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Organ Donation in Trauma Patients: An Overview of Treating Patients Versus Saving Organs in

the Emergency Department

By: Sydney Parrish

Senior Honors Thesis

School of Nursing

University of North Carolina at Chapel Hill

April 13, 2020

Approved:

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Abstract

Organ donation is a complex, controversial topic in today’s healthcare world. Even with

increased efforts to support more patients on the organ donation waiting list, the organ shortage

continues, as the number of candidates on the waiting list exponentially increases annually

compared to the number of eligible donors and performed transplants. The question is, where can

we intervene to close the gap between these numbers? Research shows that one area in need of

reformation is the emergency department, specifically regarding organ donations among

deceased patients with traumatic injuries. Trauma patients account for many of the deaths

occurring in the hospital setting; therefore, to maximize the availability of deceased donor

organs, it is extremely critical to evaluate the emergency department and trauma patients as

potential donors. A review of the literature was conducted to determine the gaps and barriers that

exist during the organ donation approach, specifically after trauma-related deaths. It is essential

that the communication gaps which occur between healthcare professionals and families, as well

as the various ethical factors associated with organ donation, are addressed in order to enhance

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Organ Donation in Trauma Patients: An Overview of Treating Patients

versus Saving Organs in the Emergency Department

Organ donation is prevalent in today’s healthcare world; however, it is a very

controversial and ethically intertwined topic to discuss. Every 10 minutes, another person is

added to the United States organ donation waiting list (Health Resources & Services

Administration, 2019). In 2017, roughly 115,000 candidates remained on the United States organ

donation waiting list according to the Organ Procurement and Transplantation Network.

Comparatively, with only 16,473 donors, both deceased and living, just 34,770 transplants were

conducted (Health Resources & Services Administration, 2019). Organ donation and

procurement rates can often be influenced by the colliding perspectives of patients, families,

healthcare professionals, and hospital systems; therefore, there are many factors to consider

when addressing the concept of organ donation. The most important consideration includes the

emotional factors and injuries relating to the patient’s death, and whether such injuries are a

result of trauma or non-trauma-related causes. Some additional influences on donation rates

include the emotions and characteristics of healthcare professionals, timing of the donation

request, the environment in which the request occurs, prior family knowledge and opinions of

organ donation, and various ethical factors involved in treating patients and organs.

In order to holistically understand this multi-faceted topic, many studies and journal

articles were reviewed to address the barriers and communication gaps which exist between

healthcare professionals and the families of patients during the organ donation approach,

specifically after trauma-related deaths. Compared to non-trauma patients, donation in trauma

patients may be more challenging due to increased emotional stress, more complicated or

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addition, organ procurement procedures are considered much more complex in nature than most

other medical procedures in the healthcare world, as maintaining viability and optimal conditions

of multiple organs after death is the priority. This, in turn, brings in many ethical considerations,

as healthcare professionals must shift from treating the patient to saving the organs. Altogether,

organ donation in the emergency department among patients with traumatic injuries is a

multi-faceted and extremely complex topic with a countless number of factors to consider.

Due to increased emotional stress associated with these sudden and unexpected deaths

and the higher levels of injury complications, there are many barriers and communication gaps

that exist between healthcare teams and families of the trauma patient. This paper will discuss

these barriers and communication gaps, as well as how organ donation in trauma patients coming

into the emergency department is much different from non-trauma patients, such as those in

long-term intensive care units.

Roles and Perspectives of Emergency Department Healthcare Professionals

It is important to consider the perspectives of healthcare professionals before, during, and

after the organ donation process, as well as how these professionals can take part in the overall

organ donation process. The first step for healthcare professionals includes identifying potential

organ donors and planning how this process will unfold closer to and after the death of the

patient. With this being said, it is important to note emergency physicians and nurses play a vital

role in identifying and referring dying or deceased patients at times in which organ donation is a

possibility. A “Potential Organ Audit” was conducted in the United Kingdom between April 1st,

2012 and March 31st, 2016. This audit revealed that over this four-year period, 1,556 patients

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these, 1,112 patients were eligible donors; however, only 45 patients, or three percent of those

that were eligible, actually donated their organs (see Figure 1).

Figure 1. The potential for organ donation from patients who died in the Emergency Department (UK Potential Donor Audit, 1st April 2012 – 31st

March 2016). Reprinted from Organ donation and the emergency department: A strategy for implementation of best practice,by NHS Blood and

Transplant Organ Donation and the Emergency Department Strategy Group, November 1 2016, retrieved from

https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/2098/ed-strategy-final-nov-2016.pdf Copyright 2016 by NHS Blood and Transplant.

During this initial step of identifying potential donors, many healthcare professionals are

faced with the dilemma of when to draw the line between treating the patient and when to begin

treating the organs. A qualitative study conducted in Pato Branco, Brazil focused on the feelings

and emotions experienced by nurses related to organ donation. There were many reports of

“conflicting feelings” due to the sadness associated with the loss of a patient, but also happiness

related to the potential opportunity to donate organs to help other patients. One nurse, in

particular, pointed out that even through her feelings of sadness, she chose to find joy and

positivity in the fact that organ donation can be the final product of death (Marcondes, Dutra da

Costa, Pessôa, & do Couto, 2019).

Furthermore, in this initial step, there are many additional considerations to think about

when deciding to treat the patients versus the organs for potential procurement after a traumatic

or unexpected accident. First, in recognizing a potential donor, all mechanically ventilated

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considered for organ donation once the decision of brain death has been made. Brain death can

be defined as death due to irreversible cessation of all functions of the entire brain, including the

brainstem (Dailey, Geary, Merrill, & Eijkholt, 2017). This becomes a problem in emergency and

trauma settings, as the resuscitation of a patient is a time-sensitive event which leaves little time

to waste. The emergency department team plays a major role in caring for the patients up until

the time of official death, with chest compressions and mechanical ventilation, as transplant

teams can only manage the donor after death. In instances in which there is limited time,

specifically during trauma cases, many nurses and doctors do not have time to consult with an

organ donation specialist team about the identification of donors. All potential donors, including

those with clearly recognizable contraindications, should be referred to an organ donation team

as soon as possible so they can advise the emergency team on the specifics of saving organs for

donation.

The next step for healthcare workers in the organ donation approach includes talking with

the families about donation. There are times in which patients are unable to consent to healthcare

decisions or make their needs known, especially following traumatic incidents which lead to

them being brought into the emergency department. In situations like these, the family members

become the point of contact for healthcare professionals. Nurses in the previously discussed

qualitative study conducted in Brazil report that the greatest difficulty related to the family

approach is the lack of knowledge family members have about organ donation and

transplantation. Along with this, nurses believe the idea and declaration of “brain death” can put

a lot of strain on the organ donation discussion in general (Marcondes et al., 2019). In the study,

many families reported they did not understand the true meaning of brain death, or they had

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emotions to the table for families. Nurses felt this factor had a negative impact on the number of

families who agreed to donation of their loved one’s organs (Marcondes et al., 2019). Altogether,

healthcare professionals agree that the manner of the organ donation approach with families, as

well as the level of baseline healthcare knowledge families have about organ donation in general,

greatly affect the percentage of families who agree to organ donation for their family members.

After talking with family members, the healthcare team’s job is focused on the

preservation of organs for donation. Doctors and nurses must apply critical thinking in this stage,

as a variety of metabolic, endocrine, and immunological conditions may impact organ

maintenance and survivability (Gardiner et al., 2017). Emergency department staff must think

ahead and anticipate these problems, in order to save the organs for donation. A major barrier

healthcare professionals face is the prolonging of the post-mortem period, the time period after

death, as they work to definitively determine the moment of death. It is reported that even if

consent for organ donation is granted by patients and families, healthcare teams struggle with the

determination of an ethically appropriate time to transition from resuscitative efforts to

preservation of the organs (Daily et al., 2017). Clearly, in this stage, some ethically challenging

situations and feelings arise, and healthcare professionals struggle with the idea of doing no harm

to the patient while balancing treatment between the patient, their families, and their organs.

In conclusion, there are many factors to consider within the perspectives of healthcare

professionals before, during, and after the organ donation process. Many professionals report

worrying about not only approaching the family about organ donation, but also about the ethical

factors related to declaring death or attempting resuscitation for potential donors. The decision of

declaring a patient dead is a discretionary judgment made by the healthcare team, therefore,

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All in all, teams in the emergency department report struggling with their default emotions and

natural actions in saving the patient over the organs, as well as when to terminate

cardiopulmonary resuscitation (CPR). There is a major gap between the number of eligible

donors who come into the emergency department and the number of patients who actually donate

their organs.

Perspectives of Families in the Organ Donation Process

Traumatic accidents and subsequent injuries take a major toll on a patient’s ability to

make healthcare-based decisions for themselves. Specifically, organ donation requires that

consent be given from either the patient or the family; however, families are often the ones left to

consent to the donation of their dying or deceased loved one’s organs. For healthcare

professionals, it is of utmost importance that communication to and from the family is clear, and

that the well-being of the family is consistently considered through the consent process. Not only

are families largely impacted by the content and manner of the request made by healthcare

professionals regarding organ donation, but they also tailor their decision based on the patient’s

circumstances of death. In a high-stress emergency setting, these factors may be skewed, and

many families are impacted by the alterations in the characteristics of the organ donation

process.

An article describing a scoping review of peer-reviewed literature discusses “effective

requesting” of organ donation. Family members report that healthcare providers who engage in

“ongoing, timely, adequate, and comprehensible” discussions about organ donation are perceived

as more supportive and understanding (Chandler, Conners, Holland, & Shemie, 2017). Care of

the family is a major factor of organ donation in trauma patients; therefore, it is something that

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Healthcare professionals’ approach to families regarding organ donation is the most

modifiable factor of the donation process. First, having a healthcare team which exhibits

empathy, support, and sensitivity to the bereavement experienced by the family is extremely

important (López et al., 2018). Family satisfaction with the care provided by the healthcare team

is associated with a higher likelihood of consent to donation. Characteristics of both the

requestor, as well as of the conversation as a whole, are important factors in approaching

families about organ donations (López et al., 2018).

First, characteristics of the healthcare professional who is discussing organ donation with

a family are important when considering donation consent rates. Based on an integrated

psycho-social study conducted in Spain, families report that healthcare professionals who are both

empathetic and sensitive to families subsequently contribute to higher satisfaction and, therefore,

higher consent rates (López et al., 2018). Among this, patients’ relatives report that confidence is

a key characteristic they look for in healthcare professionals. Having a healthcare team that can

confidently answer questions and suppress any doubts related to the death or donation process is

essential, especially since organ donation is such a complex topic to consider (López et al.,

2018). Additionally, providing information in a clear, slow manner in simple terms shows a

correlation with higher consent rates. Healthcare professionals whose communication is

consistent, clear, and progressive is better understood by families, and organ donation is more

seriously considered (López et al., 2018).

Next, characteristics of the conversation, including the setting, timing, and chosen topics

of discussion are important to consider when requesting the donation of family members’ organs.

Ensuring the discussion takes place in a private, quiet area is important, especially since organ

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environment, such as the emergency department, finding a calm, private area can be difficult or

nearly impossible. As stated earlier, with such a high percentage of potential organ donor deaths

occurring in the emergency department, it is imperative that hospitals be equipped with the

resources they need for the discussion of donation with families and/or patients. Family members

report they feel much more comfortable and think more clearly in a private discussion area

(Chandler et al., 2017). Refusing families are much more likely to report feeling rushed than

families who consent to donation, as the natural flow of the emergency department is fast-paced.

Having a comfortable location which gives the family space to think and talk both during and

after the donation conversation is a key factor in increasing organ procurement rates (Chandler et

al., 2017).

In addition to implementing consistent, clear communication with families about a

patient’s condition, prognosis, and outcome, planning the timing of a conversation is extremely

important. One of the most important characteristics of the organ donation request conversation

includes the idea of “decoupling.” Decoupling in regard to organ donation means to separate the

discussion of donation from the notification of death (Chandler et al., 2017). Separating these

two instances gives the family more time to process the information about each topic without

feeling overwhelmed with too much information. Family members need time to talk to one

another and consider all of their options, and they also need time to reflect on their individual

emotions. Disagreement between relatives is a major factor which contributes to higher rates of

refusal for organ donation. Therefore, giving families time to talk, which includes discussing the

known or unknown patient’s preference of donation, has shown to be linked to increased organ

donation agreements. In the fast-paced emergency setting, this conversational factor is often

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enough for future organ donation unless the conversation occurs immediately (Chandler et al.,

2017). Unfortunately, as organ donation in trauma patients is an extremely time-sensitive event,

healthcare professionals often feel pressured to work quickly and talk to families about both

death and organ donation in the same conversation. However, there is a strong association

between the timing of the request and family consent; therefore, this is an essential factor to

consider in the emergency department (Chandler et al., 2017).

Additionally, families have reported the care their loved one receives before, during, and

after death impacts their decision about donation. High quality care, respect, and dedication are

at the top of this list, and many religious factors are intertwined into this. A cross-sectional,

retrospective, descriptive study conducted in Brazil regarding aspects of organ donation after

trauma-related deaths illustrates that religious beliefs significantly alter the donation discussion

and process (de Freitas et al., 2015). In this study, out of the twenty-six families that refused

donation, six families, or 23 percent, refused due to religious beliefs or belief in miracles. Some

of the religious reasons given included: wishes to not receive blood products if needed to keep

the organs functioning, wishes for the body to remain intact, and conflicting beliefs in what

constitutes “death” (de Freitas et al., 2015).

Religious factors regarding organ donation are often overlooked in the emergency setting,

specifically due to the various time constraints and lack of timely resources. A survey

questionnaire was conducted by the Medical University of Bialystok among 1,273 citizens living

in Poland. As life-saving organ donations are connected with the tragedy of death, death is

inseparably associated with religious and spiritual factors (Kobus, Malyszko, J. S., Malyszko, J.,

2016). In most cultures and religions, families respect and honor the loss of a loved one;

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donation, especially after an unexpected fatality. When being faced with such a high-stress

decision, families often resort to religion to search for answers. Amidst deciding whether to

agree to the donation of the patient’s organs, families may justify their decision with religion,

especially when the ultimate outcome is not agreeing to the donation (Kobus et al., 2016). With

this, unaddressed religious factors may be an area that healthcare systems, specifically in the

emergency department, need to address in working to increase organ donation rates.

Among the 1,273 respondents participating in the survey questionnaire addressing

religious factors about organ donation, the greatest percentage of objections to donation occurred

in those who reported to be Muslim. The most common reasoning cited was that organ donation

and transplant is a “violation of the human body,” in regard to both living and dead persons

(Kobus et al., 2016). However, Catholics and Christians regarded organ donation as “a great act

of altruism,” as they expressed more positive opinions related to making decisions about organ

donation in relatives (Kobus et al., 2016). Altogether, it is important to identify religious factors

among families during the donation process. Identifying and addressing religion as it relates to

donation may lead to increasing organ donation in many cases. Religion, whether it be

Christianity, Islam, Judaism, Buddhism, or another doctrine, lies at the root of many decisions

families have to make when it comes to the donation of a loved one’s organs; therefore, it is

important to create an element in the organ donation process which addresses any and all

religious concerns within families.

Ethical Considerations of Organ Donation

Clinical judgments and decisions from healthcare professionals are extremely intertwined

into organ donation in hospitalized patients. Organ donation is a topic most people spend time

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trauma patients who are in the emergency department, decisions about organ donation are made

without the luxury of time. Through chaos and time constraints, decisions made in emergency

settings regarding critically injured trauma patients must occur quickly. This brings an important

question to the table: When should we stop trying to save the patient and focus on saving the

organs? Furthermore, how do healthcare providers decide whether to attempt resuscitation or

save the patient’s organs in order to save other lives if death seems inevitable?

Currently, there are various options to consider regarding the lifesaving protocols of

patients in the emergency department. The first option to consider upon admission of a trauma

patient is cardiopulmonary resuscitation (CPR). CPR includes manually performing chest

compressions as well as artificial ventilation in an attempt to restore blood circulation and

breathing in emergency situations (Bernat, 2017). In recent years, however, new resuscitative

technologies have been developed, including the idea of emergency preservation and

resuscitation (EPR). If the EPR protocol is chosen, the patient is not immediately declared dead.

The patient’s blood is drained and a cold solution is infused into the body to prevent ischemic

injury to internal organs, which occurs if oxygen delivery is not maintained to essential areas in

the body. Then, surgeons attempt to repair all of the patient’s injuries resulting from the trauma,

before finally replacing the cold solution with blood and rewarming the patient (Prabhu, Parker,

& DeVita, 2017). Introducing this state of “temporary hypothermia” buys time for the patient,

allowing the healthcare team to make decisions on the plan of care.

Typically, CPR is attempted before EPR, as the healthcare team works to decide if EPR

is a feasible option for the patient (Bernat, 2017). If it is not likely the patient will benefit from

EPR, it is left up to the physicians to determine the next steps for the patient. This introduces the

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to determine whether a patient should be considered as a candidate for experimental EPR, or if

the person should be considered a potential organ donor and be declared dead (Bernat, 2017).

First, it is important to note that CPR does not save lives in every case. It does not reverse

every case of cardiac arrest; therefore, in emergency situations, the healthcare team must be

thinking ahead as to what their next steps are going to be. Sometimes, the outcome may be to

declare the patient dead if it does not seem other interventions are going to save the person.

However, how do physicians and other members of the healthcare team determine when to

terminate CPR? In unexpected situations and after traumatic accidents, declaring a patient dead

is a discretionary judgement (Bernat, 2017). How do physicians know for sure they are not

terminating their CPR efforts prematurely? This is a major ethical factor surrounding the process

of organ donation. As a result of this dilemma, two additional life-saving technologies have been

developed, EPR and uncontrolled donation after circulatory determination of death (uDCDD),

which may render the idea of death and “irreversible circulatory cessation” more complex and

ambiguous in today’s world (Bernat, 2017).

Deciding between two potentially lifesaving protocols, emergency preservation and

resuscitation (EPR) versus uncontrolled donation after circulatory determination of death

(uDCDD), brings in various ethical factors to consider. Both consist of similar technical

procedures to buy the patients “time”; however, their clinical goals are much different (Prabhu et

al., 2017). Amidst making the decision on what is the best option for the patient, the healthcare

team may consider whether it is ethically suitable to pick one option over another, particularly

based on a patient’s age, perceived outcomes, and current organ donation demands. This is when

the idea and recommendation of creating necessary “protocols” is brought into the mix. It is

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personally deciding whether to implement EPR or uDCDD (Prabhu et al., 2017). Instead,

institutional protocols should be developed to guide staff on how to treat patients based on the

particular situations. All patients should be individually evaluated, and whether or not a patient

will benefit from CPR should be considered first. If it is determined that CPR would not benefit a

patient, a protocol would suggest that EPR eligibility be considered next. EPR is the midway

point between CPR and uDCDD, as CPR has a main objective of saving the patient, and uDCDD

focuses on saving the organs (Prabhu et al., 2017). EPR attempts to maintain organ viability if

the patient does not recover, while also working to treat the patient’s injuries in an attempt to

save their life. When the patient is not eligible for EPR or has requested a do-not-resuscitate

order, uDCDD may be considered in order to save the patient’s organs (Prabhu et al., 2017).

For example, if a patient arrives to the emergency department with traumatic injuries,

CPR may be initiated first. If traditional CPR is unsuccessful, institutions with an EPR protocol

available may begin the process. Between the time of resuscitation and transplantation, there

must come a point when the healthcare team shifts its mindset to focus on optimizing the success

of the donation process. It is important to ethically consider when this transition should happen,

and how healthcare teams can ensure it is not too early or too late for both the patient and the

organs (Dailey et al., 2017). If the hospital does not have the available resources or if the patient

does not meet protocol criteria, death may be declared and the uDCDD protocol may be

followed, if available (Prabhu et al., 2017). Inclusion criteria for uDCDD include: being less than

50 years of age, having had a witnessed cardiac arrest, having a resuscitation duration of less

than thirty minutes, possessing no organ disease in target organs for donation and

transplantation, and having a negative human immunodeficiency virus (HIV) status available

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donation and future transplantation. However, during the process of uDCDD when the blood is

being drained from the body and the actions to keep the organs viable are underway, a solution

that lacks the ability to carry oxygen is used to cool the organs. This is done to avoid the

possibility of unintentionally resuscitating the patient, which could occur if an oxygen-carrying

solution is used (Prabhu, et al., 2017). This presents another ethical dilemma, as a family

member could propose that the patient is not dead if his or her organs are not “dead.”

It is argued that with the implementation of these particular public protocols to guide

healthcare teams’ decisions, there will be more community trust in the United States healthcare

system. The organ donation system and its reputation depend critically on the public’s trust and

understanding of all decisions made about a patient up to the point of deciding on donation

(Prabhu et al., 2017). A major controversy remains prevalent, as the public may argue how one

determines if a patient is truly dead, especially considering all of the advancements in care.

Having a higher level of trust for healthcare decisions which are being made at a very pivotal

moment amidst saving the patients and/or the organs may result in an overall increase in the pool

of organ donors in our country (Prabhu et al., 2017).

In addition to the creation of specific hospital protocols, it is essential to consider how

resources have an effect on the ethics of the CPR and EPR versus uDCDD. Currently, EPR and

uDCDD are only utilized at particular hospitals, as many resources are necessary to safely and

effectively implement them. Because EPR is more resource-intensive in nature, it is typical for

healthcare teams to decide between CPR and uDCDD (Prabhu et al., 2017). Being that EPR is

considered “experimental” due to the fact that the patient may not survive even after the surgical

corrections are made, funding is often not delegated to this procedure. In addition, specific

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that uDCDD is declared if the patient is thought to have irreversible cessation of circulation and

respiration, is it ethical to skip directly to uDCDD simply if EPR resources are not available

(Bernat, 2017)? Among these three pathways which could be taken by a healthcare team, ethical

factors surround every decision in treating the patient versus saving the organs.

Brain Death

In the United States, the majority of organ donations are from donors who have been

declared brain dead. Consequently, explaining organ death or, more specifically, brain death to

families is an essential factor of donation ethics (Dailey et al., 2017). One of the most important

jobs of a healthcare professional is to provide families with available, up-to-date information,

including explaining brain death to families when it is declared, in order to allow them to make

the most educated health decisions for themselves and their family members. By explaining and

providing information to families, rather than assuming families understand, family members are

able to feel more at ease and comfortable with their decisions; however, many misunderstandings

or contradictions may arise during discussions.

Many organ donation opportunities present in the emergency department; however, it is

common for systems to lack the resources needed to effectively and proactively present coherent,

understandable information to families. Taking the time to explain the meaning of brain death is

extremely important, and recognizing that this is intertwined with informed consent is necessary.

With emergency settings being extremely fast-paced, brain death is not always described to

families. It is a commonly presented assumption for healthcare workers to assume all families

understand this concept. Brain death is clearly defined as the irreversible cessation of all

functions of the entire brain, including the brain stem, which controls basic body functions such

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support by clarifying family members’ levels of understanding is something that is often

overlooked; however, in order to optimize the donor pool, it is important to address the ethics of

brain death.

According to a study conducted by Radboud University Medical Center in the

Netherlands, families reported a factor which held them back from agreeing to organ donation

was the lack of “agreement” with the determination and diagnosis of brain death (de Groot et al.,

2015). In formal interviews, many family members articulated they wished to be with the patient

at the time of visible death; however, in situations where brain death is declared, this is not

always possible (de Groot et al., 2015). The patient may continue to breathe with the assistance

of a ventilator, and the heart is still able to beat, but the patient has no brain activity, meaning he

or she has no quality of life if taken off of life support devices. It is common for families to

doubt healthcare professionals, as many people stand firm in the fact that a brain dead patient

still has a chance of waking up. Often times, family members do not believe their loved one is

dead, so they often push away the idea of organ donation. Explaining, providing supplemental

educational resources, and assessing the family’s understanding of brain death, including the

future outlook for the brain dead patient, are important ethically-sound actions in expanding

organ donation in patients with traumatic injuries.

Do No Harm

Aside from brain death and shifting care goals from resuscitative efforts to organ

preservation efforts, an overarching ethical consideration in preparing for organ donation is

doing no harm to patients. In a patient who is traumatically injured, it is common for emergency

department staff to do all they can to save the patient. In the heat of the moment, staff may not

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patient. Some life-saving actions may have unknown or uncertain benefits; therefore, it is

important for staff to pause to assess whether an action or procedure has the potential to more

harm than good for the patient.

Nurses have a duty to maintain a sense of nonmaleficence for all patients. In the dying

patient, it is important to consider the things that do and do not help them. For example, if

invasive lines, heparin administration, continued compressions, or other measures are not helping

the dying patient, these actions should be discontinued (Dailey et al., 2017). Bringing organ

donation into the mix can be tricky, as there are specific actions nurses and doctors must take to

maintain temporary organ preservation. This puts not only healthcare professionals, but also

family members, into an ethical dilemma. Is it ethical to maintain organ viability in a dying or

dead patient with lines and infusions that otherwise would not be there? Moreover, how do

clinicians draw the line between ethically doing no harm to the organ donating patient while,

ethically, doing good by donating organs to save another individual?

Overall, it is important for all healthcare experts to re-assess their standards regarding

death and organ donation, as these are two very equitably intertwined concepts. It is necessary

that all processes and procedures are explicit and consistent, especially for patients coming into

the emergency department.

Recommendations for Practice

It is important to present recommendations which can be implemented to increase the

organ donation rates in trauma patients who present to the emergency department. The organ

donation process in emergency settings is dramatically different than in other healthcare

contexts; however, there are many factors which can be tailored to this environment to make the

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Recommendations for Healthcare Professionals

The first recommendation which can be implemented primarily for healthcare

professionals is the creation of organ donation request training sessions. In these sessions,

healthcare workers would be trained on how to approach families and talk to them about organ

donation. Amidst all the chaos in the emergency department, many doctors and nurses become

accustomed to the fast-paced hospital life. This may lead them to unintentionally approaching

families in a rushed manner, which may come off as disrespectful and harsh. As a result, this

may lead to fewer families consenting to organ donation for a dying family member.

A training course could teach emergency healthcare staff members how to effectively

communicate with families, including how to explain organ donation clearly and effectively.

Being that the organ donation request is undeniably made at a time of loss and trauma for

families, this training would also teach doctors and nurses how to best time the conversation. It is

necessary to consider a family’s emotions, as well as the patient’s condition, as keeping organs

viable for harvest and delivery is a very time-sensitive process. It is common for the discussion

of imminent death to be immediately followed by a request for organ donation, which does not

leave the family any time to process that their loved one will not be with them much longer. In

this training course, it would be important to teach staff about “decoupling,” which means they

would separate the death discussion from the organ donation discussion. Giving the family time

to process the death, even if it is not an extended period of time, would lead to more interfamilial

discussions about not only their wishes, but the patient’s wishes. Family disagreement and

confrontation is one of the leading causes of families not consenting to organ donation; therefore,

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There are many ways the organ donation process can be modified, alongside the manner

of the donation request, in order to increase family consent rates. Not only should these essential

workers be trained on how to approach families about organ donation, but they should also be

educated on discussing brain death with families who may be experiencing this reality with their

loved one. It is important that nurses and doctors understand brain death and feel comfortable

educating patients’ families on what it is. A misunderstanding of what brain death means could

cause a family to not consent to organ donation, as they may have false hope in the patient

waking back up. Altogether, the concept of brain death can put a lot of strain on an organ

donation decision, so it is important that everyone in the family and on the healthcare team have

a clear understanding of what it entails (Marcondes et al., 2019).

Recommendations to Address Family Perspectives

After a traumatic accident, the emergency department elicits the first stage of emotions

for families. There are recommendations for supporting the emotional aspects of handling the

death of a loved one as well as grappling with the decision of organ donation. First, families need

and deserve to have a private space to discuss organ donation. It is important that there be private

rooms or areas dedicated to the initial organ donation discussion, as this gives families an area of

comfort where they can think more clearly (Chandler et al., 2017). Refusing families are more

likely to report feeling rushed as compared to consenting families. Being that the emergency

setting is a very hectic environment, having an isolated area for families to talk could allow for

increased organ donation consent rates (Chandler et al., 2017).

Another recommendation is to have spiritual and/or religious persons available not only

for the patients, but also for family members. Chaplains are available in every hospital for

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immediately available to families when they are making decisions about organ donation

(Chandler et al., 2017). As previously discussed, many ethical dilemmas arise when considering

organ donation; therefore, it is important to have a qualified person available when families are

contemplating their decision. Many families are in need of true bereavement and psychological

support not only at the time of death, which is when it is typically provided, but also during the

time in which they are making tough decisions regarding organ donation. In addition, these

spiritual leaders should also be available during the donation process, if the family consents.

Post-donation support should also be available for as long as the family desires. Many families

report wishing to hear about the transplant outcome, as this may help them grieve (Chandler et

al., 2017). Overall, care of the family, both emotionally and spiritually, is an important

recommendation to implement during the organ donation process, especially in trauma patients.

Implementation of National and Institutional Protocols/Policies

In addition to adaptations being made by healthcare professionals and the hospital

environment, it is important that protocols or policies be implemented in our healthcare system.

Currently the United States (U.S.) is operating under an opt-in organ donation system, meaning

people have to actively register at some point in order that their organs be available for donation

after death (Ahmad & Ifitikhar, 2016). Other countries function under an opt-out system,

meaning organ donation will automatically occur for all citizens unless a specific request is made

before death for organs to not be donated. As of 2016, about 28 percent of the U.S. population

had “opted in” regarding consent to organ donation (Ahmad & Ifitikhar, 2016). Compared to

Austria, which functions under an opt-out system, the United States falls extremely behind. In

2016, Austria had 99.98 percent of their population consenting to organ donation (Ahmad &

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The implementation of the opt-out method in the United States may significantly increase

organ donation rates, thus, decreasing the number of deaths among individuals on the organ

transplant waiting list. Depending on the country’s preference, people think the default of opt-in

versus opt-out is a suggestion favored by the government and society (Ahmad & Ifitikhar, 2016).

This, as a result, influences citizens’ decisions regarding organ donation. Overall, a

recommendation to increase organ donation in patients, including those with traumatic injuries,

would be for the United States to consider implementing a system similar to the opt-out method.

Along with an opt-in or opt-out organ donation consent method, it is possible that the

United States could simply alter factors of the current opt-in policy. Citizens are typically only

asked about organ donation registration in one place, the Department of Motor Vehicles (DMV),

when receiving or renewing one's driver’s license. A recommendation from this author to

increase organ donation consent rates is providing citizens coming into the DMV with more

information on how to truly “register” to become an organ donor. Most DMVs only ask a simple

yes or no question: “Would you like to be an organ donor?” It is likely that a lot of individuals

say yes, as they may think they will be criticized or judged if they say no. With this, it is

important to provide individuals with essential information about organ donation in DMV

offices, with the use of fliers, videos, or brochures. In addition, the United States could train

DMV workers to communicate to the public about organ donation, including the importance of

providing people with registration websites or paperwork where they can gain more information,

more definitively register, and provide consent.

As many ethical considerations must be made with regard to organ donation, especially

regarding treating the patient versus treating the organs, institutional or national protocols should

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these ethical considerations would be to adopt a process to clearly evaluate all patients,

especially those with traumatic injuries, coming into the emergency department. Protocols

should be developed for healthcare teams to follow. With this, based on the patient’s condition

and injuries, it will be clear as to whether healthcare teams should initiate cardiopulmonary

resuscitation (CPR), emergency preservation and resuscitation (EPR), uncontrolled donation

after circulation determination of death (uDCDD), or another life-saving mechanism. Physicians,

nurses, and members of the healthcare team should not have to make a life versus death decision

based on judgment. Having clear protocols and policies in place would take a lot of stress off of

these workers. Additionally, these protocols should be available for the public to view, as it

would alleviate a lot of stress for families if they had a general understanding of what to expect

going into a potential organ donation situation. This would increase the level of trust the public

has with regard to organ donation decisions, and, potentially, increase donation rates across the

Unites States.

Conclusion

Organ donation is a multi-faceted, ethically-intertwined topic in today’s healthcare world.

Specifically, organ donation in trauma patients is much different than with non-trauma patients,

such as patients in intensive care units or other long-term facilities. In the emergency department,

especially during trauma situations, the focus is typically on saving the patient’s life, as opposed

to determining a plan and assessing patients for potential donation of organs. In these situations,

emotions run high, and injuries related to the patient’s condition can be extremely complex, or

even unknown. Many communication gaps exist between healthcare professionals and families,

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donation conversation. Additionally, ethical factors, beliefs, and judgments come into play from

all angles of donation in a life or death situation.

Through the review and analysis of literature, gaps and barriers to the organ donation

approach were identified, and many recommendations were proposed. Collectively, the

recommendations propose the importance of increasing the identification and awareness of

potential organ donors in the emergency department, as well as the implementation of more

efficient practices in the time before, during, and after organ donation has occurred. By altering

many factors of the organ donation discussion between the healthcare professionals and families,

a more supportive environment is created for families in one of the most stressful and traumatic

times of their lives. In addition, not only do families of trauma patients need support, but

emergency healthcare teams need the support of the hospital and the public through training

sessions, decision-guiding protocols, and resources to better utilize their facility for identifying

organ donors.

Altogether, keeping these considerations in mind, there are many ways the emergency

department could and should be utilized to increase organ donation and procurement rates. As

trauma patients account for many of the deaths occurring in the hospital setting, it is important to

enhance this area in our hospitals and evaluate the emergency department in identifying trauma

patients as potential donors. One organ donor can save many lives; therefore, it is important to

address some of the many barriers preventing the growth and expansion of consenting organ

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References

Ahmad, G. & Ifitikhar, S. (2016). An analysis of organ donation policy in the United States.

Rhode Island Medical Journal, 99(5), 25-27. Retrieved from:

http://www.rimed.org/rimedicaljournal/2016/05/2016-05-25-cont-ahmad.pdf

Bernat, J. L. (2017). Declare death of attempt experimental resuscitation. American Journal of

Bioethics, 17(5), 17-33. doi:10.1080/15265161.2017.1299239

Cameron, A., Erdogan, M., Lanteigne, S., Hetherington, A., & Green, R.S. (2018). Organ

donation in trauma victims: A systemic review and meta-analysis. Journal of Trauma

Acute Care Surgery, 84(6), 994-1001. doi:10.1097/ta.0000000000001886

Chandler, J. A., Conners, M., Holland, G., & Shemie, S. D. (2017). “Effective” requesting: A

scoping review of the literature on asking families to consent to organ and tissue

donation. Transplantation, 101(5S), S1-S16. doi:10.1097/TP.0000000000001695

Dailey, M., Geary, S. P., Merrill, S., & Eijkholt, M. (2017). Enabling donation after cardiac

death in the emergency department: Overcoming clinical, legal, and ethical concerns. The

Journal of Emergency Medicine, 52(4), 588-592. doi:10.1016/j.jemermed.2016.11.025

de Freitas, R. A., Dell’Agnolo, C. M., Alves, E. F., Benguella, E. A., Pelloso, S. M. & Carvalho,

M. D. (2015). Organ and tissue donation for transplantation from fatal trauma victims.

Transplantation Proceedings, 47(4), 874-878.

https://doi.org/10.1016/j.transproceed.2015.03.026

de Groot, J., van Hoek, M., Hoedemaekers, C., Hoitsma, A., Smeets, W., Vernooij-Dassen, M.,

& van Leewen, E. (2015). Decision making on organ donation: the dilemmas of relatives

of potential brain dead donors. BMC Medical Ethics, 16(64), 1-11.

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Gardiner, D. C., Nee, M. S., Wootten, A. E., Andrews, F. J., Bonney, S. C., & Nee, P. A. (2017).

Critical care in the emergency department: Organ donation. Emergency Medicine

Journal, 34, 256-263. doi:10.1136/emermed-2016-206397

Health Resources & Services Administration. (2019). Organ donation statistics: Statistics at a

glance. Retrieved from

https://www.organdonor.gov/statistics-stories/statistics.html#waiting-list

Kobus, G., Malyszko, J. S., Malyszko, J. (2016). Do age and religion have an impact on the

attitude to organ donation? Transplantation Proceedings, 48(5), 1354-1359. doi:10.1016/

j.transproceed.2016.02.055

López, J. S., Martínez, J. M., Soria-Oliver, M., Aramayona, B., García-Sánchez, R., Martín, M.

J., & Almendros, C. (2018). Bereaved relatives’ decision about deceased organ donation:

An integrated psycho-social study conducted in Spain. Journal ofSocial Science &

Medicine, 205(1), 37-47. doi:10.1016/j.socscimed.2018.03.039

Marcondes, C., Dutra da Costa, A., Pessôa, J., do Couto, R. M. (2019). Family approach to organ

donation: Perception of nurses. Journal of Nursing: UFPE online, 13(5), 1253-1263.

https://doi.org/10.5205/1981-8963-v13i05a236249p1253-1263-2019

NHS Blood and Transplant. (2016). Organ donation and the emergency department: A strategy

for implementation of best practice. Retrieved from

https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/2098/ed-strategy-final-nov-2016.pdf

Prabhu, A., Parker, L. S., & DeVita, M. A. (2017). Caring for patients or organs: New therapies

raise new dilemmas in the emergency department. American Journal of Bioethics, 17(5),

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Study Author(s)

Year Number of Participant s Sample Characterist ics Study Design Level of Evide-nce Intervention(s) Measures of Results Major Findings Cameron, A., Erdogan, M., Lanteigne, S., Hetheringto

n, A., & Green, R. S.

2018 123,142 total participants within 27 studies 27 studies were investigated, with study cohorts ranging from 28 to 120,512 9 studies included various types of trauma patients, 7 studies included patients with gunshot wounds to the head, 4 studies included trauma patients who Systematic review & meta-analysis

1 Evaluation of multiple data sources to interpret the organ donor conversion rates

(DCRs) in the large pool of potential trauma patient organ donors Organ procureme nt organizatio

ns in the U.S. aim to

achieve donor conversion rates of 75.0% and higher. In this systematic review, donor conversion rates ranged from 14.0% to 75.2%. Conversion rates were higher in head The donor conversion rates are dependent on consent rates, hospital characteristic s, and definition of a “potential organ donor.” In trauma patients, the average donor conversion rate is only 48.1%, which

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suffered from cardiac arrest, 3 studies were limited to other severe head traumas trauma patients compared with traumatic cardiac arrest patients AND higher in pediatric patients than adult patients Marcondes, C., Dutra da Costa, A. M., Pessôa,

J., & do Couto, R.

M.

2019 Six adult registered nurses The interviewed nurses were from two different health institutions (institution “A” and “B”). Institution A: accredited as

Qualitative 5 Staff training on a more knowledge-based, sensitive, ethical family approach when discussing organ donation(s) in family members Interviews consisted of eight open-ended questions about the realization of the nurse’s family approach in organ donations, difficulties, nursing The family approach is a

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a regional reference in bariatric surgery, neurosurgery , neonatalogy, obstetrics, and ICU; considered an organ collection center Institution B: accredited for cardiac surgery, cardiac and renal transplants, and orthopedic-trauma; considered a transplantatio n center skills, and suggestions . The interviews were recorded. After three phases of systematizi ng the interviews, they were grouped based on keywords and categories. demonstrated that the lack of knowledge of family members is the largest impediment to organ donation. A major suggestion is that health institutions invest resources in continuing and ongoing education about the organ donation process for all employees. Organ donation requests should be done in an

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respectful, sensitive

manner.

Dailey, M., Geary, S. P.,

Merrill, S., & Eijkholt,

M.

2017 A case study about one

man who went through the Emergency Department at Albany Medical Center Hospital This case study focused on a

man who experienced an untimely death and, subsequently, donated his organs after death. The process of requesting his organ donation was investigated to determine where changes could be made to further increase donation rates among Case report/study 5 Emergency preservation and resuscitation (EPR) and uDCDD (uncontrolled donation after cardiac death determination) Prolonging the postmorte m period to definitively determine the moment of death, without possibility of auto-resuscitatio

n, leads to diminishin g rates of successful

organ transplantat

ions.

Information for the ethics section of the paper. This case study discusses ways in which opportunities for organ donation present in the

Emergency Department,

and how ethical factors are unique in this

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trauma patients.

process after unexpected deaths related

to traumatic injuries. The ultimate goal of this case

study is to present how to adjust the

current systems stigma and

ethical limitations to

expand the donor pool in dying/deceas

ed trauma patients.

Gardiner, D. C., Nee, M. S., Wootten,

A. E., Andrews, F.

J., Bonney, S. C., & Nee, P. A.

2017 Systematic

review of descriptive

studies

5 Addressing the ethical factors

of organ donation cases

in the emergency department

Information regarding the

emergency department’s

role in identifying

potential organ donors

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injuries. This primarily focuses on

how the emergency department can expand their roles to

increase the donor pool in

this population.

Chandler, J. A., Connors, M., Holland,

G., & Shemie, S.

D.

2017 168 articles 168 peer-reviewed articles were

examined from January

2000 to February

2015.

Scoping review

(research synthesis)

1 Modifying the family approach

process with “ongoing,

timely, adequate, and comprehensible

” discussions about organ

donation

Information used in the

family perspective

section regarding “effective requesting” characteristic

s. This focuses on how the ways

healthcare professionals

talk to families about organ donation can

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affect their decision. Kobus, G., Malyszko, J. S., & Malyszko, J. 2016 1,273 participants Participants were citizens from the northeastern part of Poland. 91.2% of participants were aged

60 years, and 8.8% were

aged ¿60 years. Respondents’ religious sectors/doctri nes included: Catholic, Orthodox, Islam (Muslim), and Baptists Quantitativ e study

5 About 96%

of questionnai re respondent s, regardless of religion, had a positive attitude towards organ transplanta tion. However, when clearly asked if they would agree to organ donation in

their close relatives after death, only 80% of the participants Information in the family

perspectives section of the

paper. This article discussed religious factors which naturally arise during organ donation. Religion is a

factor that many healthcare professionals do not consider in the emergency setting, and it

is an important

issue to consider in

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responded “yes.” Younger participants

(≤ 60 years old) were more likely

to consent to organ donation

for their relatives, as

well as for themselves.

transplantatio n. This article discusses the importance of

addressing religious factors for

families considering

organ donation.

Prabhu, A., Parker, L.

S., & DeVita, M.

A.

2017 General

information about ethics of new

life-saving protocols to

consider implementing

before declaring

“death”

Emergency preservation

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uncontrolled donation after circulatory determination of death (uDCDD)

de Groot, J., van Hoek, M., Hoedemaek ers, C., Hoitsma, A., Smeets, W., Vernooij-Dassen, M., & van Leeuwan, E. 2015 39 participants; 22 family interviews among the 39 participants The 39 participants consisted of relatives of the patients. 22 interviews were conducted among the 39

participants. Ten families (17 participants) refused consent to donation, nine families (14 participants) gave full consent to donation, and three families (8 participants) Qualitative study

5 For each

interview, basic patient information was obtained (sex, age, days in hospital, critical injury/illne ss). Interview information was coded and analyzed by an ethicist, who combined the codes into themes. Information used in the ethics section

discussing brain death.

The aim of this study was to determine the decision-making process of potential brain dead organ donors. Ethical consideration s (values, motives, dilemmas) are considered as

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did not give permission for donation

after brain death, but only have circulatory

death.

organ donation and

brain death.

Bernat, J. L. 2017 Information

used in the ethics section

discussing emergency preservation

and resuscitation

(EPR) and uncontrolled donation after

circulatory determination

of death (uDCDD).

Used in the discussion of

when to ethically stop

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a life or organ saving

protocol.

López, J. S., Martínez, J. M., Soria-Oliver, M., Aramayona, B., García-Sánchez, R., Martín, M. J., & Almendros, C.

2018 421 family cases 338 donations; 83 refusals Cases from 16 Spanish hospitals over 36 months Observatio nal study (Cohort study)

4 Alteration of the attitudes and approaches healthcare professionals take when discussing organ donation with families. Healthcare professionals who are more empathetic,

sensitive, confident, and knowledgeable are perceived in

a more positive manner by families. In addition, providing information in a

clear, slow manner in simple terms is

In situations in which emotional support was not provided in healthcare-family interviews, 44 families refused consent, while 135 still consented to organ donation. When emotional support was provided, only 37 refused, with 202 families consenting. Information used in the

family perspectives section of the

paper. This article discusses how healthcare professionals ’ approach to

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important. Altogether, this altered approach

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to organ donation.

de Freitas, R. A., Dell’Agnolo

, C. M., Alves, E. F.,

Benguella, E. A., Pelloso, S. M. & Carvalho, M. D.

2015 134 trauma patients (871 deaths were eligible for donation, but 134/871 were of trauma-related deaths) All patients were between the ages of 2 and

70 and were considered to

have traumatic injuries. 41

out of the 134 deaths occurred in

the emergency department (ED), and the

other 92 deaths occurred in an ICU setting after being transferred from the ED.

Deaths owing to nontraumatic causes, cases that occurred Cross-sectional retrospectiv e descriptive study

6 Training of healthcare professionals to

be trained on how to approach

families regarding organ donation Emotional and religious support for families, as almost 25% of non-consenting families stated it

was due to religious factors

Out of the 134 eligible donors, 52% consented to organ donation. Out of the

eligible and consenting

families, a total of 29

organ donations actually occurred, which translates to roughly 40% the eligible donors (8 out of the ED and 20

out of the ICU). This study shows that the percentage of families asked for donation consent and the actual conversion of potential donors into actual donors

is very low. The major causes for patients not consenting to donatation: religious convictions (23%), wish for the body to remain intact (8%), dissatisfactio

n with care provided

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at the accident site,

and cases of patients without identification

were excluded

from the study as they

were not considered

“potential donors.”

deceased refused while

alive (4%), and unspecific

Figure

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References

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