. In the operating room the patient will be positioned, prepped, and draped in a standard fashion.
viii. Cannulation of the femoral artery and vein access under local anesthetic will be completed if
necessary and as approved by patient, NOK authorization, or appropriate surrogate authorization.
ix. Family members are allowed to be present in the operating room for the withdrawal of life-
sustaining treatment and declaration of death if they wish. After death is declared and prior to the
recovery procedure, the family will be escorted out of the operating room to a pre-determined
location with a pre-determined support staff person.
x. Pre-donation medications are given by an attending physician or senior fellow, under the direction
of a critical care attending physician, prior to the withdrawal of support.
xi. The ICU nurse will be present for end-of-life care.
xii. The respiratory care professional will assist with cares for as long as ventilatory support may be
required.
xiii. Discontinuation of mechanical ventilation, extubation (removal of the endotracheal tube),
withdrawal of non-beneficial life sustaining medical therapies, provision of comfort care, and the
declaration of circulatory death are the responsibility of the potential donor’s attending physician,
critical care attending physician, or senior critical care fellow under the direction of a critical care
attending physician. These aforementioned responsibilities may not be delegated to an
anesthesiologist, anesthetist, anesthesia resident, or member of the transplantation team. For
AFCH, this will be an attending physician.
D. The patient's vital signs will be closely monitored and recorded by a UW OTD coordinator as required



UW HEALTH CLINICAL POLICY 5
Policy Title: Organ and Tissue Donation
Policy Number: 1.2.14

following removal of ventilator and vasopressor support.
E. No UW OTD surgeons or recovery specialists may be present in the operating room when the removal of life
sustaining therapies takes place and may not return until after death has been declared.
F. The physician will, immediately following the death, write a pronouncement note and document the time of
death in the patient's medical record.
G. The organ recovery procedure will take place in accordance to UW OTD DCD recovery protocols.
H. If the patient does not achieve circulatory death within the appropriate time interval for organ donation, the
appropriate service and physician (patient’s attending or critical care physician) will continue to provide care
and the patient will be transferred to the appropriate pre-determined location (ICU or palliative care setting)
for end of life and comfort care.

VI. DCD RECOVERY OF LUNGS

A. The anesthesiologist, other than when acting in the role of the critical care physician, will not be involved in
the pre-mortem care of the potential donor, or declare death.
B. The potential donor being considered as a potential lung donor will require postmortem intubation.
i. Postmortem procedures may not be performed by the physicians involved in the withdrawal of life-
sustaining therapies or the declaration of death; cases potentially requiring postmortem intubation
will necessitate notification of an attending anesthesiologist by the OPC at the time the case is
posted with the OR.
a. This discussion should include:
1. Planned OR time
2. Need for the presence of the anesthesiologist for postmortem intubation
3. Number of minutes between extubation and declaration of death (warm ischemia
time) the thoracic or cardiac surgeon will accept before declaring the lungs not
viable for transplantation
4. The name of the attending physician responsible for caring for the potential donor
in the OR (or ICU if withdrawal of life sustaining therapies is to occur in ICU)
5. Expected time of extubation
6. Whether and which ventilator will accompany the patient to the OR
7. A discussion between the potential donor’s attending physician or critical care
attending physician and an attending anesthesiologist prior to the potential donor
being transported to the OR, or before the withdrawal of life sustaining therapies
in the ICUs.
ii. The anesthesiologist to be contacted is dependent upon which hospital and at what time the
withdrawal will occur.
a. At University Hospital the attending anesthesiologist to contact is:
1. Monday - Friday 7 a.m.- 4 p.m.: – the attending anesthesiologist in charge of the
OR
2. Monday - Friday 4:01 p.m. - 6:59 a.m. – the first call attending anesthesiologist
3. Weekends and Holidays (all day) – the first call attending anesthesiologist
b. At AFCH the attending anesthesiologist to contact is:
1. Monday - Friday 7 a.m. - 4 p.m. – the attending pediatric anesthesiologist in
charge of the OR
2. Monday - Friday 4:01 p.m. - 6:59 a.m. – the first call pediatric attending
anesthesiologist
3. Weekends and Holidays (all day) – the first call pediatric attending
anesthesiologist
iii. The anesthesiologist contacted will be responsible for assuring the presence of an attending
anesthesiologist or resident under direct supervision of the attending anesthesiologist at the
specific time arranged.
C. The designated attending anesthesiologist or resident under the direct supervision of the attending
anesthesiologist will intubate the donor immediately following the 5 minute wait period following circulatory
arrest if this occurs within a time frame consistent with lung donation (typically up to 30 minutes following
extubation)
D. The sole responsibility of the anesthesiologist (or resident under direction) is to intubate the donor (if
deemed a candidate for lung donation), assure that the endotracheal tube is in the correct position, and
inflate the lungs. The continued ventilation of the donor is the responsibility of the transplantation



UW HEALTH CLINICAL POLICY 6
Policy Title: Organ and Tissue Donation
Policy Number: 1.2.14

physicians, their designees, or Respiratory Therapy. The continued ventilation of the donor’s lungs should
be via the potential donor’s ventilator, an additional ventilator, or transport ventilator, and not be via the
ventilator or circuit on the anesthesia machine.
E. The anesthesiologist responsible for postmortem intubation must be immediately available. If it is decided
either the potential donor or the donor is not a candidate for lung donation or if the potential donor does not
achieve circulatory death within the timeframe consistent with lung donation, the presence of or availability
of the anesthesiologist is no longer required.

VII. ICU WITHDRAWAL OF LIFE SUSTAINING THERAPIES AND DECLARATION OF DEATH

A. When organ donation is being considered, the ICU is not the preferred location for withdrawal of life-
sustaining therapies but will be considered in extenuating circumstances.
B. The following are modifications to the process as outlined in Section V.C, Operating Room Withdrawal of
Life Sustaining Therapies and Declaration of Death
i. After withdrawal of life-sustaining therapies circulatory death is declared by an attending physician,
or senior fellow, under the direction of an attending physician, following a five (5) minute waiting
period after cessation of cardio-respiratory function.
ii. The declaration of circulatory death may occur in the ICU and then the patient is transferred to the
operating room.
iii. Alternatively, the patient may be transferred to the operating room after the cessation of cardio-
respiratory function and death may be declared in the operating room.
C. In the event there is persistent cardio respiratory function greater than 120 minutes following extubation, the
patient remains in their room and under the care of the attending physician.
D. After death is declared and arrival to the operating room, an active time-out will be conducted to confirm
correct patient, procedure, position, and availability of any special equipment needed according to UWHC
policy #8.48, Operative, Invasive, and Other Procedures.

VIII. TISSUE AND EYE DONATION

A. Tissue and eye donation only occurs after cardiac standstill.
B. All deaths reported to the Donor Referral Line are referred to the respective tissue and eye bank (Wisconsin
Tissue Bank and the Wisconsin Lion’s Eye Bank).
C. The Wisconsin Tissue Bank coordinator will provide direction via telephone for the tissue recovery process.
i. The tissue recovery may occur in the operating room within 24-hours of the patient’s death. In
some instances the patient may be transferred to another location for the recovery to occur (e.g.
request for autopsy, etc.).
ii. The body should be placed in the refrigerated morgue, as soon as possible after death, with proper
identification.
iii. The body should NOT be released to the funeral home until a decision about donation has been
determined.
D. The Lions Eye Bank coordinator will provide direction via telephone for the eye recovery process.
i. Gently close the eyelids immediately after death.
ii. Elevate the head at least 30 degrees.
iii. Apply small wet ice packs to the closed lids.
E. Hospital staff should only speak with families about tissue and eye donation with consultation from
Wisconsin Tissue Bank and/or Lions Eye Bank.

IX. POST MORTEM CARE

A. Once all organs, tissue, and/or eyes have been recovered, the body is prepared and transferred to the
morgue. Release to the medical examiner or the funeral home designated by the family may then proceed.
(See UW Health policy #3.3.8, Disposition of the Body After Death.)

X. FINANCIAL CONSIDERATIONS

A. The UW OTD bears financial responsibility for all procedures and processes related to anticipated organ
recovery. At such time that the recovery process is initiated, the donor “flag” will be instituted; effectively
notifying hospital billing of appropriate billing lines.



UW HEALTH CLINICAL POLICY 7
Policy Title: Organ and Tissue Donation
Policy Number: 1.2.14

B. Should a DCD recovery be terminated due to persistent cardiac function, the UW OTD is responsible for
removing the billing flag.

XI. FORMS

Document of Anatomical Gift Authorization for Organ and Tissue Donation (DPH 43025)
Donation After Circulatory Death (DCD) Consent Form
Consent to Operations, Anesthetics, Diagnostic Radiology, Transfusions, or other Procedures (#1289139)
Report of Death Flowsheet in the Discharge Navigator in Health Link (#4009322)
State of Wisconsin Donor Registry Certificate of Gift form, when applicable

XII. COORDINATION

Author: Director, Organ and Tissue Donation
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Director, Nursing Quality and Safety
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: July 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

XIII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

XIV. REFERENCES

Wis. Stats., sec. 157.06.
UWHC policy #8.48, Operative, Invasive, and Other Procedures
UW Health policy #3.3.8, Disposition of the Body After Death


XV. REVIEW DETAILS

Version: Revision
Last Full Review: August 28, 2017
Next Revision Due: August 2020
Formerly Known as: Hospital Administrative policy #4.31