**6. The process of organ procurement**

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

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.

viability of the donor's organs [56, 57]. As was the case in our hypothetical vignette, the patient should be stable before undergoing any confirmatory testing. In the current example, such stabilization required approximately 10–12 h of continuous effort by the critical care team. Once the decision is made to donate by the family in the case of brain death or circulatory death, the OPO helps coordinate the remainder of the care process, including the distribution of the organs and the provision of highly trained staff to prepare for the actual organ procurement and preservation, as well as highly efficient transport of preserved organs to each recipient's institution [7]. At this time, we will discuss key components of the process of organ donation,

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

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

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As discussed earlier in the chapter, declaration of death—whether that be circulatory death or brain death—has been a controversial topic over the years. In 2014, an international forum was held in Montreal, Canada with the objective to provide a functional definition of death that encompassed the concepts of brain and circulatory death. They reported that "Death is the permanent loss of capacity for consciousness and all brainstem functions. This may result from permanent cessation of circulation or catastrophic brain injury. In the context of death determination, 'permanent' refers to loss of function that cannot resume spontaneously and will not be restored through intervention" [58]. It is important for health care practitioners of all levels working with potential donor patients to have a good understanding of the definition of death in order to be able to explain to grieving families the reality of the situation and its finality [59]. It is well established that adequate explanation of brain death is one of the critical components of the donation process [60]. The optimal timing of the consent process is also of great importance [61]. Checklists are helpful in maintaining the thoroughness of brain death determination, but do not replace the expertise, knowledge and compassion of physi-

When a patient presents to the hospital with concern for altered consciousness, it is imperative to rule out all reversible causes of coma, first excluding the presence of any substances of abuse, medication side effects, electrolyte, metabolic or acid-base derangements [62]. Once these are ruled out, imaging can often shed some light on potential causes of neurological compromise. In the current case vignette, the CT was utilized in order to give the treating physician an indication of the magnitude of injury and likelihood of recovery. With that being said, official declaration of BD is actually a clinical one [63]. From definitional standpoint, BD is considered to be present when there is irreversible damage to the brain and brainstem [36]. In order to assess brain function, several key components are required, with the most important one being a thorough neurological examination including assessment of brainstem reflexes [62]. Various ancillary tests can also be performed to assess cerebral blood flow and brain electrical activity in cases with equivocal exam findings. The final declaration of BD

including the determination of death and physiologic optimization of the donor.

cians in end-of-life discussions with families of the potential donor.

(including the official time of death) rests with the treating physician.

**7. Determination of death**

**8. Brain death determination**

**Figure 2.** Simplified schematic of the organ donation process. Following the identification of potential organ donor, a cascade of events takes place that ultimately ends with successful organ transplantation. Further details regarding this complex process can be obtained from Wojda et al. [7].

Another critically important consideration is the emotional state of a family coming to grips with the untimely and unexpected loss of a loved one. The grief combined with the immense responsibility of determining what a loved one "may have wanted" can place a significant burden on his or her relatives. This can be especially difficult for families of patients with no advance directive, living will, power of attorney, or prior conversation concerning their organ donation wishes. When dealing with issues related to organ donation, health care providers must be extremely sensitive to family needs and ensure that their local OPO is involved early on in the process in order to prevent any potential conflict of interest [7]. The separation of responsibilities during these proceedings is critical in alleviating any concerns regarding the simultaneous provision of care for the patient along with facilitation of the organ donation process by the same individual and/or team [53, 54].

From the time a potential donor arrives to the hospital and is determined to have non-survivable injury, it is important that they are managed under the assumption that they may donate organs, and that care is both optimal and timely [6, 55, 56]. This includes early notification of the local OPO regarding the presence of a potential donor [7]. A great deal of attention must be paid to prevent hypoxia and systemic hypo-perfusion, both of which could compromise the viability of the donor's organs [56, 57]. As was the case in our hypothetical vignette, the patient should be stable before undergoing any confirmatory testing. In the current example, such stabilization required approximately 10–12 h of continuous effort by the critical care team. Once the decision is made to donate by the family in the case of brain death or circulatory death, the OPO helps coordinate the remainder of the care process, including the distribution of the organs and the provision of highly trained staff to prepare for the actual organ procurement and preservation, as well as highly efficient transport of preserved organs to each recipient's institution [7]. At this time, we will discuss key components of the process of organ donation, including the determination of death and physiologic optimization of the donor.
