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Introduction   

Doctor Joseph Edward Murray performed the first successful human kidney transplant on December 23, 1954, in Boston, Massachusetts [1]. This groundbreaking procedure took place between identical twins, and it enabled the recipient twin to live an additional eight years. Over the years, transplant milestones have included the first simultaneous kidney/pancreas transplant in 1966, the first liver transplant in 1967, and the first heart and lung transplants in 1981 [2].  

According to the United Network for Organ Sharing (UNOS), the U.S. achieved over 42,800 transplants in 2022 alone, marking 1 million total transplants as of September 2022 [3]. There are over 103,924 individuals waiting for transplants, with kidneys being the most needed organ [4]. Each day, 20 people die waiting for a transplant with a single donor having the capacity to save up to eight lives and affect over 50 more by donating organs and tissues [4].  

In the United States various regulations and guidelines govern organ donation. The National Organ Transplant Act (NOTA) of 1984 established the Organ Procurement and Transplantation Network (OPTN), managed by UNOS under federal contract [5]. This organization oversees organ allocation policies, data collection, and educates both the public and healthcare professionals.  

The Centers for Medicare and Medicaid Services (CMS) ensure hospital compliance with U.S. donation programs, while The Joint Commission requires hospitals to maintain agreements with organ procurement organizations and follow specific donation procedures [6].  

UNOS also coordinates the matching of donors with recipients, prioritizing based on medical urgency, tissue compatibility, waiting times, and geographical factors, with special consideration for pediatric patients and previous living donors who are experiencing organ failure [7]. 

Becoming a Donor 

Organ transplantation is a critical medical procedure that transfers a healthy organ from one individual to another and can occur either during the donor's lifetime or after their death. The collections of organs from deceased donors occurs after the declaration of brain-death—a permanent cessation of all brain activity—or following cardiac death, when heart and respiratory functions stop due to severe cardiac issues [9].  

In 2019, the American Academy of Neurology (AAN) supported this by affirming that brain death constitutes the irreversible loss of all functions of the entire brain and is equivalent to circulatory death [10]. 

Individuals interested in becoming organ donors can register through online platforms, local Department of Motor Vehicles (DMV) offices, or via voter registration cards, as state regulations allow. This registration serves as legal consent for organ donation, followed by a medical evaluation to ensure the suitability of the donor’s organs for transplantation.  

Donatable organs and tissues include the heart, heart valves, kidneys, liver, lungs, pancreas, intestines, corneas, skin, veins, bone, and bone marrow. Living donors can donate kidneys, parts of their liver, lungs, intestines, or bone marrow [4]. According to the Health Resources & Services Administration (HRSA), kidneys are the most transplanted organ [4]. 

Determination of Brain Death/Death by Neurologic Criteria  

The process to determine Brain Death or Death by Neurologic Criteria (BD/DNC) requires a thorough clinical examination that verifies the absence of neurological function, evidenced by coma, brainstem areflexia, and apnea. The specific clinical indicators include: (1) no arousal or awareness in response to strong external stimuli such as visual, auditory, or tactile pain; (2) pupils that are midsize or dilated and do not respond to light; (3) no corneal, oculocephalic, or oculovestibular reflexes; (4) lack of facial movement in reaction to painful stimuli; (5) no gag reflex upon stimulation of the back of the throat; (6) absence of a cough reflex when performing deep tracheal suctioning; (7) absence of brain-mediated motor responses to painful stimulation of the limbs; and (8) no spontaneous breathing when apnea testing results in a pH below 7.30 and a Paco2 of 60 mm Hg or more [11].  

Healthcare professionals and nurses give special considerations to certain groups including children, individuals undergoing extracorporeal membrane oxygenation, patients experiencing therapeutic hypothermia, and factors related to religious, societal, and cultural norms [11]. 

The Nurse's Role in Organ and Tissue Donation 

Nurses are a foundational component of the organ and tissue donation process. Their roles extend beyond clinical duties to encompass emotional support, educational advocacy, and participation in multidisciplinary teams [12]. Their involvement is critical at every stage, ensuring that they oversee both the technical and human aspects of the donation process with care and expertise.  

A significant part of a nurse's role involves ensuring that the family is well-informed about the brain death diagnosis, what it means, and the processes involved in organ donation [14]. This role is crucial as it often helps families understand and accept their loved one's condition, facilitating their decision about organ donation.  

Nurses are vital in guiding patients and their families through this complex journey by providing detailed education on what to expect before, during, and after the surgery [14]. They explain the surgical procedures, potential risks, and complications, and address any concerns the patient or their family might have, including dispelling myths about the extensive recovery process.  

Nurses also advocate for better educational programs to inform both the healthcare team and the public about the importance of organ donation. They work towards enhancing the understanding of organ donation's impact, thereby increasing participation in donation programs. This advocacy is crucial for shifting public perceptions and improving the rates of organ donations [13].  

Nurses are key connectors between hospitals, organ procurement organizations, physicians, and families of potential donors. Their attitudes and knowledge impact the success of the donation process [13][15]. Along with other healthcare providers, Nurses help identify patients who are brain dead or nearing brain death due to severe medical conditions and in order of frequency: cardiopulmonary arrest, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage [16].  

Nurses are responsible for informing the Organ Procurement Organization (OPO) about all potential donors, and it is the OPO's duty to assess whether these individuals qualify as potential donors [17]. Organ Procurement Organizations (OPOs) are vital not-for-profit entities in the U.S., tasked with the recovery of organs from deceased donors for transplantation. The U.S. has 56 federally mandated OPOs, each responsible for a specific donation service area [23].  

Their main functions include assessing donor potential, gathering and providing accurate clinical information, and adhering to national policies for organ offerings [23]. While OPOs manage the initial stages of organ procurement and work with the families of potential donors to facilitate the donation process, transplant hospitals are responsible for reviewing and accepting organ offers [17][23]. OPOs play a crucial role in the authorization, testing, recovery, and delivery of donor organs to transplant hospitals, ensuring that each step of the process supports the life-saving mission of organ transplantation. 

The presumption is that a registered donor has consented to organ donation, and this decision is often final and not reversible by the family. If the donor has not registered, the nurse must facilitate obtaining consent from an authorized party according to the Uniform Anatomical Gift Act, which governs organ and tissue donation in the U.S. [18].  

In an ideal setting, organ recipients benefit from the care of a dedicated transplant nurse, supported by a multidisciplinary team. Transplant nurses assist the patient and their family throughout the transplant process—before, during, and after surgery—managing critical tasks such as fluid and blood replacement and monitoring for potential complications. The process from obtaining consent to organ recovery takes 48 to 72 hours [17]. During this period, the nurse and coordinator collaborate to manage the donor and provide ongoing support to the family, ensuring successful organ recovery and helping to save the lives of recipients.  

However, the organ donation journey can be challenging. Recipients may experience desperation while waiting for a suitable organ match or face difficulties during their recovery post-transplantation.  

Ethical Considerations  

Ethical considerations are paramount in the transplant process, often leading care teams to seek third-party ethical consultations. The American Nurses Association’s Code of Ethics offers guidance to nurses, including those involved in transplantation [19].  

Key among these is ensuring that the perception of hastening of a donor's death for organ procurement does not exist, and that decisions of the individual's donor status are independent decisions and with prioritization of the patient's wishes. Another important consideration is ensuring that transplant patients, both donors and recipients, have adequate support systems in place after discharge. This support is often critical for their long-term care and is something confirmed during the pre-screening process.  

The motivations behind an individual's decision to donate organs are complex and require private discussions during pre-screening. Reasons including expected rewards, feelings of obligation, or the fear of losing a loved one can influence a decision to donate. By advocating for their patients, nurses play a crucial role in preserving patient autonomy and respecting their decisions about life and the meaningful impact of their potential organ donation. 

Medical Management of Potential Donors Before Brain Death 

Patients with devastating brain injuries (DBI) require aggressive resuscitation and full support to achieve physiological stability, which is crucial both for their immediate health and their potential as organ donors [20]. This includes maintaining hemodynamic stability, ensuring end-organ perfusion, and achieving euvolemia. Hormone Replacement Therapy HRT plays a significant role in managing patients with DBI before brain death, promoting hemodynamic stability, enhancing organ recovery rates, and improving graft function and survival [17][21][22].  

HRT involving thyroid hormones, corticosteroids, insulin, and vasopressin is a key part of this management strategy, though the effects of early HRT still require further study [21][22]. However, the routine use of corticosteroids in patients with severe TBI is controversial due to associations with poorer outcomes [1]. 

In managing potential donors who have not entered the donation process, it is vital to continue aggressive care unless there are directives from a Legally Authorized Representative (LAR) or explicit advanced directives restricting treatment [17]. This approach helps optimize perfusion, stabilize physiological parameters, and sets the necessary conditions for a formal brain death examination. 

Integrating donor-specific management strategies, such as invasive monitoring or renal replacement therapy, must align with the overall goals of care, respecting the patient’s health status and the expectations of families or LARs. This comprehensive approach emphasizes the complexity of managing potential donors and the necessity for tailored medical interventions that respect the patient’s medical needs and their potential to contribute to life-saving organ donations. 

Conclusion

Dr. Joseph Edward Murray pioneered the first successful human kidney transplant in 1954, marking the beginning of a series of advancements in organ transplantation [1]. With decades of considerable progress, including the introduction of multi-organ transplants and increases in transplant numbers, with over 42,800 transplants recorded in 2022 alone in the U.S. [3]. Today, the demand for organs outweighs supply, as evidenced by over 103,924 individuals waiting for transplants, highlighting the critical need for more donors [4].  

The governance of organ donation process is a stringent and regulated process, with the National Organ Transplant Act (NOTA) and organizations like the United Network for Organ Sharing (UNOS) playing key roles in managing and overseeing organ allocation and transplantation guidelines [5][7].  

Nurses are instrumental throughout the organ donation process, bridging the gap between potential donors, healthcare facilities, and organ procurement organizations. Their roles encompass clinical duties, educational advocacy, and providing emotional support to donors' families, which is crucial in navigating the complex process of organ donation.  

Nurses ensure thorough communication and understanding between all parties involved, including educating families about brain death and the significance of organ donation. Nurses are also pivotal in managing the medical care of potential donors to maintain organ viability, further underscoring their essential role in the success of transplant outcomes and rate of organ donations.  

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