**4. Ethical considerations**

• 8:30 am: After stabilizing the patient sufficiently for transfer to the radiology department for confirmatory brain flow study, determination was made to proceed with such testing (**Figure 1**). Following the confirmatory study to determine brain death, the patient continued to receive maximum medical management to ensure adequate organ perfusion and maintain tissue oxygenation. Representatives of the local OPO were introduced to the fam-

• 9:00 am: All required procedures for determining blood type and tissue match were progressing as planned. Organ placement discussions between the local OPO and potential receiving institutions were ongoing. The patient underwent trans-esophageal echocardiography and bronchoscopy to determine his suitability as a heart and lung donor, respectively. Throughout this process, medical optimization of end-organ perfusion continued, including the use of advanced cardiac monitoring, as well as intermittent use of vasopres-

• 11:00 am: After determining that the patient will be able to donate his kidneys, pancreas, and liver. However, due to severe chest trauma his lungs and heart were not suitable for

• 12:00 pm: The patient's family members were allowed to see him prior to the organ procurement operation. The process was to occur within the next several hours, and was predicated on finding a suitable recipient for one of the kidneys. Medical optimization therapy continued. • 15:30 pm: The patient was taken to the Operating Room for the procurement of bilateral kidneys, pancreas and liver. Three different institutions received kidney, liver and combined kidney-pancreas for transplantation, respectively. Recipients of the above organs underwent uneventful immediate post-transplantation recovery and were able to resume normal lives.

Organ transplantation and procurement has a rich history, with early accounts of tissue removal and re-implantation involving skin, bone and teeth [8]. During the past several decades, significant progress was made in the area of human transplantation. The evolution of both surgical techniques and immunosuppression resulted in organ transplantation becoming commonplace [9, 10]. Notable medical pioneers of modern transplantation include Dr Christiaan Barnard, Dr Alexis Carrel, Dr Joseph Murray, Dr Thomas Starzl and many others who helped advance the basic scientific and medical understanding required to achieve

From a clinical perspective, the first successful transplants of the modern era involved skin and corneal tissues, and took place in the early 1900s [8]. These experiences, especially involving skin grafting, were plagued by failures well before the concept of tissue compatibility and rejection was fully elucidated [11]. Solid organ transplantation beginning with the kidney was even more challenging. Russian surgeon, Dr Yuri Voronov is credited with the first recorded

ily and the formal process of organ donation was initiated.

72 Organ Donation and Transplantation - Current Status and Future Challenges

transplantation. At this time, final placement decisions were made.

sors and inotropes.

**3. Historical background**

today's state of knowledge and clinical reliability [11, 12].

It is the responsibility of physicians to "above all, do no harm" [28]. This concept should permeate each clinical decision made. In theory, this ethical principle is paramount to an equitable and just system of medicine, but oftentimes physicians find themselves in situations where they must weigh the risks and benefits of treatment, and answers are far from apparent [29–32]. The field of transplantation is among the most complex medical settings to navigate from the ethics standpoint. This is even more evident with the emergence of extremity and face transplants [33–35].

**5. Organ procurement organizations**

and effectively providing organs to those in need [8, 46].

**6. The process of organ procurement**

fied schematic of the overall process is shown in **Figure 2**.

The organ procurement process begins with the identification of a potential organ donor, then proceeds through the stages of notification of next of kin, the decision to donate, the process of physiologic donor optimization, the process of organ procurement and finally the transplantation of donated organs. Throughout this entire sequence of events, the OPO plays a central and an integral role [7]. The evolution of OPOs stems from the increased demand for organ donation, the need to organize and prioritize the process, and the necessity to ensure that organ allocation is performed in a fair and impartial fashion while at the same time efficiently

The Process of Organ Donation from Non-Living Donors: A Case-Based Journey from Potential…

http://dx.doi.org/10.5772/intechopen.76078

75

Prior to the inception of the modern network of OPOs, the organ procurement and allocation process was the responsibility of individual transplant centers [8]. They also shouldered the costs of the procurement and transportation process. As one can imagine this created a fragmented system in which each center would instinctively focus on providing resources to those in need of organs within their own hospital or locality [47, 48]. The evolution of OPO's provided a structured, equitable solution to streamline the process from organ donation to transplantation [7]. The current scope of functions of OPOs is vast and diverse, including interfacing with patient families; providing support to grieving relatives while helping them make critical decisions concerning organ donation; working in conjunction with hospitals and health care practitioners to physiologically optimize donors prior to organ procurement; coordinating with the United Network for Organ Sharing (UNOS) to find proper donor matches;

and facilitating professional and public education as well as related research [7, 49].

From the time of identification of potential donor to successful procurement and transplant, the process of organ procurement is a complex and intricate undertaking that we will discuss in greater detail in this section. For the purposes of our discussion, we will direct our attention to donation after death since the subject of live donors is outlined in other chapters. A simpli-

The initial step in donation is centered on the potential organ donor. Although each clinical situation is uniquely different, the first step in the process is the recognition of the irreversible process of brain death, or the circumstances leading to non-heart beating donation [7, 50]. When examining the topic of donation after cardiac or circulatory death, we must go back to the corresponding legal and ethical definitions [23, 51, 52]. How and when does one determine brain death and circulatory death? In the current chapter's vignette, the circumstances of brain death were unequivocal as the patient had suffered a non-survivable injury. We realize that in clinical practice it may not be this straightforward, and repeated exams or confirmatory testing may provide the family with a greater degree of certainty regarding the finality of this devastating diagnosis. More specifically, confirmatory brain death determination with the brain scan showing "no blood flow" to the brain was helpful in the current scenario.

As Dr Murray embarked on the first living donor transplant, he faced an ethical dilemma. The concept of retrieving an organ from a perfectly healthy individual for implantation in another patient was, and still is, a gray area considering that by removing an organ from a perfectly healthy donor, you are exposing them to a number of risks. [36]. At the same time, certain organs (e.g., heart and pancreas) can only be procured from deceased donors, which raises a completely different set of ethical issues. These include questions of donor and recipient eligibility, fairness, procurement procedures, the legal definition of death, donor designation versus family permission and compensation [7, 36]. There is also a major concern regarding the potential of inequitable allocation of organs [36, 37]. This dilemma gained international attention with the first successful cardiac transplant in 1967 by Dr Barnard [38]. The concept of taking a still beating heart from someone considered "dead" created a significant conceptual and ethical problem in the eyes of many, with calls for a more concrete definition or list of objective criteria including non-responsiveness and other neurological signs that defined irreversible coma [8, 36]. It would be another 10 years before the Presidential Commission of the Study of the Ethics in Medicine proposed the current legal definition of death which included "irreversible cessation of circulatory and respiratory function" or "irreversible cessation of brain function including brainstem function" [36, 39]. The concepts of brain death and circulatory death will be discussed in greater detail later in this chapter.

Over 33,000 organ transplants were performed in the US in 2016, representing a 20% increase in donations over the past 5 years [40]. Yet about 115,000 individuals are currently on the waitlist for organ donation and 7000 waitlist candidates died in 2016, while awaiting a life-saving transplantation [40]. Although significant strides were made with regard to increasing donations, there continues to be an organ shortage, which has led to some ethically questionable practices [35, 41]. The National Organ Transplant Act of 1984 brought together top content experts and outlined key issues related to the different aspects of the organ procurement process [42–44]. This group established key ethical principles, including the requirement that there would be no payment in exchange for organs and that organs must be voluntarily given [36, 43, 44]. This act also established our current U.S. system of organ allocation [45]. As one can see, there are numerous ethical concerns to take into account from a purely systematic viewpoint. This does not even account for the sensitivity of broaching the topic of organ donation to a grieving family coming to grips with the loss of a loved one. Even with efforts to encourage individuals to make these end-of-life decisions early on through donor registries, it is still common practice in many states to consult the family prior to proceeding with the organ procurement process [7]. Because the primary focus of this chapter is to describe the organ donation process in non-living donors, we will not be discussing numerous other ethical issues that arise when taking into account living donors. The subsequent sections of this chapter will outline OPO's and their critical role in the donation process. We will then proceed to describe the organ donation process in the context of both the above ethical and historical considerations, as well as the vignette presented earlier in the text.
