Legal and Ethical Dilemmas of Organ Donation A Case Review UCDMC

1. Legal and Ethical DilemmasofOrgan DonationA Case ReviewUCDMC Traci Eaton, RN–Clinical Manager GinniJannicelli, In-house Coordinator

2. Sierra Donor Services • Serves Greater Sacramento area, 13 counties and 29 hospitals with a population of approximately 4 million • Recovers and processes eye and tissue in the Greater Sacramento and Northwestern Nevada area

3. The Uniform Anatomical Gift Act (UAGA) • The primary legal authority for organ and tissue donation • First drafted in 1968 • Revised in 2007

4. The Donate Life California Registry HELPING CALIFORNIANS USE THEIR POWER TO DONATE LIFE Over 9.5 Million Californians have signed up www.donateLIFEcalifonia.org

5. First Person Authorization Adult individuals have the right to make a legally binding anatomical gift prior to death.

6. We are not asking permission, but explaining their loved one’s wishes. Part of our purpose is to help families in their pain and grief. None of us wake up with the thought: “I hope I can do something to cause a grieving family more pain.” Families believe that not donating will relieve their pain. Studies show that this is not true.

7. Why is it Important? • As an organ procurement organization, we are obligated to follow a patient’s first person authorization. • As a Health Care Provider the hospital is protected for doing the right thing, and could be prosecuted for not following the law.

8. Ethical Basis of First Person Authorization • Self-determination concept that adult individuals should be able to make their own decisions about donation of organs and tissues after their death • Consistent with ethical principles behind other advanced directives

10. Case Overview 41 y/o cauc female s/p high speed MVA with rollover. Prolonged extrication by EMS. Unable to obtain airway immediately in field per report, King tube placed en route. Left thoracotomy performed in ED and brought to OR immediately with trauma for exploration and washout of wound. Head CT showed TBI. Pt has C-Spine Injury C7 spinous process and transverse process fx, Clavicle Fx, Mediastinum fx, bilateral chest tubes for pneumothoraces, LUE fasciotomy for compartment syndrome, R 1st rib fx. Neurology has seen pt and has determined her injuries are non-survivable. Brain death exams were performed with apnea exam and pt was declared brain dead on 05/01/2012 @ 1150.

11. Some of the issues arising from this case: • The resident spoke to the family about donation prior to BD • The family was concerned with “what would be left to bury” after tissue recovery • The pt’s LNOK was supportive of the pt’s wishes throughout the donation process • The family’s threat to hire an attorney and go to the media

12. The Huddle • Meet with hospital administration prior to any issues arising to ensure the hospital is aware of the OPO moving forward, and to solidify the hospital’s support • Contact upper level hospital administration as soon as possible if you know there may be a family issue • This huddle should address: • Who will speak to the family • When will the family be approached • Where will the discussion take place • These 3 elements are critical

13. Some of the issues: • Prior to “huddle” with Sierra Donor Services, the resident caring for the patient mentioned to the family that pt was a registered donor • LNOK, pt’s estranged husband, was in agreement with donation, other family members were not in agreement • Mentioning donation prior to declaring BD or the family making the decision to withdraw support can sometimes lead the family to ask if: • Everything was done to save their loved one? • Did the hospital and/or healthcare team just want to get organs?

14. 98% would choose donation again • 92% identified positive aspects to the donation process/experience • Majority agreed that donation was comforting • Associated with less depression