Understanding the Donation Process
It is important to know that in Australia the family of every potential donor will be asked to confirm the donation decision of their loved one before organ and tissue donation for transplantation can proceed.
Some families have discussed organ and tissue donation and may already know their loved one's donation decisions. Other families who have not discussed donation will also need to make a decision about whether their loved one will become a donor.
Organ and tissue donation involves removing organs and tissues from someone who has died (a donor) and transplanting them into someone who, in many cases, is very ill or dying (a recipient).
Organs that can be transplanted include the heart, lungs, liver, kidneys, intestine and pancreas.
Tissues that can be transplanted include heart valves and other heart tissue, bone, tendons, ligaments, skin and parts of the eye, such as the cornea and sclera.
Death must have occurred before donation can take place.
Death can be determined in two ways:
- Brain death occurs when a person's brain permanently stops functioning.
- Circulatory death occurs when the circulation of blood in a person permanently stops.
It is important to understand the difference between brain death and circulatory death. The way a person dies influences how the donation process can occur and which organs and tissues can be donated.
The information below is to support you and your family to make a decision about donation that is right for you and your loved one.
Understanding brain death
Brain death occurs when the brain has been so badly damaged that it completely and permanently stops functioning. This can occur as the result of severe head injury, a stroke from bleeding (haemorrhage) or blockage of blood flow in the brain, brain infection or tumour, or following a period of prolonged lack of oxygen to the brain.
Just like any other part of the body when the brain is injured it swells. The brain is contained within a rigid ‘box’, the skull, which normally protects it from harm but also limits how much the brain can expand. This is different to other parts of the body, such as an injured ankle, that can continue to swell without restriction. If the brain continues to swell, pressure builds up within the skull causing permanently damaging effects.
The swelling places pressure on the brainstem where the brain joins with the spinal cord at the back of the neck. The brainstem controls many functions that are necessary for life including breathing, heart rate, blood pressure and body temperature.
As the brain swelling increases, the pressure inside the skull increases to the point that blood is unable to flow to the brain (see Diagram 1). Without blood and oxygen, brain cells die. Unlike many other cells in the body, brain cells cannot regrow or recover. If the brain dies, that person’s brain will never ever function again, and the person has died. This is called “brain death”.
The brain and brainstem control many of the body’s vital functions, including breathing. When a person has suffered a brain injury, they are connected to a machine called a ventilator, which artificially blows oxygen into the lungs (ventilation). The oxygen is then pumped around the body by the heart. The heartbeat does not rely on the brain, but is controlled by a natural pacemaker in the heart that functions when it is receiving oxygen.
While a ventilator is providing oxygen to the body, the person’s chest will continue to rise and fall giving them the appearance of breathing, their heart will continue to beat and they will feel warm to touch. This can make it difficult to accept that death has occurred. However, even with continued artificial ventilation, the heart will eventually deteriorate and stop functioning.
How do doctors know that a person's brain has died?
People who are critically ill in hospital are under constant observation by the specialist medical and nursing teams caring for them and are closely monitored for changes in their condition. There are a number of physical changes that take place when the brain dies. These include loss of the normal constriction of the pupils to light, ability to cough, inability to breathe without the ventilator, and reduced blood pressure and body temperature.
When the medical team observes these changes they will perform clinical brain death testing to confirm whether the brain has stopped functioning or not.
Two senior doctors will independently conduct the same set of clinical tests at the bedside. The doctors performing the brain death testing will be looking to see if the person has any:
- response to a painful stimulus
- pupil constriction when a bright light is shone in the eye
- blinking response when the eye is touched
- eye movement when ice cold water is put into the ear canal
- gag reaction when the back of the throat is touched
- cough when a suction tube is put down the breathing tube
- ability to breathe when the ventilator is temporarily disconnected.
If a person shows no response to all of these tests, it means that their brain has stopped functioning and the person has died. Although they have died the heart will still be beating because oxygen is still getting to the heart with the assistance of the ventilator.
There are times when the person’s injury or illness means that clinical brain death testing cannot be done. For example, facial injuries may limit examination of the eyes or ears. In these circumstances medical imaging tests are done to determine if there is any blood flow to the brain (a cerebral angiogram or cerebral perfusion scan). The hospital staff will provide further information if such a test is necessary.
What happens after brain death has been confirmed?
Once brain death has been confirmed, the person will remain connected to the ventilator while members of the healthcare team speak with the person’s family about the next steps. These will include the person’s end-of-life wishes, the opportunity for organ and tissue donation and timing of removing the ventilator.
If the family supports donation, everything possible will be done to make sure those wishes are fulfilled. Timeframes can vary as every circumstance is different. It can take an extended period of time for the necessary arrangements for donation to be made. The person will remain connected to the ventilator and medications provided to support the blood pressure and keep oxygen circulating to the organs. Increased medical activity may be seen around the person, due to further tests such as chest X-rays. If it becomes clear that organs are not suitable for donation, the senior next of kin will be notified and it may still be possible for the donation of tissue including eye, heart, bone and skin to occur.
When the arrangements for donation have been made, the person will be moved to the operating theatre for the organ and tissue retrieval surgery. The ventilator will be removed during the operation.
If donation is not supported, the doctor will speak with the family about removing the ventilator. When the ventilator is removed, the person’s heart will stop beating due to a lack of oxygen and their skin will become cold and pale because blood is no longer being circulated around the body.
Care, dignity and respect are always maintained during end of life care, whether or not donation proceeds.
Understanding circulatory death
Circulatory death occurs when a person stops breathing and their heart stops beating (there is no blood flow in the body). This can occur after a sudden illness or accident, or can be the final stage of a long illness.
Organ donation is sometimes possible after circulatory death although only in particular situations, as organs quickly deteriorate once blood flow to them stops. The usual circumstance is when a person is in an intensive care unit following a severe illness from which they cannot recover and the doctors and family agree it is in the person’s best interests to remove artificial ventilation and any other life supports. This may occur following a very severe brain injury resulting in permanent severe disability, people with terminal heart or lung failure, or people who have suffered a very severe spinal injury where they cannot move or breathe unassisted.
The priority is then to support the person with care, comfort and compassion at the end of their life. The withdrawal of life supports is always discussed with and agreed by the family (and patient if possible) and this decision is made prior to and independently of any consideration of donation. Only when this decision has been made, is there any consideration of donation.
What happens after the doctors believe the person's heart is going to stop beating?
When the family and the doctors agree that continuing treatment is not in the patient’s interests, they will speak with the person’s family about the next steps. This will include discussion on the person’s end-of-life wishes and the removal of the ventilator and other treatments, with a focus on providing comfort and pain relief.
If the doctors expect that the person will stop breathing and circulatory death will occur a short time after taking away the ventilator and any other life supports, there may be the opportunity for organ and tissue donation.
If the person and family supports donation, everything possible will be done to make sure those wishes are fulfilled. It can be very difficult to predict the exact time it will take for a person to die following removal of the ventilator and other life supports. Some people die within an hour or so and donation may be possible. Others may not die until many hours later. If this occurs, organ donation will no longer be possible but donation of tissues may still be possible. If death does occur soon after removing life supports, the person will need to be moved quickly to the operating theatre so that the organ retrieval surgery can occur before the organs become damaged.
If donation is not supported by the family, the doctor will speak with the family about removing the ventilator. When the ventilator is removed the person’s heart will stop beating due to a lack of oxygen and their skin will become cold and pale because blood is no longer being circulated around the body.
Care, dignity and respect are always maintained during end of life care irrespective of whether or not donation proceeds.
The donation process and further information
When donation is able to proceed, the person who has died will be moved to an operating theatre for surgery. Below is some information on the donation process.
What does the donation operation involve?
The donation operation is conducted with the same care as any other operation, and the person’s body is always treated with respect and dignity. This operation is performed by highly skilled surgeons and health professionals. Specialist doctors and their teams may be called in from other hospitals to perform the operation.
Similar to other operations, a surgical incision is made in order to retrieve the organs and this incision will then be closed and covered with a dressing. Depending on which organs and tissues are being donated, the operation can take up to eight hours to complete.
What happens after the operation?
Following the operation, the donated organs will be transported from the operating theatre to the hospitals where transplantation will occur. If the family would like to see their loved one after the operation, this can be arranged by the donation specialist staff.
Will the person look different?
When a person has died and blood and oxygen are no longer circulating around the body it is usual for them to appear pale and for their skin to feel cool. The donation operation does not result in any other significant changes to the person’s appearance. The surgical incision made during the operation will be closed and covered as in any other operation.
Will funeral arrangements be affected?
Organ and tissue donation does not affect funeral arrangements. Viewing the loved one and an open casket funeral are both possible. If a coroner’s investigation is required, this may delay funeral arrangements.
When is a Coroner's investigation required?
Some deaths, such as those following an accident or due to unnatural causes (e.g. poisoning, suicide), are required by law to be reported to the court and investigated by a coroner. Any decision about donation does not influence whether a coroner’s investigation is required. The hospital or donation specialist staff will discuss with the family if the circumstance of the death means it is reportable to the coroner.
Most state and territory coroner’s offices provide access to counsellors who can provide more detailed information and support about the process when a coronial investigation is required.
Can the family change their minds about their donation decision?
Yes. The family can change their minds about donation at any point up to the time when the person is taken to the operating room.
What are the religious opinions about donation?
Most major religions are supportive of organ and tissue donation. If a family has any questions they would like to discuss, the donation specialist staff can provide them with additional information and assist them in contacting their religious leader.
Will the person's family be expected to pay for the cost of donation?
No, there is no financial cost to the family for the donation.
Which organs and tissues will be donated?
The donation specialist staff will discuss with the family which organs and tissues may be possible to donate. This will depend on the person’s age, medical history and the circumstances of their death. The family will be asked to confirm which organs and tissues they agree to be donated. They will be asked to sign an authority form detailing this information.
Does the person's family have a say in who receives the organs and tissues?
Organ and tissue allocation is determined by transplant teams in accordance with national protocols1. These are based on a number of criteria, including who will be the best match and waiting lists, to ensure the best possible outcome of the donation.
1 Transplantation Society of Australia and New Zealand (TSANZ) Clinical Guidelines for Organ Transplantation from Deceased Donors http://www.donatelife.gov.au/clinical-and-ethical-guidelines-organ-trans...
Will the person's organs definitely be transplanted?
If the family supports donation, everything possible will be done to make sure those wishes are fulfilled. At the time of the donation it can sometimes become clear that organs intended for donation are not medically suitable for transplantation. The donation specialist staff will discuss this with the family if it arises.
Is transplantation always successful?
Australia is internationally recognised for its successful transplants and having excellent long-term survival of recipients. The majority of people who receive a transplant benefit greatly and are able to lead full and active lives as a result. Transplantation, however, is not without risk including that of the transplant surgery and the ongoing treatments required after transplantation.
Will the family receive information about the patients who have benefited from the donation?
Health professionals involved in donation and transplantation must keep the identity of donors and recipients anonymous by law. Initial outcomes will be discussed with families, and families can request further updates from the DonateLife Agency. Donor families and transplant recipients can write anonymous letters to each other through the state or territory donation agency and transplant units.
What support services are available for donor families?
The donation specialist staff will keep in contact with the family and provide ongoing support and information. State and territory donation agencies can provide access to bereavement support and care.
You can find contact details for the DonateLife agency in your state or territory here.