Nursing challenges associated with non heart beating organ donation.

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Author: Levvey, Bronwyn J.1

NHBD is a process where organs are donated after the patient has been declared dead due to irreversible cessation of cardiopulmonary function. This contrasts with heart beating donation (HBD) where organs are donated following brain death. Prior to neurologic definitions of death being established in the 1970s, all organs for transplantation were donated from NHBD. However, as HBD is technically easier to perform, and maintaining organ perfusion provides better quality organs, this became the most common practice for organ donation.(n1) Technical advances in preservation solutions and procedures have facilitated shortened warm ischaemic times (WIT) and improved organ quality from NHBD.

There are four categories of NHBD, referred to as Maastricht categories.(n2) These are divided into controlled or uncontrolled NHBD. In the controlled situation -- typically in an intensive care unit (ICU) -- a decision has been made to withdraw life support and the family has consented to organ donation.

In the uncontrolled situation, usually in the emergency room or coronary care, death is sudden and unexpected. Although this type of NHBD could potentially provide the most donors, the reduced time frame available to obtain consent for donation and for organ preservation procedures to minimise WIT currently limits the utilisation of uncontrolled NHBD.(n3)

While organ donation is generally a positive outcome from a traumatic situation, caring for a potential organ donor and their family can be both rewarding and stressful. The reemergence of NHBD presents new challenges for health professionals, particularly for ICU and operating theatre nurses.(n4)

After the certification of brain death and consent for organ donation, nursing care of a HBD in ICU focuses on maintaining patient comfort, as well as ventilatory and haemodynamic stability to ensure optimum organ perfusion. Due to the support of cardiopulmonary function, the HBD donor does not appear deceased clinically (i.e. warm with a pulse), thus the concept of death may be difficult for the family to comprehend. The ICU nurse also supports the family, who may spend many hours with the donor until transfer to theatre.

In contrast, following cardiopulmonary cessation, the NHBD is obviously clinically deceased (i.e. cool and pulseless) and this may be more confronting for the family and even for nurses experienced in the organ donation process. Due to the need to transfer the NHBD to theatre within 30 rains after death (to reduce WIT) the family has less time to spend with the donor, and this may be challenging for some families. In some hospitals withdrawal of treatment may take place in the theatre. Not all theatres are ideally suited to having family present and theatre nurses may find supporting the family difficult, particularly when they too are adjusting to a change in practice.

Other requirements with NHBD may also make the donation process more challenging. To reduce WIT damage, organ specific preservation procedures must be instituted, and these may occur whilst the NHBD donor is still in ICU or when transferred to theatre. The timing of these procedures varies depending on the specific NHBD protocol(s) used and generally are performed by the organ procurement team. However there may be occasions where the nursing staff in ICU or theatre will be required to assist with these procedures, and education should be provided as soon as a NHBD protocol is introduced, so that nursing staff are familiar with these procedures.

Organisational and timing issues, dealing with strained relations with surgical teams, and concerns about donor dignity reportedly contribute to theatre nursing staff stress in relation to organ donation.(n5) Effective and timely communication, and provision of additional resources and staff, can minimise additional stress when planning for organ procurement from a NHBD, particularly if it occurs during peak operating time.

Nurses in ICU and theatre are integral to the success of the NHBD donation process. It is important to acknowledge the challenges that ICU and theatre nurses face with NHBD organ donation and to provide ongoing education and support.

As with HBD, the role of donor coordinator is vital in the NHBD process, primarily in providing support for the donor family, but also for nursing staff.

Notwithstanding the challenges of this change in organ donation processes, nurses have a duty to facilitate positive societal attitudes toward organ donation, particularly when this aligns with expressed patient and family wishes surrounding end of life care.

(*) NHBD is also known in some countries as donation after cardiac death (DCD).

(n1.) National Health and Medical Research Council, Ethical issues in organ donation, Discussion paper No. 4, Certifying death: the brain function criteria, Commonwealth of Australia, 1997.

(n2.) Koostra, G. et al. The non heart beating donor, Transplantation Proceedings, 28:1, 1996, p.16.

(n3.) Levvey, B. et al. Non heart beating organ donors: a realistic opportunity to expand the donor pool, Transplant Nurses Journal, 13:3, 2004, pp.8-12.

(n4.) De Veaux, T.E. Non heart beating organ donation: issues and ethics for the critical care nurse, Journal of Vascular Nursing, 24:1,2006, pp.17-21.

(n5.) Regehr, C. et al. Issues in clinical nursing. Trauma and tribulation: the experiences and attitudes of operating room nurses working with organ donors, Journal of Clinical Nursing, 13, 2004, pp.430-437.