Algorithms, strict criteria guide organ donation

One frigid morning in February 2014, a 22-year-old Plainview, Minnesota, woman was driving to work when she collided with a pickup truck. It took paramedics 12 minutes to extricate her from the wreck. When she arrived in the emergency department of Mayo Clinic Hospital, Saint Marys Campus, she was hypothermic, with a severe skull fracture and life-threatening brain injury. Because she wasn't likely to survive, trauma physicians contacted LifeSource, an organization that manages organ and tissue donation across the Upper Midwest.

The young woman wasn't donor designated, but the family was interested in donating her organs. Eventually, her heart, liver, pancreas, and both kidneys and eyes went to five different recipients, and various types of tissue to 47 others.

LifeSource's Cathy Dudley, R.N., hospital coordinator for organ, tissue and eye donation at Mayo Clinic's campus in Rochester, Minnesota, says the story illustrates how the collaborative relationship between hospitals and organizations such as LifeSource works.

"Federal law mandates that hospitals contact their local organ procurement organization each time a patient dies or is nearing death," she explains. "If the patient is a potential candidate for donation, a representative from the organization immediately travels to the hospital, searches the donor registry to see if the patient had enrolled as a donor and if not, seeks consent from the family.

"The Organ Procurement and Transplantation Network is then contacted for matching recipients. Meanwhile, the patient is maintained on life-sustaining support and the condition of each organ is carefully monitored by both the hospital staff and the organization's representative."

Organs must meet specific criteria in order to be eligible for transplant. For example, liver function, as measured by tests such as blood aspartate transaminase (AST) and alanine transaminase (ALT) must be within a relatively low range, and the heart's pumping ability, as measured by ejection fraction, must be relatively strong.

"Many patients have experienced a tremendous amount of trauma and damage, and we do everything possible to support their organs," Dudley says. "Even so, only about 1 percent of patients are able to be donors."

Ethical concerns

Close to 123,000 people are currently awaiting transplants in the United States, and one patient is added to a list somewhere every 10 minutes. About 30,000 people will receive a donated organ this year, but nearly 8,000 others will die waiting. In the area served by LifeSource — Minnesota, North Dakota, South Dakota and Douglas County, Wisconsin — 3,200 people, many of them children, need transplants.

Because the organ shortage is so dire and the need so great, the algorithms used to determine allocation are continually being adjusted. They typically take into account the blood and tissue type of both donor and recipient, medical urgency, length of wait, and local primacy.

Each of these categories, with the possible exception of blood type and tissue compatibility, raises ethical considerations and questions of fairness. For instance, although age isn't a criterion per se, it can be — and has been — argued that it makes more sense to give an organ to a younger, healthier person than to an older one, even though the older patient may have been waiting longer.

Dudley says decisions also have to be made about the viability and health of donated organs. "In some situations, a liver may not be perfect. But because around 20 percent of patients on the liver transplant list die each year due to organ shortage, the transplant doctor may decide to use the liver for transplantation instead of waiting longer for a better one. In such a case, the risk is early, not long-term, primary non-function. These are the difficult issues transplant doctors have to work with every day," she says.

Time is a factor, too, both for organ viability and for recipients. "We work 24 hours a day to keep organs suitable for transplant while we assess donors and transplant patients for the right situation and fit," Dudley says. "And time becomes even more of an issue after organs and tissue are recovered from the patient — then they remain healthy for a very short period of time, which is why procurement organizations offer organs to local transplant centers first."

Donation

In the first six months of 2015, just 7,322 people donated organs or tissue nationwide, but Dudley says the numbers are increasing, especially in Minnesota, where 61 percent of people are now designated donors. Although most organ donation campaigns target the general public, Dudley also wants to heighten awareness among providers.

"This issue touches medical personnel at all levels, not just those in the emergency department, although they are on the front lines," she says. "While providers are doing all they can to save lives, please don't overlook the possibility of donation. One organ donor can potentially save seven lives and offer healing to 60 others. That is why we work so hard, for the people waiting for a second chance."