In 1987, the United Network for Organ Sharing began administering the national Organ Procurement and Transplantation Network, comprising 58 organ procurement organizations (OPOs) around the country. That laid the foundation for what was to become a major overhaul of the U.S. organ donation system. Since then, great strides have been made in increasing the numbers of donors and donated organs.
Figure. Wendy Kazlul...Image Tools
Unfortunately, the waiting lists for those organs have also risen dramatically, far outstripping those gains.
Since 1987 several other initiatives have contributed to the increases in organ donations. The Centers for Medicare and Medicaid Services and the Joint Commission (under their former names) revised their conditions of participation to require hospitals to work more closely with their region's OPO. A series of “organ donation breakthrough collaboratives,” started in 2001, identified best practices and developed donation protocols; these later morphed into the Donation and Transplant Community of Practice (DTCP), which shares best practices of high-performing OPOs and donor hospitals and publishes data on donors and the numbers of donor organs made available.
In 2006, the Uniform Anatomical Gift Act was revised, enabling states to create effective organ donor registries, and the nation saw growth in the use of donation after cardiac death and “expanded criteria donor kidneys” (kidneys from donors with medical complexities), which helped to meet the transplantation needs of the nation's aging population. Recently, the national lung allocation policy was revised, on a trial basis, to enable candidates 11 years old and younger to be dually listed—at their hospital and at hospitals up to 1,000 miles away—to allow offers from adult and adolescent donors.
The DTCP began setting yearly donor goals in 2011, and we've already exceeded 2013’s goals in two areas: a 75.4% conversion rate of possible donors to actual donors (the target was 75%) and a rate of donation after cardiac death of 11.8% (the target was 10%).
As the U.S. population ages, however, the gap between organ supply and organ demand is only going to rise.
Back in 1987, 6,976 patients received cadaverous kidneys and 11,922 were on the waiting list, a deficit of nearly 5,000; by 2000, according to Wynn and Alexander (Transplant International, April 2011), the waiting list had ballooned to nearly 45,000. And the news hasn't gotten much better in the years since then; according to the National Kidney Foundation, of the nearly 119,000 people waiting for lifesaving organ transplants, more than 96,000 are waiting for kidneys; in 2012 only about 17,000 kidneys were transplanted, approximately 11,000 of which came from deceased donors.
THE OPO SYSTEM
Hospital-based nurses are the primary source of potential-donor referrals to OPOs, and they make those referrals based on the information, support, and administrative supervision they get from the OPO coordinator serving their hospital's donation service area.
OPO coordinators, the majority of whom come out of critical care, go by many names, such as hospital services coordinator, hospital development manager, or organ placement specialist. They educate targeted staff—intensive care nurses, physicians, residents, and facility-based transplantation coordinators, for example—on all aspects of donor identification, referral, and management (care of the donor that maximizes the potential for successful donation); work closely with hospital organ and tissue recovery teams; and follow up with the hospital and donor families on placement of the organ and the recipient's status.
OPO staff essentially become part of the donor hospital's health care team, says Teresa Shafer, MSN, RN, CPTC, former vice president and chief operating officer at LifeGift Organ Donation Center in Fort Worth, Texas. And according to Gina Garcher, RN, a hospital services coordinator at Cleveland-based Lifebanc, which works with more than 80 facilities in Northeast Ohio, “The goal with just about everything [OPO coordinators] do is to increase knowledge and donations—especially at the smaller hospitals that may see only two or three donations a year—and eliminate the myths and misconceptions that go along with organ donation.”
What donation involves. A variety of strategies are employed to give potential donors and families a greater understanding of what donation really involves. Rather than sending an OPO, for instance, University of Wisconsin Organ and Tissue Donation trains and certifies designated requestors who are on a hospital's staff. They're trained to identify potential donors, assess a family's understanding of the patient's prognosis, explain brain and cardiac death, and act as an advocate for both the donor and the potential organ recipient.
LifeNet Health in Virginia uses the so-called Spanish model, in which nurse champions on all critical care units are trained to be donor advocates with patient families.
“Even though our OPO is always the designated requestor, these nurses are very involved in the approach process,” says Britta Cruz, LifeNet's hospital development manager. “One hospital made the nurse champion program part of the nurse evaluation process and clinical career ladder.”
“Think, Care, Act: The Role of the Nurse in Organ and Tissue Donation” is a free, online continuing education course (see http://bit.ly/15bTtog) that walks nurses through the professional, legal, and regulatory roles nurses play in organ donation.
KNOCKING DOWN BARRIERS
Among the greatest of the barriers to progress are the myths and misconceptions to which Garcher refers. The Mayo Clinic in Rochester, Minnesota, maintains a list of common myths surrounding organ donation (http://mayocl.in/19xv30) that keep patients and families from considering it. Here are just a few:
* “If I agree to donate my organs, the hospital staff won't work as hard to save my life.”
* “Maybe I won't really be dead when they sign my death certificate.”
* “Organ donation is against my religion.”
* “I'm too old to donate. Nobody would want my organs.”
* “I'm not in the best of health. Nobody would want my organs or tissues.”
Battling the attitude. The attitudes of bedside nurses themselves create yet another barrier. Roels and colleagues, reporting in the August 2010 Transplant International, asked (non-American) physicians and nurses whether they supported donation and whether they would donate their own, their children's, or other relatives’ organs after death, and nurses in nearly every case were less inclined to say yes than physicians. And a study of moral distress among nurses by Elpern and colleagues in the November 2005 American Journal of Critical Care revealed a correlation between moral distress and organ donation, some of which came from “seeing blood products and organs ‘wasted’ on patients who were not expected to benefit from transfusion or transplantation.”
Patrice Pfeiffenberger, BSN, RN, International Transplant Nurses Society board member and Penn Transplant Institute's transplant coordinator, says that changing attitudes isn't easy because they're tied to beliefs. “If [nurses] believe in [organ donation], they believe in it. If they don't, they don't.”
To change attitudes and beliefs, though, nurses must be exposed, while they are still in school, to the entire donation–transplantation continuum, not just to the role the bedside nurse plays in identifying a potential donor, says Debra Whisenant, PhD, MSPH, BSN, coauthor of a study in the September 2012 International Journal of Nursing Education and Scholarship on attitudes of baccalaureate nursing students toward organ donation. “When students were shown videos of actual organ procurement—how it happened, that it wasn't brutal or disrespectful—it made a big difference in their attitudes about organ donation,” she says, and made them “more likely to approach a potential donor.”
Pfeiffenberger believes that's easier said than done. She points out that adding donation-specific coursework to an already crowded curriculum may be difficult because “nursing programs can't touch on every subspecialty there is.”—Eileen Beal
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