Organ and Tissue Donation Policy
Version
2
Name of responsible (ratifying) committee
Organ Donation Committee
Date ratified
8th July 2014
Document Manager (job title)
Clinical Lead for Organ Donation
Date issued
20th August 2014
Review date
19th August 2016
Electronic location
Trust Intranet & NHSBT intranet.
Related Procedural Documents
Controlled Non Heart Beating Donation Protocol
Key Words (to aid with searching)
Organ & Tissue Donation, Brainstem death, Donation
after circulatory death (DCD). Donation after brainstem
death (DBD). Withdrawal of treatment. Liverpool Care
Pathway.
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
Policy for Organ and Tissue Donation. Version 2. Issued:20th August 2014 (review date 19th August 2016)
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CONTENTS
QUICK REFERENCE GUIDE ............................................................................................................. 2
INTRODUCTION ................................................................................................................................ 3
2. PURPOSE ................................................................................................................................... 4
3. SCOPE ........................................................................................................................................ 4
4. DEFINITIONS .............................................................................................................................. 4
5. DUTIES AND RESPONSIBILITIES ............................................................................................. 5
6. PROCESS Adults & Paediatrics ................................................................................................ 6
7. TRAINING REQUIREMENTS ...................................................................................................... 9
8. REFERENCES AND ASSOCIATED DOCUMENTATION ........................................................... 9
9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS………………………………………………………………………………………………….10
10. EQUALITY IMPACT STATEMENT…………………………………………………………………….10
Appendix Flowchart I - Donation after Brainstem Death (DBD) ………………………………………...12
Appendix Flowchart II - Donation after Circulatory Death (DCD) ………………………………………..13
Appendix Flowchart III - Tissue Donation ………………………………………………………………….14
Appendix IV - National Tissue Services referral guide …………………………………………………...15
QUICK REFERENCE GUIDE
This document helps to support staff in aiming to provide tissue or organ donation as
an option to all patients (and their relatives) of Portsmouth Hospitals as part of end of
life care; making donation “usual”.
There is detailed background, references and processes laid out in the policy
At the end, there are FLOW DIAGRAMS that aid with the specific scenarios that will occur.
Policy for Organ and Tissue Donation. Version 2. Issued:20th August 2014 (review date 19th August 2016)
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INTRODUCTION
1.1.
The policy aims to provide guidelines on organ and tissue donation at Queen Alexandra
Hospital, supporting recommendations from the DH Organ Donation Taskforce report (Jan
2008), “Taking Organ Transplantation to 2020 (TOT20), a UK strategy” (DoH, July 2013) report,
and NICE guidance on organ donation (2011).
This policy will ensure that, where suitable, the option of organ and/or tissue donation will be
offered to the patient’s next of kin (NOK - where NOK may include relatives, friends and
significant others). It also ensures that healthcare professionals are aware of their role in
caring for the potential donor and their NOK, and receive adequate support. This policy covers
donation in adults and paediatrics.
“Organ donation should become usual and be a normal part of end-of-life care for appropriate
patients, involving timely consultation of the NHS Organ Donor Register and appropriate
involvement of the Specialist Nurse Organ Donation (SN-OD). Organ and tissue donation
should be considered in all areas where end-of-life care is provided.”
1.2. In conjunction, the donation committee aims:
 To influence policy and practice in order to ensure that organ & tissue donation is
considered in all appropriate situations. To identify and resolve any obstacles to this.
 To ensure that a discussion about donation features in all end-of-life care, wherever
located and wherever appropriate, recognizing and respecting the wishes of individuals,
or the NOK for patients unable to make choices (paediatrics and patients whom have
previously lacked mental capacity to make their wishes known).
 To maximize the overall number of organs donated, through better support to potential
donors and their NOK
 To ensure that donation is accepted and viewed as usual, not unusual. To maximize
organ donation.
Ensuring:
 All potential donors are identified.
 Early contact made with the relevant Specialist Nurse-Organ Donation (SN-OD).
 Routine checking of the organ donation register in relevant patients.
 Donation is offered to all NOK where possible.
 Respect at all times to the decisions and views of the patients and their families.
 Encouragement to seek the views of all NOK as to the patient’s likely wishes.
 Provision of quality counselling, comfort and quality end-of-life care to patients and their
NOK.
 Move towards a culture of considering organ donation as a normal end-of-life process.
 Provision of embedded in-house SN-OD to support staff and NOK, and to educate with
a view to seeing donation as a normal part of the end-of-life pathway.
 Provision of sensitive and professional practice when approaching NOK.
 Follow best practice guidelines.
 Sensitive feedback and audit collection.
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2. PURPOSE
This policy has been written to reflect current legislation and existing codes of practice on organ
and tissue donation in the United Kingdom (UK). The policy will ensure that, where appropriate,
the positive option of organ and/or tissue donation will be offered to all patients, and where
appropriate (in most cases) their NOK, and that the explicit wishes of the patient are identified
and respected. It also ensures that healthcare professionals are aware of their role in the
identification and management of potential donors and their NOK.
3. SCOPE
3.1. This policy applies to healthcare professionals, who will ensure that, where appropriate,
the positive option of organ and / or tissue donation will be offered to all potential donors
and their NOK and that their explicit wishes identified and respected as part of end of life
care. It also ensures that healthcare professionals are aware of their role in the
identification and management of potential donors and their NOK.
3.2. This policy covers donation from both brain stem dead patients and those where the
decision has been made for withdrawal of life sustaining therapies. Many steps in the
donation process are the same for both donation following brain stem death (DBD) and
donation following circulatory death (DCD); explanation is offered throughout this
document where differences occur. This includes adults and paediatrics.
3.3. All patients undergoing brain stem death tests to be referred to the appropriate SN-OD at
the earliest opportunity for consideration for donation after DBD.
3.4. Where the decision has been made to withdraw life sustaining treatment in the
Emergency Department or Critical Care, these patients will be referred to the SN-OD as a
potential donor for donation after circulatory death (DCD).
3.5. That brain stem death (BSD) testing should be carried out in all patients where BSD is a
likely diagnosis, even if organ donation is an unlikely outcome.
3.6. Consideration of tissue donation in patients following death.
3.7. Clinical priorities will take precedence in the situation where activity must be directed
away from organ donation towards life-sustaining actions for other patients being cared for
by the relevant clinical staff (eg where acute admissions pathway +/- hospital capacity is
overwhelmed by unpredictable workload such as ‘flu pandemics or major incidents).
4. DEFINITIONS
Brain stem death (BSD)
Irreversible cessation of conscious brain activity together with the loss of the ability to breathe
(ACoMRC 2008). This is confirmed by well laid out brain stem death tests performed by
experienced medical staff.
Brain stem death tests
A series of clearly defined tests used to establish whether or not the brain stem still has any
function.
Clinical Lead for organ donation (CLOD)
An appointed clinical lead for the promotion of the potential for organ donation in the
organisation, and ensuring any potential donation maximises the transplantation opportunities.
Donation after brain stem death (DBD)
The donation of an organ or organs after death has been confirmed by neurological criteria, ie
BSD.
Donation after circulatory death (DCD)
The donation of an organ or organs after death has been confirmed following permanent
cessation of the heartbeat. This pathway for donation has previously been termed donation
after cardiac death, and non-heart beating donation.
Donation committee
Is a multi-disciplinary group of individuals committed to organ donation that provides consensus
and expertise to improve donation rates through education, policy implementation, awareness
and audit.
Human Tissue Acts
The Human Tissue Act 2004 applies in England, Wales and Northern Ireland and the Human
Tissue Act (Scotland) 2006 applies in Scotland. Both Acts came into force in full in September
Policy for Organ and Tissue Donation. Version 2. Issued:20th August 2014 (review date 19th August 2016)
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2006. The Acts are very similar but not identical, and cover (amongst other issues) the removal,
storage and use of organs from dead people for transplants.
Human Tissue Authority (HTA)
The regulatory authority established under the Human Tissue Acts that, amongst many
functions, defines the consent process (authorisation in Scotland) required for organ donation.
Mental Capacity Act 2005
The Act that describes, amongst many other things, what can and cannot be done to a person
or patient who lacks the capacity to give consent themselves.
National Blood Service (NBS)
An operating division of NHSBT responsible for ensuring that there is a safe and secure supply
of blood and most blood products for England and North Wales. It also has responsibility for
some, but not all, tissue donation, banking and supply.
NHS Blood and Transplant (NHSBT)
A Special Health Authority within the NHS, established in 2005, that incorporates both UK
Transplant and the National Blood Service, together with Bio Products Laboratory.
Organ Donor Register
The NHS computer register of those who have recorded their wish to donate their organs
and/or tissues after death.
Potential Donor Audit (PDA)
A UK-wide audit of patients who die in intensive care units. It was established in 2003 and
provides information about the number of potential organ donors and whether they became
actual donors or not.
Specialist Nurse-Organ Donation (SN-OD).
The primary role of a SN-OD is to ensure that the choices that individuals make in life are
identified and fulfilled at the time of their death. Where an individual has not expressed a wish
in life, SN-ODs support families when they make the decision on behalf of their loved one. More
strategically, specialist nurses for donation are expected to work with CLODs and donation
committees, to identify and overcome local barriers to donation and to make donation ‘usual,
not unusual’.
5. DUTIES AND RESPONSIBILITIES
5.1. SN-OD.
To support and deliver training in the process of organ and tissue donation, The SN-OD
will co-ordinate and support actual donation processes in conjunction with the team caring
for the potential donor. The SN-OD has professional accountability to NHSBT and, locally,
is responsible to the Modern Matron of Critical Care and the Senior Nurse for the
Emergency Department. The SN-OD will collate data for the Potential Donor Audit and
present findings to the donation committee and NHSBT.
5.2. Clinical Lead for Organ Donation (CLOD)
To provide clinical leadership within the Trust/hospital to raise the profile of organ
donation; to maximise the local organ retrieval rates and to ensure the Trust implements
the recommendations of the Organ Donation Task Force (ODTF) and TOT20 reports
across the whole Trust, focussing particularly on Critical Care and the Emergency
Department.
5.3. Critical Care and Emergency Department staff.
To support the training of all health care professionals in end-of-life care. To ensure that,
where appropriate, the positive option of organ and / or tissue donation will be offered to
all potential donors and their NOK and that their explicit wishes identified and respected
as part of end of life care.
5.4. Donation Committee.
 Leading on policy and practice in order to ensure that organ and or tissue donation
is considered in all appropriate situations.
 Ensuring that a discussion about donation features in all end-of-life care, wherever
located and wherever appropriate, recognising and respecting the wishes of
individuals.
 Maximising the overall number of organs donated, through better support to
potential donors and their families.
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


Ensuring that organ and tissue donation adheres to best practice guidelines, along
with national and local policies and procedures.
Ensuring that the Organisation complies with the Report of the Organ Donation
Taskforce published in January 2008, and its 14 recommendations which, amongst
others called specifically for the appointment of Trust Clinical Donation Champions
(now termed CLODs) and the formation of Trust Donation Committees chaired by a
non-clinical Donation Champion (Recommendation 4)
Ensuring the organization works towards the taking organ transplantation to 2020
strategy (DoH July 2013), especially Outcome 2. In particular, the donation
committee will look to engage the local community about organ donation and
transplantation, including making the most of all publicity opportunities.
5.5. All Healthcare Professionals have responsibility to:
Provide all next of kin/significant of potential donors, the opportunity to consider organ and
tissue donation as part of end-of-life care.
Where possible to use a collaborative approach to achieve a consistent and effective
research based approach to donation.
Ensure consideration is given to tissue donation in patients that die in any clinical area.
Inform relatives of potential donors about the support services provided for example:
Chaplaincy and Bereavement.
6. PROCESS Adults & Paediatrics (See flow charts for DBD & DCD: Appendix I, & II)
If the donation process includes paediatrics then it is recommended that extra advice is sought
from a Paediatrician where appropriate.
6.1. The referral.
Donation after brain stem death. (DBD)
6.1.1.
Outside of office hours, contact can be made with the on call SN-OD (pager
07659183499).
6.1.2. When brain death is suspected, certification of death by brain stem tests should be
performed (as set out by the Academy of the Medical Royal Colleges 2008). This should
be done regardless of the question of organ donation and allows staff and relatives to be
confident that further therapy is of no benefit.
6.1.3. Normal homeostasis is maintained with fluids and vasoactive drugs as indicated.
6.1.4. The clinician or nurse will refer all patients who are potentially going to undergo brain
stem tests to the embedded SN-OD as soon as the sedation/analgesia have been
discontinued or immediately if the patient was never on medication. If the patient is not
due to be tested imminently due to sedation, the SN-OD should still be contacted so that
they can negotiate with the consultant an appropriate time to be available at the hospital.
6.1.5. The SN-OD, clinician or nurse will check the ODR to see if the patient is registered. The
regional SN-OD’s are available at all times to assist and support families though the
decision making process.
6.1.6. The referring staff will have clinical information available for discussion with the SN-OD
to ascertain the potential suitability for donation.
Donation after circulatory death. (DCD)
6.1.7. When the decision is made to withdraw life sustaining treatment, it must be based on a
multi-disciplinary consensus on the futility of continued organ support. Where possible,
this should involve senior medical and nursing staff and key family members. A decision
to withdraw must be transparently independent from any discussion about organ
donation.
6.1.8. The criteria for organ donors after circulatory death are as follows:
 A decision to withdraw life sustaining treatment has been made.
 Patients are on advanced respiratory support. (Non invasive ventilation is not a total
exclusion to referral).
 The patient has been clear of any malignancy (excluding primary brain tumours) for 3
years and does not have HIV disease (not HIV infection) or suspected CJD.
 Relative contraindications for all organs should be discussed with transplant teams via
the SN-OD e.g. high oxygen requirements, blood pressure, BMI, diabetes mellitus etc.
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6.1.9. If a patient meets these criteria, then the nurse or clinician should contact the SN-OD for
patient assessment.
6.1.10. The SN-OD, clinician or nurse will check the ODR to see if the patient is registered.
6.1.11. The referring staff will have clinical information available for discussion with the SN-OD
to ascertain the potential suitability for donation.
6.2.
The approach for donation (DBD & DCD)
6.2.1. A planned approach should be made. A collaborative approach has been shown to
increase consent rates.
6.2.2. The approach to the NOK should be made at an appropriate time, normally once the
NOK understand that brain stem death has been confirmed or that treatment will be
withdrawn and the patient is likely to die. The NOK should be given time and privacy to
consider events and the information about organ donation.
6.2.3. The option of organ donation should NOT be given to the NOK in the same discussion
as the decision to withdraw treatment (unless the NOK raises the issue) and the NOK
should be given the time to accept this decision.
6.2.4. The approach to the NOK would usually be carried out by the SN-OD so that there was
no perceived conflict of interest.
6.2.5. Whatever the NOK’s decision, this will be respected and continued care and support be
given as appropriate. The outcome of discussions must be documented in the patient
notes and if the NOK decline to proceed with donation, the reason should be
documented.
6.3.
Donation process (DBD & DCD)
If the patient is on the Organ Donor Register, which is now recognised as lawful consent (HTA
2004), the SN-OD will inform the NOK of the patient’s wishes regarding donation. The SN-OD
will discuss the organ donation procedure and answer any questions. Consent documentation
will be completed, along with a medical and social history assessment obtained from the NOK.
If the NOK disagree with the patient’s wishes, this would require further investigation and
exploration. (There are clearly some circumstances when the NOKs’ wishes should be taken
into account and therefore donation should not occur. These should be assessed on an
individual basis).
If the patient has not made their wishes known during their lifetime, the SN-OD will make
reasonable enquiries to determine if the patient has nominated a representative during their
lifetime to act on their behalf after their death. If no representative is identified, then the relative
ranking highest within the hierarchy (as per the Mental Capacity Act 2005) will be approached
to discuss the possibility of organ donation.
If the NOK happens to raise the possibility of organ donation with local staff without being
formally asked for donation, the duty consultant should be informed and a referral to the SN-OD
should be made. The SN-OD will advise staff on how to proceed, and will discuss donation with
the family and facilitate the organ donation process.
The SN-OD will provide information for the NOK on organ donation and the processes involved.
The NOK will be encouraged to ask questions which will be addressed. Where requested the
NOK should be left to discuss donation privately, ensuring appropriate support is available
should they require it.
If the NOK give their consent for organ donation to proceed, The SN-OD will discuss donation
with the NOK and obtain formal documented consent along with a medical and relevant social
history assessment.
The SN-OD/doctors will discuss potential donors with HM Coroner where indicated (as is the
case in almost all cases); if further investigations into the cause of death are required, this will
be discussed with the coroner’s officer on an individual basis. Occasionally HM Coroner may
place some restrictions on the donation dependant upon the circumstances of the patient’s
death.
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Donation after circulatory death (DCD)
The SN-OD will facilitate the donation process; once consent is obtained Critical Care staff will
be asked to perform several investigations, which include the collecting of blood specimens for
tissue typing and virology testing.
Withdrawal of treatment takes place in the Critical Care or other agreed area (i.e. recovery or
anaesthetic room), at a time negotiated and agreed by the NOK, SN-OD (in collaboration with
the organ retrieval teams) and hospital staff. A member of the Critical Care, Emergency
Department or anaesthetic staff performs the withdrawal of supportive therapies. Family may
wish to be present during this time; medical and nursing staff are also present during this stage.
The patient is closely monitored following withdrawal.
After five minutes of the absence of cardiac output the Doctor declares the patient dead using
current standard criteria (Academy of Medical Royal Collages 2008). Written confirmation of
death by circulatory criteria must be entered in the hospital notes, and be in accompaniment
with the patient. Following the confirmation of death, the patient is moved into the operating
theatre and the retrieval operation can begin. The surgical team will be on site and on standby
within the theatre complex prior to withdrawal of treatment.
In all cases the organ retrieval process will be coordinated by the SN-OD who will support all
staff involved in the patient’s care throughout. Care of the deceased patient’s body is performed
by the hospital staff and assisted by the SN-OD in accordance with the hospital policy. Respect
and dignity for the patient is maintained at all times.
Donation after brain stem death (DBD)
The SN-OD will facilitate the donation process. Critical Care staff will be asked to perform
several investigations which include the collecting of blood specimens, ECG, chest X-ray,
echocardiogram, and the administration of methylprednisolone, T3 and Pitressin. An organ
donation reference folder is available, providing detailed information on donor management and
the rationale for investigations. The SN-OD will be present for advice and guidance as to the
management of the organ donor. A care bundle has been developed by NHSBT for the
management to these patients and will be given to the care team by the SN-OD after consent
has been given.
6.4. Documentation
The SN-OD and the medical staff involved with the patient’s care will record a clear and precise
record of all events in the hospital medical notes.
Brain stem death should be recorded as indicated in the Code of Practice for the Diagnosis of
Brain Stem Death and attached to the medical notes.
If the patient proceeds to organ donation, a copy of the consent and the patient assessment
forms should be filed in the medical notes. The retrieval teams will record the surgery in the
patient’s notes.
6.5. Tissue Donation – See Flowchart on the Process for Tissue Donation (Appendix III)
Approach for tissue donation
6.5.1. In the event of all deaths within the Trust, a member of staff who is knowledgeable and
confident should ascertain whether the patient had expressed a wish to donate after
his/her death. NOK should be offered information regarding tissue donation options. The
SN-OD can offer support and guidance to the healthcare professionals involved with
approaching the NOK at this time.
6.5.2. At the time of renewing this policy the ICU and ED departments have become part of the
Alliance Site project (National Blood Service) to increase tissue donation by a mandatory
referral system. All deaths in ICU and ED that are under 80yrs old and do not have
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absolute contra-indications to tissue donation are to be referred using the referral form at
appendix IV
6.5.3. This system does not require nursing or medical staff to discuss tissue donation with the
bereaved as they will be given a tissue donation booklet along with the standard
bereavement care booklet. The staff are to then make the referral using the referral form
and NBS Tissue services will contact the bereaved to offer tissue donation if it is
appropriate.
6.5.4. The national tissue referral centre can also advise on tissue donation and will take
referrals to consent for tissue donation (National Blood Service (NBS) Tissue
Coordinator: 0800 432 0559) by email or fax, see appendix IV.
Tissue Donation process
6.5.5. If the NOK give their consent for organ donation to proceed, the SN-OD will discuss
tissue donation with the relatives and obtain formal documented or recorded consent
along with a medical and social history assessment, as per NHS Blood and Transplant
policy & Human Tissue Act 2004 on obtaining consent for donation.
6.5.6. If consent is given for Tissue donation and further investigations into the cause of death
are required the patient should be discussed with HM Coroner. Occasionally HM
Coroner may place some restrictions on the donation dependant upon the
circumstances of the patient’s death.
6.5.7. NBS tissue services or the SN-OD will organise the tissue retrieval process with
assistance from relevant tissue banks. This process is carried out in the mortuary and
does not delay movement of the patient from the ward area. The hospital staff, in
accordance with the hospital policy, performs standard care of the deceased. Respect
and dignity for the patient is maintained at all times.
6.5.8. The patient is required to be in the mortuary within 6 hours of confirmation of circulatory
death to donate tissues. If this is likely to be longer, then please check with tissue
services on potential for tissue retrieval.
7. TRAINING REQUIREMENTS
All staff should be trained in end-of-life care, understanding which patients would be suitable for
organ and tissue donation.
Staff should be trained in how and when to make tissue referals to NBS tissue services. Staff
are still very much supported to talk to the bereaved about tissue donation if they feel they have
the appropriate skills and knowledge to approach next of kin for tissue donation.
Staff will understand the flow processes to donation.
Training will be facilitated by members of the Donation Committee for the relevant Departments
and Trust staff, and attendance recorded at a local level.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Academy of the Medical Royal Colleges (2008) A code of practice for the diagnosis and
confirmation of death
Human tissue act (2004)
Mental Capacity Act 2005
Links to other key Strategies & Policies
Department of Health (2008) Organs for Transplants: A report from the
Organ donation taskforce.
UK NHSBT (2004) Donor Family Care Policy.
Human Tissue Authority. Code of Practice – Donation of organs.
Human Tissue Act 2004. www.hta.gov.uk.
Intensive care society (2005) Organ and tissue donation guidelines.
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Legal issues relevant to non-heartbeating organ donation
2009 Department of Health
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_108825
Map of medicine: http://www.mapofmedicine.com
Organ donation: http://www.organdonation.nhs.uk
Organs for Transplants – A Report from the Organ Donation Taskforce. DOH January 2008.
www.dh.gov.uk
Saving Lives, Valuing Donors: A Transplant Framework for England. DOH July 2003.
www.dh.gov.uk
United Kingdom Hospital Policy for Organ and Tissue Donation – UK Transplant 2003
Tissue and cells for transplantation. Code 2 July 2006. www.hta.gov.uk.
Withholding and withdrawing - guidance for doctors, 2010 General Medical Council
http://www.gmc-uk.org/guidance/ethical_guidance/6858.asp
Taking organ transplantation to 2020. A UK strategy 2013 DoH
Organ donation: implementing NICE guidelines Nov 2011 DoH
9. MONITORING COMPLIANCE
PROCEDURAL DOCUMENTS

WITH,
AND
THE
EFFECTIVENESS
OF,
Embedded SN-OD to audit all deaths occurring within Critical Care/ED Units – Potential
Donor Audit. This audit will demonstrate rates of potential donor identification, referral, and
approach to the NOK and consent to donation.
 Embedded SN-OD to continue to collect data on all potential tissue donor referrals –
proceeding to donation and non–proceeding.
 This document will be reviewed after one year or sooner if new evidence, legislation or change
in best practice occurs. All of the above information will be taken into account along with
details of adverse events in assessing the effectiveness of the Policy
 If through ongoing compliance monitoring the policy is found to not be delivering the expected
results, the SN-OD and Donation Committee will review the results and amend the Policy
accordingly.
10. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
All policies must include this standard equality impact statement. However, when sending for
ratification and publication, this must be accompanied by the full equality screening assessment
tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy
Documentation
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Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
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Donation after Brain-stem Death (DBD)
Appendix I
Brain stem death
(BSD) is suspected.
Notification of potential
donor to Specialist
Nurse Organ Donation
(SN-OD).
Pager: 07659183499
Maintain therapy and
physiological stability
: (Perform BSD
Check Organ Donor Register:
Duty Office at the Directorate of
Organ Donation and
Transplantation in Bristol on
0117 9757580 or 0117 9757581
Testing)
Patient has a confirmed
diagnosis of BSD
Discuss the case with the coroner.
Record any coroner’s restrictions to
donation
Patient DOES NOT
have a diagnosis of BSD.
Discussions with NOK
ensuring understanding of
BSD
Patient is not
BSD Consider
DCD pathway
Assessment of patient for donation by the SN-OD & clinician
Patient NOT
potentially suitable for organ
donation
Patient potentially
suitable for organ
donation?
Planned approach for
donation to include SN-OD,
clinician & nurse.
- use NHSBT donor care bundle
Family agree or consent to donation
Family object to
donation
End of life care
pathway
Maintain therapy and
physiological stability
End of life care
pathway
Consider tissue
donation
pathway
Obtain blood samples
for tissue typing and
virology
SN-OD will co-ordinate
organ offering, theatre,
retrieval teams &
family follow up
Formal consent
Maintain therapy and
and patient
physiological stability
assessment
completed by
SN-OD
Patient will require the following tests:
NOK / clinicians /
CXR, ECG, FBC, U&E’s, LFT’s (including
nurses will be kept
GGT, & amylase),
informed of the
Clotting
studies, Blood group.
process
ECHO (if cardiothoracic organs considered)
The patient remains physiologically supported and ventilated until post cross clamp in theatre.
The hospital will provide an anaesthetist. The SNOD attends theatre with the patient.
The SN-OD will arrange for staff and NOK to receive information following the donation process.
Policy for Organ and Tissue Donation. Version 2. Issued:20th August 2014 (review date 19th August 2016)
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Donation after circulatory death (DCD).
Decision made that
to continue treatment
would not be of overall
benefit to the patient
Notification of potential
donor to Specialist
Nurse Organ Donation
(SN-OD).
Pager: 07659183499
Maintain therapy and
physiological stability
Discuss the case with the coroner.
Record any coroner’s restrictions to
donation.
Appendix flowchart II
Check Organ Donor Register:
Duty Office at the Directorate of
Organ Donation and
Transplantation in Bristol on
0117 9757580 or 0117 9757581
Discussions with NOK
ensuring understanding of
futility.
Assessment of patient for donation by the SN-OD & clinician
Patient potentially
suitable for organ
donation?
Planned approach for
donation to include SN-OD,
clinician & nurse.
Maintain therapy and
physiological stability
Family agree or consent to donation
Family object to
donation
End of life care
pathway
Patient NOT
potentially suitable for organ
donation
End of life care
pathway
Consider tissue
donation
pathway
Maintain therapy and
Formal consent
physiological stability.
and patient
assessment
completed by
SN-OD
Family / clinicians /
Patient will require the following tests:
nurses will be kept
CXR, ECG, FBC, U&E’s,LFT’s
informed of the
(including GGT,& amylase),
process.
Clotting studies, Blood group.
Obtain blood
samples for
tissue typing
and virology
SN-OD will coordinate organ
offering, theatre,
retrieval teams &
family follow up
Planned withdrawal of life sustaining measures
The patient is taken to theatre immediately following certification of circulatory death.
The SNOD attends theatre with the patient.
The SN-OD will arrange for staff and NOK to receive information following donation.
Policy for Organ and Tissue Donation. Version 2. Issued:20th August 2014 (review date 19th August 2016)
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Appendix flowchart III
End of life care.
Organ and Tissue Donation
To check the Organ Donor Register (ODR)
Tel: 01179 757580 (24hrs) you will need patients name, date of birth & address.
(Not being registered does NOT exclude donation)
Yes
Has the patient died?
If the deceased is over 85 and had any of the
follow. No further action is required regarding
Tissue donation
Alzheimer’s disease and other neurological
degenerative diseases (All dementias and
Parkinsonism)
Diseases of unknown aetiology
Leukaemia and Lymphoma
HIV, Hep B, Hep C
CJD
Viral Encephalitis or Encephalitis or unknown origin,
Viral Meningitis
Give bereaved unit bereavement booklet and
Tissue donation leaflet
In all other cases:
Make
using the formbooklet
at Appendix
Give referral
unit bereavement
and Discuss
tissue
/donation
offer potential
donation
leaflettissue
and E-Mail
the with
NBSNOK.
referral form
Inform
of ODR check and any restrictions.
to
national.referral.centre@nhsbt.nhs.uk.
They do
not need to make a decision right away and
Make
sure
youconsider
have the contact
details
of bereaved
can wait to
once they
get
home. (Tissue
Should
you
have
any
questions
before
making
referral
donation can occur up to 24hrs after
deatha and
up
please
call
NBS
tissue
services
on
0800
432
0559
to 48 hrs. for some tissues)
AskTissues
if they would
like morecan
information
for donation
include:and if they do
a specialist
nurse
will
contact
them.
Skin
Tendons Warn them they
will Heart
be asked
some
personal
questions to ensure
valves
Ligaments
donation
Bone is a suitable option.
Blood vessels
Corneas
If the
Age limits apply for some tissues. Tissue
Services or a SN-OD can advise on this.
No
Is there is a plan to withdraw
treatment and the patient is receiving
advanced respiratory +/- circulatory
support?
Consultant must be involved in this
decision & aware of potential for
donation.
YES
Contact
Specialist
Nurse–
Organ
Donation
before
withdrawal, they will assess if
suitable for Organ Donation
07659 183499 – 24hrs.
Leave your name & full contact
details you will receive a reply
within 20mins.
Absolute contraindications to ORGAN donation 







Over 85yrs of age
Primary intra cerebral lymphoma
All secondary intracerebral tumors
Active CA with evidence of spread
CJD and variants
active and untreated TB.
West Nile virus
And HIV (active)
Policy for Organ and Tissue Donation. Version 1. Issued: August 2014 (review date August 2016) Page 14 of
19
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Appendix IV
Tissue referral to National Referral Centre (NRC)
All deceased patients who are:
A
B
Not absolutely contra-indicated to tissue donation
under 85years of age
Are to be referred to National Referral Centre (NRC) using the Tissue donation referral form
and E-Mailing to national.referral.centre@nhsbt.nhs.uk for consideration of potential tissue
donation, and if appropriate they will be offered the option of tissue donation by the NRC.
Absolute contra-indications to tissue donation at August 2014 are:
HIV
Hepatitis B or C
Dementia and any other neurological degenerative disease
Disease of unknown etiology
Leukemia or lymphoma
Active tuberculosis
General information about proceeding tissue donation
The deceased’s body must go to the mortuary with 6hrs of death.
Blood samples will be taken to support any tissue donation.
The deceased GP will be contacted to check past medical history
You (or the doctor) may be asked for more information of the patients past medical history
All retrieval of tissues is preformed like any surgical operation and the body is closed with
sutures where necessary and covered with dressings. For eye donation the normal shape of
the eye is restored with the eyelids closed. For Skin donation the areas are covered with
appropriate dressings.
Tissue donation will not affect any funeral arrangements.
All tissue retrieval will be done in this hospital mortuary
The body can be viewed pre and post donation
Process.
During the discussion with the family and relatives it is normal practice to give a bereavement
booklet. In addition to this booklet you must include a tissue donation leaflet. You must also fill
in the tissue donation referral form and e-mail it to national.referral.centre@nhsbt.nhs.uk.
Instructions on how to do this are attached.
Please note faxing must only be done as a last resort and a call to the NCR made pre and
post faxing to make sure that the fax has arrived at it intended destination.
The referral will be assessed for potential to donate and if tissue donation is possible the NRC
will make a call to the relatives at home to offer the option of tissue donation in line with
Portsmouth hospitals end of life care policy.
Q&A
1Q
Do I mention or offer tissue donation to the family?
1A
their is no need for you to offer the option of tissue donation. Whilst there is no reason
why you shouldn’t offer tissue donation, the criteria for tissues is ever changing. So it is better
to either; find out what is possible or refer to the specialist in that area.
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2Q
What if the family see the tissue donation leaflet and make it clear that the deceased
would not want tissue donation?
2A
Document in the notes and DO NOT make a referral
3Q
what if the deceased has an absolute contra indication to tissue donation?
3A
Document in the notes and DO NOT make a referral. You can tell the family that you
have considered tissue donation but that in this case it is not possible due to an absolute
contra-indication.
4Q
what do you do if the family ask what can they donate?
4A
Refer to the leaflet but say that a specialist nurse in that field will call them when they
get home to identify what is possible and what they would like.
5Q
should I check the Organ Donor Register?
5A
it is good practise to check the organ donor register as this will give you more
information. It may help answer questions if asked about tissue donation. However it is not
necessary to do so because the national referral centre will check the organ donation register
before they make a formal approach for tissue donation.
6Q
what should I do if I don’t know the answers to questions about tissue donation?
6A
Tell them that this is not your specialist area, and that you will get a specialist to call
them to discuss tissue donation when they are at home.
7Q
how quickly must tissue donation happen, how long does the family have to make a
decision?
7A
Tissue donation must be done within 24 hrs for corneal donation and 48hrs for all
other tissues. The decision does not need to be made immediately but allow for the
organisation of retrieval. No decision needs to be made during the initial bereavement
discussion they will receive a call from tissue services to discuss fully in due course.
8Q
should I inform the coroner?
8A
the coroner must be informed if the patient is reportable to the coroner under normal
circumstances. Otherwise the national referral centre will discuss with the coroner if required.
9Q
what should I do if I need more information now?
9A
Call the NRC and ask for advice on 0800 234 0559 or If Mick Willcox or Helen
McManus the specialist nurses for Organ donation are in the hospital ask them for help.
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11. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to
be monitored
Referrals to SN-OD
Neurological testing
Consent
Lead
SN-OD
SN-OD
SN-OD
Tool
Frequency of Report
of Compliance
NHSBT Potential
Donor Audit
Annual
NHSBT Potential Donor
Audit
Annual
NHSBT Potential Donor
Audit
Annual
Reporting arrangements
Policy audit report to:

CLOD, SN-OD
Donation Committee, NHSBT
Policy audit report to:

Lead(s) for acting on
Recommendations
CLOD, SN-OD
Donation Committee, NHSBT
Policy audit report to:
CLOD, SN-OD
 Donation Committee, NHSBT
This document will be monitored to ensure it is effective and to assurance compliance.
The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being
achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.
The details of the monitoring to be considered include:






The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);
The lead for ensuring the audit is undertaken
The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
Frequency of the monitoring e.g. quarterly, annually;
The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required.
In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on
the Trust Intranet Trust Intranet -> Policies -> Policy Documentation
The lead(s) for acting on any recommendations necessary.
Policy for Organ and Tissue Donation. Version 1. Issued: August 2014 (review date August 2016) Page 19 of 19