98410 • Supporting Organ and Tissue Donation in Clinical Settings: The Pennsylvania Requirement

Table of Contents

98410 • Supporting Organ and Tissue Donation in Clinical Settings: The Pennsylvania Requirement

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. OVERVIEW OF THE ORGAN DONATION AND TRANSPLANTATION SYSTEM

LEGISLATIVE AND REGULATORY FOUNDATION

ORGAN PROCUREMENT ORGANIZATIONS

WHO CAN DONATE?

THE TRANSPLANT WAITING LIST

3. TISSUE DONATION PROCESS

WHAT TISSUES CAN BE DONATED?

ELIGIBILITY FOR TISSUE DONATION

THE TISSUE RECOVERY PROCESS

HEALTHCARE PROFESSIONALS' ROLE IN TISSUE DONATION

4. ORGAN DONATION PROCESS

TYPES OF ORGAN DONATION

IDENTIFICATION OF POTENTIAL DONORS

THE ROLE OF THE OPO AFTER REFERRAL

ORGAN VIABILITY AND COLD ISCHEMIC TIME

5. DETERMINING DEATH AND FAMILY COMMUNICATION

NEUROLOGICAL CRITERIA FOR DEATH (BRAIN DEATH)

DECLARATION OF DEATH BY CIRCULATORY CRITERIA

COMMUNICATING WITH FAMILIES: THE DECOUPLING PRINCIPLE

6. CARING FOR FAMILIES

CULTURAL AND RELIGIOUS CONSIDERATIONS

SUPPORTING THE FAMILY THROUGHOUT THE DONATION PROCESS

THE NURSE AS PRIMARY SUPPORT

AFTER DONATION: AFTERCARE AND FOLLOW-UP

7. ORGAN DONOR MANAGEMENT

PATHOPHYSIOLOGY OF BRAIN DEATH

EVIDENCE-BASED DONOR MANAGEMENT GOALS

8. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

98410 • Supporting Organ and Tissue Donation in Clinical Settings: The Pennsylvania Requirement

Mary Franks, MSN, APRN, FNP-C

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

Every day in the United States, approximately 13 people die waiting for an organ transplant. As of 2026, more than 100,000 individuals remain on the national transplant waiting list, and a new name is added every 8 minutes. In Pennsylvania alone, more than 6,000 residents are awaiting lifesaving transplants, yet the gap between supply and demand persists --not solely due to a lack of willing donors, but often because of missed opportunities within the clinical setting. Pennsylvania law, under Act 90 of 2018, mandates that licensed nurses and physicians receive education in organ and tissue donation as part of their continuing education requirements. This course fulfills that obligation. Its purpose is not merely regulatory compliance; it is to equip the bedside clinician with the knowledge, confidence, and communication skills to identify potential donors, support grieving families, collaborate with procurement organizations, and deliver compassionate care at one of the most sensitive moments in the human experience.

98410 • Supporting Organ and Tissue Donation in Clinical Settings: The Pennsylvania Requirement

Education Category. Infection Control / Internal Medicine

Release Date. 05/01/2026

Expiration Date. 04/30/2029

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/3460 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

Every day in the United States, approximately 13 people die waiting for an organ transplant. As of 2026, more than 100,000 individuals remain on the national transplant waiting list, and a new name is added every 8 minutes. In Pennsylvania alone, more than 6,000 residents are awaiting lifesaving transplants, yet the gap between supply and demand persists --not solely due to a lack of willing donors, but often because of missed opportunities within the clinical setting. Pennsylvania law, under Act 90 of 2018, mandates that licensed nurses and physicians receive education in organ and tissue donation as part of their continuing education requirements. This course fulfills that obligation. Its purpose is not merely regulatory compliance; it is to equip the bedside clinician with the knowledge, confidence, and communication skills to identify potential donors, support grieving families, collaborate with procurement organizations, and deliver compassionate care at one of the most sensitive moments in the human experience.

Audience

This course is designed for nurses and physicians involved in the care of patients who may be eligible for organ and tissue donation.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 2 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 2 ANCC contact hour(s). NetCE designates this continuing education activity for 2.4 hours for Alabama nurses. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 2 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and/or Self-Assessment requirements of the American Board of Surgery's Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. This activity has been approved for the American Board of Anesthesiology’s® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiology Program® (MOCA®), known as MOCA 2.0®. Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program® and MOCA® are registered certification marks of the American Board of Anesthesiology®. MOCA 2.0® is a trademark of the American Board of Anesthesiology®. Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 2 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. This activity has been designated for 2 Lifelong Learning (Part II) credits for the American Board of Pathology Continuing Certification Program. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME's "CME in Support of MOC" program in Section 3 of the Royal College's MOC Program. AACN Synergy CERP Category A. NetCE is authorized by IACET to offer 0.2 CEU(s) for this program.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Special Approvals

This course fulfills the requirement for 2 hours of education on organ and tissue donation for nurses and physicians in Pennsylvania. This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

The purpose of this course is to provide healthcare professionals with an evidence-based overview of organ and tissue donation, including identification of potential donors, clinical and ethical considerations, and best practices for communication and coordination to support successful donation outcomes.

Learning Objectives

Upon completion of this course, you should be able to:

1. Describe the structure and key stakeholders of the U.S. organ donation and transplantation system, including the roles of OPTN, UNOS, OPOs, and Pennsylvania's designated procurement organizations.

2. Differentiate between donation after brain death (DBD) and donation after circulatory death (DCD).

3. Apply the clinical criteria and exclusion criteria for determining neurological death, including the required components of the brain death examination and the conditions under which ancillary testing is warranted.

4. Demonstrate effective communication strategies for notifying families of brain death and discussing donation.

5. Implement evidence-based organ donor management goals (DMGs) to optimize hemodynamic stability, respiratory function, and hormonal balance in the deceased donor.

Faculty

Mary Franks, MSN, APRN, FNP-C, is a board-certified Family Nurse Practitioner and NetCE Nurse Planner. She works as a Nurse Division Planner for NetCE and a per diem nurse practitioner in urgent care in Central Illinois. Mary graduated with her Associate’s degree in nursing from Carl Sandburg College, her BSN from OSF Saint Francis Medical Center College of Nursing in 2013, and her MSN with a focus on nursing education from Chamberlain University in 2017. She received a second master's degree in nursing as a Family Nurse Practitioner from Chamberlain University in 2019. She is an adjunct faculty member for a local university in Central Illinois in the MSN FNP program. Her previous nursing experience includes emergency/trauma nursing, critical care nursing, surgery, pediatrics, and urgent care. As a nurse practitioner, she has practiced as a primary care provider for long-term care facilities and school-based health services. She enjoys caring for minor illnesses and injuries, prevention of disease processes, health, and wellness. In her spare time, she stays busy with her two children and husband, coaching baseball, staying active with her own personal fitness journey, and cooking. She is a member of the American Association of Nurse Practitioners and the Illinois Society of Advanced Practice Nursing, for which she is a member of the bylaws committee.

Faculty Disclosure

Contributing faculty, Mary Franks, MSN, APRN, FNP-C, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John M. Leonard, MD

Margo A. Halm, RN, PhD, NEA-BC, FAAN

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Every day in the United States, approximately 13 people die waiting for an organ transplant. As of early 2026, more than 100,000 individuals remain on the national transplant waiting list, and a new name is added every 8 minutes [1]. In Pennsylvania alone, more than 6,000 residents are awaiting lifesaving transplants, yet the gap between supply and demand persists—not solely due to a lack of willing donors, but often because of missed opportunities within the clinical setting [2].

Pennsylvania law, under Act 90 of 2018, mandates that licensed nurses and physicians receive education in organ and tissue donation as part of their continuing education requirements. This course fulfills that obligation. Its purpose is not merely regulatory compliance; it is to equip the bedside clinician with the knowledge, confidence, and communication skills to identify potential donors, support grieving families, collaborate with procurement organizations, and deliver compassionate care at one of the most sensitive moments in the human experience.

2. OVERVIEW OF THE ORGAN DONATION AND TRANSPLANTATION SYSTEM

The U.S. organ donation and transplantation system is a coordinated national infrastructure governed by federal law, operated by a network of public and private entities, and grounded in the principle of equitable access to lifesaving treatment.

LEGISLATIVE AND REGULATORY FOUNDATION

The National Organ Transplant Act (NOTA) of 1984 established the legal framework for the modern transplant system. NOTA created the Organ Procurement and Transplantation Network (OPTN), a unified national network currently operated under contract by the United Network for Organ Sharing (UNOS). OPTN establishes the policies that govern organ allocation, matching, and distribution across the country [3]. NOTA also prohibited the sale of human organs, establishing organ donation as an act of voluntary altruism.

The U.S. Department of Health and Human Services (HHS) oversees the national system through HRSA's Division of Transplantation. The Centers for Medicare and Medicaid Services (CMS) conditions of participation require hospitals to have agreements with their designated organ procurement organization (OPO) and to refer all deaths and imminent deaths to that OPO in a timely fashion [4].

ORGAN PROCUREMENT ORGANIZATIONS

OPOs are nonprofit organizations responsible for the coordination of organ donation within a defined Donation Service Area (DSA). There are 58 OPOs in the United States, each designated by CMS [5]. In Pennsylvania, Gift of Life Donor Program serves the southeastern part of the state, while the Center for Organ Recovery and Education (CORE) serves the western and central regions [6]. OPOs employ specialized staff including donation coordinators, family support coordinators, and medical directors who work directly with hospital teams.

When a potential donor is identified, the OPO is responsible for evaluating medical suitability, obtaining authorization, coordinating surgical procurement, and facilitating the placement of recovered organs with waiting recipients through UNOS.

WHO CAN DONATE?

A common misconception among both the public and healthcare providers is that significant medical history automatically disqualifies someone from donation. In reality, very few absolute contraindications to donation exist. Active, untreated sepsis involving a specific organ, active metastatic cancer (with some exceptions), and certain transmissible infections such as untreated Ebola or rabies represent examples of true contraindications. For all other potential donors, including those with cancer history, diabetes, hypertension, hepatitis, or advanced age, the OPO's medical director makes the final determination on a case-by-case basis [7]. Clinicians should never independently rule out a patient as a potential donor; that determination belongs exclusively to the OPO.

THE TRANSPLANT WAITING LIST

Patients in need of transplant are listed with UNOS by their transplant center. Allocation algorithms factor in medical urgency, time on the waiting list, geographic proximity to the donor, blood type compatibility, and, for some organs, antigen matching. The goal is to maximize both equity and utility. Continuous policy refinements by OPTN have sought to reduce geographic disparities in organ allocation, most notably through the adoption of continuous distribution models beginning in 2022 for hearts and lungs [8].

Pennsylvania has one of the nation's largest populations on transplant waiting lists [6]. Act 90 mandates that all hospitals in the state have written protocols, known as Required Request Protocols, ensuring that families of patients who die or are declared brain dead are offered the option of donation. Pennsylvania also enacted an opt-in donor registry through PennDOT, with registration options available at driver's license renewal and online through the Donate Life PA registry [9].

3. TISSUE DONATION PROCESS

While organ donation garners much of the public's attention, tissue donation is equally impactful and far more prevalent. A single tissue donor can benefit more than 75 recipients [10].

WHAT TISSUES CAN BE DONATED?

Recoverable tissues include:

- Musculoskeletal tissue (bone, tendons, cartilage, ligaments): Used in orthopedic reconstructions, spinal surgeries, and trauma repairs

- Cardiovascular tissue (heart valves, pericardium, great vessels): Used in cardiac surgeries and vascular reconstruction

- Skin: Used for burn treatment, wound coverage, and reconstructive procedures

- Corneas and ocular tissue: Used to restore vision in patients with corneal disease

- Amniotic membrane: Used in ophthalmology and wound care

ELIGIBILITY FOR TISSUE DONATION

Tissue donation can occur following both cardiac death and brain death, and it can be pursued even in cases where organs are not being donated. Importantly, tissue donation can occur up to 12 to 24 hours after cardiac death, making it possible even when the patient was not identified as a potential organ donor in time. This broader window significantly expands the pool of potential tissue donors [10].

Most medically suitable individuals of all ages may be considered for tissue donation. Contraindications are tissue-specific and include active systemic infection, certain transmissible viral diseases (e.g., untreated HIV without suppressed viral load), and certain malignancies. As with organs, the tissue recovery organization (often the same OPO or an affiliated tissue bank) makes the final eligibility determination.

THE TISSUE RECOVERY PROCESS

Tissue recovery is typically performed in a hospital operating room, tissue recovery facility, or hospital morgue after the family has authorized donation and medico-legal clearance has been obtained (i.e., medical examiner approval when applicable). Tissue recovery is a sterile surgical procedure performed by trained technicians, and it does not interfere with the body's appearance for funeral purposes—an important point to communicate to families. The body is treated with dignity and respect throughout, and any incisions are closed and covered.

Following recovery, tissues are processed, tested for infectious disease, and distributed by accredited tissue banks operating under Association for Advancing Tissue and Biologics (AATB) standards and U.S. Food and Drug Administration regulations [10]. Processing methods vary by tissue type and intended use, ranging from aseptic processing to terminal sterilization.

HEALTHCARE PROFESSIONALS' ROLE IN TISSUE DONATION

Evidence Based Practice Recommendation

In its Principles of Medical Ethics, the American Medical Association recommends no member of the transplant team should have any role in the decision to withdraw treatment or the pronouncement of death in order to avoid actual or perceived conflicts of interest.

https://code-medical-ethics.ama-assn.org/ethicsopinions/guidelines-organ-transplantation-deceased-donors

Last Accessed: April 24, 2026

Level of Evidence: Expert Opinion/Consensus Statement

In the acute care or emergency setting, the clinician's role is primarily one of identification and timely referral. Any patient who has died or is expected to die should be referred to the OPO. Do not attempt to independently determine tissue eligibility. Timely referral is both a regulatory requirement and an ethical obligation to the patient whose prior wishes may have included donation.

4. ORGAN DONATION PROCESS

Organ donation is a highly time-sensitive process that depends on the seamless coordination of clinical, logistical, and legal elements. Understanding the sequence of events helps clinicians play a more effective role.

TYPES OF ORGAN DONATION

There are two pathways to organ donation: donation after brain death (DBD) and donation after circulatory death (DCD).

Donation after Brain Death (DBD)

Also referred to as standard criteria donation, this pathway involves a patient who has sustained a catastrophic neurological injury and meets established neurological criteria for brain death. The donor remains on mechanical ventilation to preserve organ perfusion while authorization is obtained and procurement logistics are arranged.

Donation after Circulatory Death (DCD)

This pathway applies to patients who do not meet brain death criteria but have a non-survivable injury or illness, and for whom a decision has been made to withdraw life-sustaining treatment (WLST). Following WLST, organ procurement occurs after the patient experiences cardiac death, typically within 60 to 120 minutes. DCD procurement has expanded significantly over the past decade and now accounts for a substantial proportion of donor cases nationally [1].

IDENTIFICATION OF POTENTIAL DONORS

Potential organ donors are typically patients with severe, non-survivable acute neurological injury (e.g., traumatic brain injury, intracranial hemorrhage, anoxic brain injury, stroke). Clinical triggers for OPO referral include [11]:

- A Glasgow Coma Scale (GCS) score ≤5

- Patients on mechanical ventilation with suspected or confirmed brain death

- Any patient in whom WLST is being considered

It is important to be aware of family members' responsiveness toward the situation to determine if they are considering WLST. Signs that a family may be accepting the non-survivable nature of an injury include but are not limited to [11]:

- Decision not to resuscitate (DNR)

- Decision not to escalate interventions

- Asking about WLST without indicating timing

- Asking what it looks like to WLST

- Asking about what happens next

- Asking for permission for, or waiting for, additional people to come say goodbye

- Discussing funeral arrangements

- Talking about the person in the past tense

- Bringing up donation

Other indications may include statements such as, "they wouldn't want to live this way," or "we don't want them to suffer/be in pain anymore." The Joint Commission, CMS, and Association of Organ Procurement Organizations all emphasize that the threshold for referral should be low and that clinicians should call the OPO early—not only after death has been declared.

THE ROLE OF THE OPO AFTER REFERRAL

Once referral is made, the OPO assumes the coordinating role. Key steps include [12]:

- Medical suitability review: The OPO's medical director reviews the patient's medical and social history to assess donor suitability.

- Brain death evaluation support: OPO coordinators can assist clinical teams with the logistics of brain death evaluation, though the declaration itself must be made by physicians independent of the transplant team.

- Authorization: Trained family support coordinators approach the next of kin (in cases where the patient has not registered as a donor) or confirm authorization per the patient's documented wishes.

- Donor management: If donation proceeds, the OPO assumes co-management of the donor, working alongside the ICU team to optimize organ function.

- Procurement coordination: Surgical teams from recipient transplant centers travel to the donor hospital to recover organs, which are then transported and transplanted on a time-sensitive basis.

ORGAN VIABILITY AND COLD ISCHEMIC TIME

Organs have different tolerances for ischemia. Approximate maximum cold ischemic times are [13]:

- Heart: 4 to 6 hours

- Lungs: 4 to 6 hours

- Liver: 8 to 12 hours

- Pancreas: 12 to 18 hours

- Kidneys: 24 to 36 hours

These windows dictate the urgency of procurement and transport logistics. Clinicians managing a potential organ donor should understand that time is a critical variable affecting outcomes for recipients.

5. DETERMINING DEATH AND FAMILY COMMUNICATION

Two distinct legal and physiological standards govern the declaration of death in the context of organ donation. A thorough understanding of both is essential for nurses and physicians.

NEUROLOGICAL CRITERIA FOR DEATH (BRAIN DEATH)

Brain death/death by neurological criteria (BD/DNC), defined as the complete and irreversible cessation of all brain function, including the brainstem, is recognized as legal death in all 50 U.S. states and the District of Columbia [14]. Brain death is not a coma, a vegetative state, or a minimally conscious state; it is death.

The clinical determination of BD/DNC requires [15,16,17]:

- An established etiology sufficient to cause irreversible neurological injury

- An observation period of 24 hours in patients 2 years of age or older after hypoxic ischemic brain injury

- In adults, exclusion of confounders:

- Core temperature >36°C

- Systolic blood pressure >100 mm Hg

- Mean arterial pressure ≥75 mm Hg (Only the mean arterial pressure goal is applicable on venoarterial extracorporeal membrane oxygenation)

- Absence of CNS-depressant drugs/exclude pharmacologic paralysis

- Absence of metabolic derangements that could mimic brain death

- Neurological examination demonstrating absent brainstem reflexes: No pupillary response to light, absent corneal reflexes, absent oculocephalic reflexes, absent oculovestibular responses, absent gag and cough reflexes

- Neuroimaging: Consistent with the mechanism and severity of brain injury

- Apnea testing: Absence of spontaneous respiratory effort at a PaCO_2 ≥60 mm Hg (20 mm Hg above baseline) after at least one test for adults after neurological exam and two tests for pediatric patients (one after each neurological exam)

Ancillary testing (EEG, cerebral angiography, nuclear perfusion scan, transcranial Doppler ultrasound) may be used when clinical examination/apnea testing cannot be completed or when there is an inability to correct metabolic derangements adequately, but the neurologic examination(s)/apnea test(s) are consistent with BD/DNC [17]. The patient's family should be allowed to be present during the neurologic examination and apnea test; however, they should be informed about the potential for spinal reflexes (e.g., Lazarus sign) and the fact that these movements do not indicate brain function.

In Pennsylvania, institutional brain death protocols, which must comply with the 2023 American Academy of Neurology guidelines, govern the exact procedural requirements [16,17]. The AAN has created an interactive algorithm to help clinicians integrate the guidelines into practice; this tool is available online at https://www.aan.com/Guidelines/BDDNC. Brain death must be declared by a physician (or, in some institutions, an advanced practice provider per institutional credentialing) who is not a member of the transplant team and who has no conflict of interest regarding donation. In Pennsylvania, two physician declarations are not legally required, but many institutions require it by policy.

DECLARATION OF DEATH BY CIRCULATORY CRITERIA

In DCD cases, death is declared following cardiac death—the irreversible cessation of circulatory and respiratory function. The "hands-off" period (typically 2 to 5 minutes per institutional protocol, most commonly 5 minutes) must elapse after cessation of cardiac activity before death is declared, to prevent auto-resuscitation [18]. The Society of Critical Care Medicine and other professional societies have published guidelines regarding the ethical and procedural standards for DCD [19].

COMMUNICATING WITH FAMILIES: THE DECOUPLING PRINCIPLE

Research and best practice consistently support the principle of decoupling (i.e., separating the notification of death or the discussion of withdrawal of life support from the request for donation). When families receive both conversations simultaneously, authorization rates decline and family distress increases [20,21].

The practical application of decoupling means a physician and/or nurse should first meet with the family to explain the patient's neurological status, the meaning of brain death, and what it means for the patient's prognosis, before any mention of donation. Only after the family has had adequate time to process this information should the OPO family support coordinator introduce the topic of donation. In many cases, this means two separate meetings, often with a short interval in between.

Communicating Brain Death to Families

For many families, the concept of brain death is profoundly counterintuitive. Their loved one appears to be breathing (via the ventilator), may feel warm to the touch, and may have a heartbeat. Physicians and nurses are often responsible for gently but clearly addressing this disconnect. Effective communication strategies include:

- Use concrete, plain-language explanations: "The brain has stopped working completely and permanently. The machine is doing all the breathing." "Your loved one's body cannot breathe on its own at all."

- Avoid euphemisms like "brain dead" without explanation; instead, affirm: "This is legal death; he has died."

- Invite questions and allow silence. Do not rush the family toward any decision.

- Avoid prematurely discussing organ donation. The family needs to come to terms with the death of their loved one first.

6. CARING FOR FAMILIES

The hours surrounding a patient's death—and particularly the donation conversation—represent some of the most emotionally intense moments a clinical team will witness. How nurses and physicians engage with families during this time has lasting consequences for the family's grief experience and for donation outcomes.

CULTURAL AND RELIGIOUS CONSIDERATIONS

Pennsylvania's population is ethnically and religiously diverse, and perspectives on donation, death, and the body vary significantly across communities. All major religious traditions in the United States, including Catholicism, Islam, Judaism, Protestantism, Hinduism, and Buddhism, either support organ donation or leave it to individual conscience [23,24]. However, cultural beliefs, independent of formal religious doctrine, may create hesitation or concern.

Effective culturally sensitive care includes:

- Asking, not assuming: Directly inquire about any cultural or religious considerations the family would like respected.

- Involving spiritual care: Chaplains and spiritual care specialists can be invaluable mediators between clinical teams and families navigating faith-based concerns.

- Using trained interpreters: For families with limited English proficiency, professional medical interpreters (not family members) should be used for all donation-related conversations.

SUPPORTING THE FAMILY THROUGHOUT THE DONATION PROCESS

When a family consents to donation, the waiting period before and during procurement can be lengthy, often 12 to 24 hours or more. This is a vulnerable time for families. Key interventions include:

- Offering a private space where family members can gather

- Keeping the family informed of the process and expected timeline

- Facilitating meaningful time with their loved one (e.g., sitting with the patient, playing music, prayer)

- Providing food, beverages, and bereavement resources

- Coordinating with the OPO family support coordinator, who serves as the primary family liaison throughout the donation process

THE NURSE AS PRIMARY SUPPORT

Nurses in the ICU, emergency department, and step-down units are often the clinicians with the most sustained contact with families. Their words, body language, and emotional availability carry enormous weight. Studies have shown that nursing staff who communicate empathy, answer questions honestly, and take time to be present with families significantly improve the family's experience, regardless of whether donation ultimately occurs [24].

Nurses should also be aware of their own emotional responses. Caring for brain-dead patients and their families can be psychologically taxing. Institutional debriefs, peer support programs, and Employee Assistance Programs are valuable resources for staff processing these experiences.

AFTER DONATION: AFTERCARE AND FOLLOW-UP

OPOs typically send follow-up communication to donor families, including information about which organs and tissues were recovered and anonymized information about recipients. Some families find deep comfort in knowing the outcome of their loved one's donation. Nurses and physicians may be asked by families about this process; clinicians should encourage families to maintain contact with the OPO's aftercare team.

Pennsylvania's Gift of Life Donor Program and CORE both offer aftercare programs, including grief support groups, annual remembrance events, and the option for families to correspond with recipients (when both parties consent).

7. ORGAN DONOR MANAGEMENT

Once a patient is identified as a potential organ donor and authorization is obtained, clinical management of the donor becomes a shared responsibility between the ICU team and the OPO. The goal shifts from survival-oriented care to preservation of organ function for transplant—a distinction that carries ethical significance and warrants a clear understanding of the physiologic changes that accompany brain death.

PATHOPHYSIOLOGY OF BRAIN DEATH

Brain death produces a predictable cascade of systemic derangements that threaten the viability of transplantable organs if not proactively managed:

- Hemodynamic instability: The initial catecholamine surge ("sympathetic storm") associated with herniation causes hypertension and tachycardia, followed by profound hypotension as hypothalamic and brainstem cardiovascular regulatory function ceases. Vasopressin depletion contributes to vascular collapse.

- Diabetes insipidus: Loss of posterior pituitary function leads to massive polyuria (often >500 mL/hour), hypernatremia, and hyperosmolarity, all of which compromise kidney and liver function if untreated.

- Hypothermia: Loss of hypothalamic thermoregulation causes progressive core temperature decline.

- Coagulopathy: Release of tissue thromboplastin from injured brain tissue triggers disseminated intravascular coagulation (DIC).

- Hormonal deficiencies: Thyroid hormone (T3/T4) and cortisol levels fall precipitously, contributing to cardiovascular instability and impaired metabolism.

- Pulmonary complications: Neurogenic pulmonary edema, aspiration, and ventilator-associated changes can impair lung function.

EVIDENCE-BASED DONOR MANAGEMENT GOALS

The United Network for Organ Sharing has established standardized donor management goals (DMGs) (Table 1) designed to optimize the number and quality of organs transplanted and to improve graft survival rates [25,26].

Table 1: STANDARDIZED DONOR MANAGEMENT GOALS

Parameter

Target Goal

Mean arterial pressure (MAP)

60–110 mm Hg

Central venous pressure (CVP)

4–12 mm Hg

Ejection fraction

≥50%

PaO_2/FiO_2 (PF ratio)

≥300 on PEEP 5

Sodium

135–155 mEq/L

Blood glucose

≤180 mg/dL

Urine output

≥0.5 cc/kg/hr

Vasopressors

≤1 agent, low-dose preferred

Arterial blood gas

pH 7.3–7.5

Source: [25,26]

Achieving all or most DMGs is associated with significantly higher rates of organ yield per donor and improved recipient outcomes [27].

Fluid and Vasopressor Management

Aggressive fluid resuscitation is often required to address diabetes insipidus-driven volume depletion and post-herniation hypotension. Isotonic crystalloids are generally preferred. Vasopressin (antidiuretic hormone) is a cornerstone of donor management. It simultaneously treats diabetes insipidus, supports hemodynamics, and reduces the need for high-dose catecholamine vasopressors. Norepinephrine (≤0.2 mcg/kg/min) is the preferred catecholamine when vasopressin alone is insufficient; alternately, neosynephrine (≤1 mcg/kg/min) may be used. High-dose dopamine (>10 mcg/kg/min) is associated with worse heart and kidney outcomes; a dosage of ≤10 mcg/kg/min should be used [28,29].

Hormonal Resuscitation

The Papworth protocol and subsequent research support the use of hormone replacement therapy in hemodynamically unstable donors. The regimen typically includes:

- Methylprednisolone: 15 mg/kg IV bolus (addresses adrenal insufficiency, reduces inflammatory cytokine release)

- Triiodothyronine (T3) or levothyroxine (T4): IV infusion to restore myocardial contractility

- Vasopressin: 0.5–2.4 units/hour IV

- Insulin: Continuous infusion targeting glucose 70–150 mg/dL

This combination has been associated with increased cardiac procurement rates and improved hemodynamic stability [30].

Respiratory Management

Protective lung ventilation strategies should be employed for all potential donors, regardless of whether lung donation is anticipated. Lungs have historically been recovered at low rates due to strict donor criteria and suboptimal donor respiratory management. The recommended strategy includes [26,31]:

- Head elevated 30 degrees with the endotracheal tube (ETT) cuff inflated to prevent aspiration

- Early and repeated bronchoscopy (with minimal saline lavage)

- Albuterol and acetylcysteine (as needed) for mucus clearance

- Chest physiotherapy, suctioning, and positioning every four hours

- Recruitment maneuvers (may improve lung function in eligible donors)

The ventilator and blood gas goals include [26,31]:

- Tidal volume: 6–8 mL/kg ideal body weight

- PEEP: 6–8 cm H_2O (higher PEEP ≥8 cm H_2O may be trialed in refractory hypoxemia)

- FiO_2: Titrate to maintain PaO_2 80–120 mm Hg; minimize FiO_2 to <0.40 when possible to reduce oxygen toxicity

- Arterial blood gas

- pH 7.35–7.45

- PaCO_2 35–45

- O_2 saturation >95%

- ≤40% oxygen (the lower the better to prevent oxygen toxicity)

- Plateau pressure <30–35

- Peak inspiratory pressure (PIP) <35–40 (generally, mid-20s needed for acceptance)

- Mean arterial pressure <20–25

Lung-protective ventilation has been shown to improve lung function and increase the number of lungs ultimately transplanted [26,31]. Recommended airway pressure release ventilation (APRV) settings should be [31]:

1. Set P High using the PIP of the previous PC mode or at the peak plateau pressure of the previous VC mode

- A plateau pressure is obtained by performing an inspiratory hold.

- Set to a minimum of 20 cm H_2O but avoid exceeding 35 cm H_2O.

- Make adjustments in 2-cm H_2O increments to maintain mean arterial pressure 25–28.

2. Set P Low to 0.

3. Set T High, initially between 4 to 6 seconds.

4. Set T Low, initially between 0.5 to 0.8 seconds.

- Set to achieve an expiratory flow rate termination that is 50% of the peak expiratory flow.

- Consult respiratory therapy for assistance.

5. Recheck arterial blood gas in two hours after initial change and then every four hours, and make adjustments as need to obtain optimal oxygenation and a normal pH.

The first arterial blood gas measurements in APRV may be worse than the baseline. Keep in mind that full recruitment may take four to six hours [31].

Temperature Management

Hypothermia accelerates coagulation, impairs cardiac function, and complicates hemodynamic management. Active warming measures, including warm IV fluids, external warming blankets, and heated/humidified ventilator circuits, should be initiated to maintain core temperature ≥36°C.

Laboratory Monitoring

Frequent laboratory monitoring is critical during the donor management period. Recommended assessments every four to six hours include: ABG, BMP, CBC, coagulation studies (PT/INR, aPTT, fibrinogen), lactate, liver function tests, and cardiac enzymes. Urine output should be monitored hourly. Trends should be communicated to the OPO coordinator in real time.

8. CONCLUSION

Effective donor management is a team endeavor. The ICU attending physician and nursing staff manage the patient's physiologic parameters, while the OPO coordinator serves as a resource, advocate, and logistics coordinator. Surgeons, respiratory therapists, and pharmacists may all play active roles. Clear, proactive communication among all team members, including consistent shift-to-shift handoff that emphasizes donor status and DMG attainment, is essential to maximizing outcomes.

Works Cited

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Evidence-Based Practice Recommendations Citations

1. American Medical Association. Principles of Medical Ethics: Opinion 6.2.1 Guidelines for Organ Transplantation from Deceased Donors. Available at https://code-medical-ethics.ama-assn.org/ethics-opinions/guidelines-organ-transplantation-deceased-donors. Last accessed April 24, 2026.