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Updated:
18 September, 2024
Here, procedures for identifying a potential organ donor and navigating the donation process are described. A checklist for organ donation, along with a description of donor characteristics and the donation process, including breakpoint conversations and continued management, is provided. Both DBD and DCD are covered.
- Donation Investigation
- Checklist for Organ Donation
- Medical Investigation Before Organ Donation
- Treatment Goals (Adult Donors)
- The Donation Process
- Donor Characterization
- Medical Record for Donation Procedure on Deceased Donor DBD/DCD
- Clinical Brain Death Diagnostics
- Flowchart for the Donation Process at DBD
- Flowchart Operation/Anesthesia – DBD
- Flowchart ICU – DCD
- Flowchart Operation/Anesthesia – DCD
Donation Investigation
When a person dies in such a way that organ donation is possible, the healthcare system is obliged to investigate the will for donation (SOSFS 2009:30, SFS 1995:831 Transplantation Law).
The Transplantation Law is based on “Presumed Consent,” meaning that if the patient has not expressed opposition to donating organs or tissues after death, it is assumed that he/she was in favor of donating. The deceased’s will can be communicated through
- Registration in the donation register
- Donation card
- Informing relatives
All three methods are equally significant. The last communicated will is the one that applies. It is the responsible physician’s duty to determine which expression of will was the most recently communicated. Information from the donation register can be retrieved by the transplant coordinator after the breakpoint decision is documented in the medical journal (SFS 2018:307). If the patient’s will is known, it must be respected. Relatives do not have the legal right to alter the patient’s decision.
- If the patient’s will is unknown, an effort should be made to determine the deceased’s position through discussions with the relatives (interpretation of the will to donate).
- If conflicting information about the patient’s will emerges, donation cannot proceed.
- If the relatives are divided regarding the veto right, the donation cannot proceed.
- If the patient’s known will is positive and no relatives can be reached/no relatives exist, donation may proceed.
- If the patient’s will is unknown and no relatives can be reached, donation cannot proceed.
- If the patient’s will is unknown and it is confirmed that no relatives exist, donation may proceed (presumed consent).
The Concept of Relatives (SOSFS 2009:30)
- The term “relatives” generally refers to:
- Spouse
- Cohabitant
- Registered partner
- Children, parents, siblings
- Grandparents
- Close friend, neighbor
- Legal guardian
There may also be cases where a close relative, who the deceased had not been in contact with for a long time, should not be considered as a “relative.”
Foreign Citizen
If the patient is a foreign citizen, the same rules apply as for a Swedish citizen.
Which Relatives Must Be Contacted?
It is sufficient to inform one relative. This relative is then responsible for contacting and consulting with other relatives.
What Happens If No Relatives Can Be Found?
Even though many people live alone, it is rare for them to have no one who is close to them. The law states that individuals close to the deceased must be informed of the intended procedure, but there is no prohibition against donation from a person who completely lacks relatives, if their will can be established. This means that if a person made a positive statement and it can be determined that no one “stood close” to the deceased, donation is possible under the Transplantation Act.
Conversation with Relatives
The responsible person for investigating the donation will is the ICU doctor. It is often most practical to conduct this investigation during the daytime, and continuity is important. The responsible nurse and preferably a nursing assistant should participate in the conversation to be able to relay information to the relatives continuously and provide support. Sometimes the relatives raise the issue of donation early in the process. When the question of donation should be addressed varies from case to case. Since the new regulation came into force on May 25, 2018 (SFS 2018:307), it is legally possible to conduct a full investigation of the donation will (register, donation card, relative conversations) after the breakpoint is documented in the journal. However, when it is appropriate to raise the issue of donation in each case may vary. It is important that the relatives have had time to process what has happened, what medical measures were possible to try to save their relative, and that they have had time to accept the dying/death, before discussing the donation issue.
It is the ICU doctor’s responsibility to offer the possibility of donation. It is important that the relatives understand the meaning of the word donation, that it can be life-saving for other people, and that a donation operation is carried out with dignity and the same routines as an operation on a living patient.
How one informs relatives naturally depends on the individual case and personal experiences. It is often appropriate to begin the information by stating that the patient “has a severe brain injury and is deeply unconscious without reactions.” The phrasing afterward varies, for example: “We suspect that blood supply to the brain has stopped. We will now conduct thorough examinations to find out if this is the case.” Then, we try to explain what it means, perhaps using some of the following keywords: “brain swelling, no blood flow to the brain, lack of oxygen, the brain has stopped functioning.” One can mention the term “total brain infarction” and explain its meaning, i.e., that it means the person has died if total brain infarction is confirmed. One can also complement the information with an illustration. “If one dies while receiving ongoing ventilator treatment, there is a possibility to donate organs and help other people.”
It is important to ensure that the information has been understood by the relatives. Repeat the information several times, try to vary the wording. It is valuable if a dialogue can be established. The hospital chaplain and/or social worker can be helpful both during the conversations with relatives regarding donation and after a possible donation.
Checklist for Organ Donation
Identify Potential Donor
- Severe new-onset brain injury and
- Ventilator care and
- RLS ≥ 7 and
- Loss of at least one cranial nerve reflex
Suspected Herniation – Identify Potential Donor
If it hasn’t already been done, this is the point in the process where the breakpoint decision is often made. The decision is documented in the medical journal. Breakpoint discussions with relatives are held as soon as possible.
- Also see the PM on Organ-Supporting Treatment and Medical Interventions After Death on the SFAI website
Investigation of Donation Will
The appropriate time to investigate the donation will (donation register + donation card + discussions with relatives) varies. Since May 2018 (SFS 2018:307), it is permissible to search for a known will in the donation register after the breakpoint decision is documented (i.e., before the patient is declared dead).
Frequent follow-up discussions with relatives are recommended. Always involve a nurse, preferably also a nursing assistant. A younger colleague may be present? Avoid phones. Once the donation will is clarified, complete the “Medical Record for Donation Procedure on the Deceased” form.
The critical conversations: What does “donation” mean? Do the relatives know? Life-saving! Do the relatives know the deceased’s will? Can they interpret it? The deceased’s will is what matters. “Presumed consent” applies if the will is unknown. Legally, relatives can only veto if the will to donate is unknown.
Donor Characterization
Begin donor characterization early. Notify the transplant coordinator at the appropriate phone number. The coordinator typically asks about: age, gender, height, weight, blood type, diagnosis, previous illnesses, malignancy, substance abuse, smoking, risk group for blood-borne diseases, hemodynamics, duration of CPR during cardiac arrest, LUCAS duration, respiration, and lab results.
Clinical Diagnosis x 2
- Inform relatives about why the diagnostics are being done. Relatives may be present. Inform about spinal reflexes before the examination. Bring a younger colleague? Maintain calm in the room when diagnostics are performed.
- Always conduct clinical diagnosis x 2, even if it is incomplete and cerebral angiography is planned later.
- Recruit after the apnea test! There are pitfalls in diagnostics, e.g., facial trauma, facial nerve palsy, high cervical spinal injury, pacemaker, sick sinus, chronic hypercapnia… contact the donation-responsible physician as needed.
Cerebral Angiography x 2 in Certain Cases
In the following cases:
- The brain functions are affected by metabolic or pharmacological factors (e.g., liver/kidney failure/hypothermia treatment)
- The central body temperature is below 35 degrees Celsius
- The cause of suspected total brain infarction is unclear
- There is isolated impact on the brainstem or an isolated process in the posterior fossa
- It has not been possible to perform all parts of the clinical neurological examinations
If the patient is transferred from another hospital, check the following (refer to current guidelines):
- That two clinical death diagnoses have been made.
- That the relatives are informed about why the patient is being transferred and that the investigation of the patient’s donation will is complete.
- That the police have been contacted in relevant cases. See below for more information.
Declaration of Death
- Complete the death certificate in the digital medical journal. Note the date and time of death declaration in the journal.
- Inform the relatives that the patient has been declared dead.
- Consider whether the police need to be contacted.
- Administer a single dose of Solu-M
edrol 15 mg/kg iv (max 1 g) if not already given, and initiate/switch to Meronem 0.5 g x 3 iv. after cultures.
Further Investigation of Donor Suitability
- Complete donor characterization
- Maintain ongoing contact with the coordinator at the appropriate phone number. Notify of all status changes. Thoroughly review the donor characterization with the coordinator.
- The transplant surgeon ultimately decides if the patient is medically suitable. There are few absolute contraindications. Note: Ask the coordinator so you know during family discussions what “tissue for other medical purposes” means.
Police Contact When Necessary
In the following deaths, the police MUST be contacted:
- If death has or may have been caused by external factors (injury or poisoning) through accident, suicide, or suspicion of crime.
- If death may be linked to malpractice or negligence in healthcare.
The police decide whether a forensic autopsy is required, and in collaboration with forensic medicine, whether there are any obstacles to organ donation. During daytime, contact the “Death Group” and during on-call hours, contact the on-call commissioner at 010-xxxxxxxx.
Inform Relatives if the Patient is a Suitable Organ Donor
If the patient is not a suitable donor: explain why (medical reasons or police veto).
If the patient is a suitable donor:
- Inform about any further investigations that may change the decision regarding medical suitability; the transplant surgeon makes the final decision. Inform that the investigations take time and about the 24-hour rule.
- Inform about any potential forensic autopsy.
- Don’t forget to ask if “tissue for other medical purposes” may be collected.
- Inform and recommend a farewell in the ICU after the donation surgery.
- Inform that the relatives will be called for a follow-up conversation.
Referrals for Organ Investigation
The ICU doctor writes all referrals for organ investigation according to the surgeon’s instructions. Don’t forget that corneas can be donated even if other organs are not medically suitable.
Ensure that all forms are filled out:
- “Medical Record for Donation Procedure on the Deceased”
- Donor characterization
- Clinical diagnosis
- Cerebral angiography
- Death certificate
Medical Investigation Before Organ Donation
Medical investigation, including donor characterization, is conducted by the ICU according to SOSFS 2012:14. To assess the medical suitability of the donor and determine which specific organs can be used, an investigation into previous illnesses, lifestyle habits, and potential risk behaviors must be carried out through a review of medical records and additional questions to relatives, donor characterization.
Based on this investigation, the transplant surgeons perform a risk assessment and determine the medical suitability.
Information to Have Ready for Discussions with the Transplant Coordinator:
- Current diagnosis and course of illness
- Previous illnesses and medications, lifestyle habits, substance abuse – donor characterization
- Age, gender
- Height and weight (measure, don’t estimate)
- Blood type
- Blood pressure, MAP, heart rate, rhythm
- Cardiac arrest, if yes, how long, LUCAS
- Hypotensive period
- Circulatory support medications
- Time on ventilator, FiO2
- Suspicion of aspiration
- Urine output
- Temperature
- Ongoing infection, antibiotics
- Other medications, infusions, blood transfusions
- Test results, lab values
Targeted Examinations (in Agreement with the Transplant Coordinator)
The transplant surgeons may order additional examinations to ensure the assessment of organ function. Local radiologists should review images and write reports (promptly) based on the following questions. Please ask the radiology department to link images directly to the hospital’s radiology department.
Use the following questions:
CT Thorax/Chest X-ray
Aspiration, atelectasis, infiltrates, congestion, other structural lung changes, tumors, COVID changes.
For potential lung donors, measure lungs:
- Width: frontal image, total internal width of thorax at hilum level
- Depth: lateral image, anteroposterior
- Length: lateral image, from the highest point of the diaphragm to the apex
CT Abdomen with Contrast in 4 Phases
Abnormalities/changes in the abdomen, tumors.
Liver: Steatosis, fibrosis, other changes. Vascular anatomy of the liver: portal vein, hepatic artery (are there accessory arteries?), and hepatic veins
Measure the following dimensions of the liver:
- Depth: anteroposterior (largest measurement over the right liver lobe).
If requested: volume and size assessment of the entire liver or segments II and III, and the largest depth anteroposterior: lateral segment
Kidneys: abnormalities, vascular anatomy, number of arteries and veins.
Ultrasound Heart
- Heart movement, regionally impaired movement
- Left ventricular function – LVEF, ejection fraction
- Right ventricular function – RVEF Degree of left ventricular hypertrophy
- Valve function (grading: normal, mild, moderate, severe)
- Aortic insufficiency/stenosis, AI/AS
- Mitral insufficiency/stenosis, MI/MS
- Tricuspid insufficiency, TI
Coronary Angiography
- Atheromatosis
- Significant stenoses
Bronchoscopy
Examination to assess potential aspirate or pus (infection?) in the bronchial tree. Suctioning to (if possible) optimize lung function.
Tissue Typing and Virus Serology
- Blood test for tissue typing – HLA
- Blood test for virus serology (HIV, Hepatitis, CMV, and LUES)
- Test for SARS-CoV-2 RNA (COVID-19)
Orders from the Transplant Unit:
- Steroids – Methylprednisolone 15 mg/kg iv
- Antibiotics – Meropenem 0.5 g x 3 iv, per standing order from the transplant surgeon (unless contraindications or other reasons exist)
- Order 2 units of blood and 2 units of plasma for the donation surgery
Treatment Goals (Adult Donors)
- HR: 50–110 beats/min
- SaO2: 95–98%
- MAP: 65–100 mmHg
- Urine output: 0.5–1 ml/kg/hour
- Fluid balance: -500 ml to +/- 0 ml (including insensible losses)
- Hb: >80 g/l
- PaO2: 10–13 kPa
- PCO2 and pH normal (within reference range)
- Blood glucose: 5–10 mmol/l
- P-Na: 135–145 mmol/l
- P-K: 4–4.5 mmol/l
- Normal levels for calcium and magnesium
- Temperature: 35.5–38.0° C
- Stable weight – Daily weight checks
- Consider enhanced hemodynamic monitoring, e.g., PICCO, CVP, or ScvO2, if necessary
The Donation Process
Click here to download the PDF file
Donor Characterization
Click here to download the PDF file
Medical Record for Donation Procedure on Deceased Donor DBD/DCD
Click here to download the PDF file
Clinical Brain Death Diagnostics
Click here to download the protocol for clinical brain death diagnostics
Flowchart for the Donation Process at DBD
Click here to download the flowchart for DBD at the ICU
Flowchart Operation/Anesthesia – DBD
Click here to download the flowchart for DBD in Operation
Flowchart ICU – DCD
Click here to download the flowchart for DCD at the ICU
Flowchart Operation/Anesthesia – DCD
Click here to download the flowchart for DCD in Operation
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