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PRACTICE GUIDELINE PRACTICE GUIDELINE TITLE: Organ and Tissue Donation TARGET AUDIENCE This guideline applies to clinical staff involved in the processes of organ and tissue donation. Further information and enquiries about organ and tissue donation can be made to the Donation Specialist Nursing Coordinators (DSNC). They are available 24 hours a day; 8am – 10pm Mon-Fri via pager 4040, and outside of those hours on 9347 0408. PURPOSE The purpose of this guideline is to provide clinical staff with an overview of organ and tissue donation practice. This guideline explains the details of the various pathways to organ and tissue donation, and the key requirements and personnel. This guideline covers: • Donation of organs and tissue from deceased persons. This guideline does not cover: • Donation of organs from living persons. • Blood donation for transfusion, cord blood donation, donation of reproductive tissues or bone marrow. • Donation of tissue used for routine medical care (e.g. femoral head, heart valves, iliac vessels). GUIDELINE Introduction and Explanation of Terms Organ and tissue transplantation are an effective and well-established treatments that can save lives or significantly improve the quality of life of transplant recipients. The majority of organ and tissue transplants occur after the donation of organs and tissues from deceased donors. The terminology used in this field may be complex and requires explanation: Organ donation: Donation of solid organs such as heart, lung, liver, kidney, pancreas, stomach and intestine. Tissue donation: Donation of bone, tendon, skin, heart valves, blood vessels, thoracic aorta, pericardium, islet cells. Eye and corneal donation: Eye and corneal donation is usually referred to separately, but for the purpose of this document will be considered with tissue. ORGAN AND TISSUE DONATION SERVICES NB: Each state of Australia has their individual Organ and Tissues Donations Services. For the purpose of this practice guideline, the State of Victoria’s services will be identified. There are three donation services in the state of Victoria. DonateLife Victoria facilitates donation of solid organs. The Lions Eye Donation Service are responsible for eye/corneal donation and research, and the Donor Tissue Bank of Victoria (DTBV) facilitate the donation of bone and related musculoskeletal tissue, skin, heart valves and pericardium. When a person is identified as a potential organ and/or tissue donor, rather than all three different services contacting the families, the Donation Specialist Nurse Coordinator (DSNC) will liaise with the families on behalf of the Lions Eye Donation Service and the Donor Tissue Bank of Victoria. Organ and Tissue Donation Roles • Donation Specialist Nursing Coordinator (DSNC) – Key Roles: PRACTICE GUIDELINE TITLE: Organ and Tissue Donation o Facilitating organ and tissue donation cases, including checking the Australian Organ Donor Register prior to discussing donation with the families of potential donors o Being the primary point of contact for all communication relating to donation cases within the ICU, operating theatres and other wards in the hospital o Responsibility for coordinating logistics and operational/organisational aspects of all donation cases o Providing staff education and support regarding organ and tissue donation o Providing community awareness and education regarding organ and tissue donation o Implementing best practices in the donation process o Auditing and reviewing all donation cases o Hospital representation at DonateLife Network meetings • Medical Donation Specialist (MDS) – Key Roles: o Staff support, education and case follow up o Maintenance of up to date guidelines and review of processes within the hospital o Representation at DonateLife Network meetings o Chair meetings of the Hospital’s Health’s Organ and Tissue Donation Advisory Committee o Engagement with the Hospitals Health’s executive and administration, and also with other relevant stakeholders within the Hospital o Implementing best practice in the organ donation process o Auditing and reviewing all organ donation cases • Designated Officer It is an offence for staff to remove human tissue from a deceased person, except where the Human Tissue Act 1982 (Vic) provides that it is lawful (e.g. where it is validly authorised by the Designated Officer). At the Hospital, only the Designated Officer of the hospital may provide authorisation for the retrieval of donated organs or tissue. The Designated Officer is usually contacted by the DSNC or the MDS. For more information regarding the role of the Designated Officer, see the Consent - Designated Officer Guideline. IDENTIFICATION OF THE POTENTIAL ORGAN AND/OR TISSUE DONOR Tissue Donors Potentially anyone who dies in hospital and is ≤70 years old may become a tissue donor; ≤ 80 years old may become a corneal/whole eye donor. Information about eye and tissue donation can be obtained by contacting the Donation Specialist Nursing Coordinator on page 4040 or phone 93470408. Additional information can be obtained from Lions Eye Donation Services (03 9929 8708 or 0408 370 148), or the Donor Tissue Bank of Victoria (03 9684 4444). Automatic referral of deaths within the Hospital to the Donor Tissue Bank of Victoria At the Hospital, the patient administration system automatically notifies the Donor Tissue Bank of Victoria (DTBV) of all patients under the age of 70 who die. Staff at the DTBV then screen these patients for suitability for tissue donation, which may include contacting medical staff from the admitting unit and/or nursing staff who cared for the patient to clarify medical suitability. If the patient is suitable, DTBV staff will then contact the deceased’s senior available next of kin to seek consent for tissue donation. Section 45 of the Human Tissue Act 1982 (Vic)1 allows hospital staff to disclose medical information to staff at the DTBV for the purposes of assessing suitability for tissue donation. PRACTICE GUIDELINE TITLE: Organ and Tissue Donation Modified from Alfred Hospital Care of the Dying Patient Guideline November 2018 Organ Donors Potential organ donors are those who: a) Have been declared brain dead; or b) Are being considered for withdrawal of cardio-respiratory support; and c) Have been considered medically suitable for donation by a DSNC in consultation with DonateLife. CONTRAINDICATIONS TO ORGAN AND TISSUE DONTATION There are very few absolute contraindications to organ, eye and tissue donation2. Staff are required to discuss all potential cases with the DSNC, even where medical suitability is considered unlikely. DONATION PATHWAYS Donation after Brain Death (DBD) - The majority of organ and tissue donors are brain dead. The diagnosis of brain death and the management of brain-dead donors are covered in the separate document, Donation after Brain Death Guideline. Donation after Circulatory Death (DCD) - In the case of DCD, retrieval of organs takes place after cessation of the circulation which follows a planned withdrawal of cardio-respiratory support within the ICU. The process and management of organ donation after circulatory death is covered in a separate document, Donation after Circulatory Death Guideline. Tissue Donation - Donation of tissue can occur in the mortuary or external agency up to 12 hours after death, and any patient who dies at Alfred Health may become a tissue donor unless there are specific contraindications, which include but are not limited to haematological malignancy, progressive neurological disorders such as Parkinson’s Disease, Alzheimer’s, Multiple Sclerosis and Motor Neuron Disease, Viraemia or fungaemia, as well as hepatitis B and C. OVERVIEW OF THE ORGAN DONATION PROCESS Every organ donation case is different. It is the role of the DSNC to coordinate the process. Organ donation can take many hours, from 3 to over 24 hours. The length of time a donation case takes depends of a number of factors including: • Ability to physiologically support the intended donor • Organs potentially being donated • Family needs When organ donation proceeds, the deceased will be moved to the operating theatre for surgery at a time that has been agreed upon by the family, theatre and the DSNC. For theatre preparation and anaesthetic management, refer to Australasian Transplant Coordinators Association (ATCA) Guidelines. The DSNC is the primary point of contact for all communication relating to donation cases, which includes communication with the family, ICU, operating theatre, anaesthetics and visiting retrieval surgeons. A viewing may take place post donation surgery depending on the wishes of the family. ESCALATION PROCESS FOR DIFFICULT CASES Co-ordination of organ donation cases can be complex, with a number of competing interests that need to be considered for each stakeholder involved in a donation case. The DSNC is the key person responsible to co- ordinate a number of aspects necessary for a case to proceed to donation. Most of the time, this occurs without problems. There are some situations where escalation to the Hospital donation clinical team and/or hospital executive may help in progressing a complex case. PRACTICE GUIDELINE TITLE: Organ and Tissue Donation 1. The treating Intensivist may wish to only manage the withdrawal process and relinquish the organ donation related responsibilities to a Medical Donation Specialist (MDS), particularly in a DCD case. 2. For any case that may have anticipated complexity, particularly due to the patient or family situation, the DSNC should involve one of the Alfred MDSs as soon as is reasonable. The best MDS to contact should be discussed with the treating Intensivist. Examples include, but are not limited to, un-survivable burns, all ECMO cases or a difficult family dynamic. 3. For any case that is not following standard process that potentially compromises the outcome, for any reason, this should be discussed with the MDS and escalated to the Emergency and Acute Medicine Service Director (in hours) or the Service Director (on call) after-hours (contactable through switchboard). An example would include delayed access to theatre or where there is more than one organ donation being managed simultaneously. DISCUSSING ORGAN AND/ OR TISSUE DONATION WITH THE FAMILY All families of patients who are dying should receive information about organ and/or tissue donation. The provision of this information should be delivered in a manner that is matched to the family’s needs, and in the context of multi-disciplinary support for the family, to ensure that family members are