Important pointers for administrators of hospices and nursing homes
Per CMS regulation, a hospital must refer every death to the OPO federally designated to serve that hospital, to an eye bank, and to a tissue bank with whom the hospital has an agreement for services (having such agreements is also required by CMS). By agreement with our hospitals, LifeNet and the Lions Medical Eye Bank and Research Center of Eastern Virginia have chosen to make the referral process a single phone call. The OPO (LifeNet in the Tidewater region), the tissue bank (also LifeNet), and the eye bank (Lions Medical Eye Bank and Research Center of Eastern Virginia) have trained staff whose job is to examine, case-by-case, whether or not a patient is eligible for donation. The OPO or applicable agency will ask a series of questions to determine eligibility for organ, tissue, and eye donation. If the patient is suitable for eye donation, exclusive or inclusive of organ/tissue donation, the eye bank receives the referral and all information gathered up to that point from the OPO. The OPO will remain the one donation organization to contact the hospital if organ and/or tissue donation remains a potential, even if eye donation potential is involved. This reduces the burden on hospital staff with respect to the donation process.
Every hospital has their own protocol for who is responsible for calling a referral to the OPO and/or who is the contact person throughout the screening process. Commonly, a nurse or nursing supervisor is responsible for referring a death. A best practice for the point of contact in the screening process is to put a nurse who cared for the patient on the phone with the donation agency to best facilitate screening by someone familiar with the patient’s history and dying process.
Most cancers do not rule out eye donation. Corneas are avascular tissues that are isolated in the eyes, which are organs remote to most metastases. With few exceptions, a patient with cancer history may be eligible to donate corneas for transplantation.
Every patient’s medical and social history is considered on a case-by-case basis. Eligibility criteria are constantly under review. Donor eligibility criteria are not only set by the U.S. Food and Drug Administration, but by the Eye Bank Association of America, the Commonwealth of Virginia, and the Medical Directors of the Lions Medical Eye Bank and Research Center of Eastern Virginia. In addition to criteria to evaluate safety of tissue for transplant purposes, there are criteria to determine whether donated tissue may be found safe for research, medical education, or training. Our staff receives ongoing training to ensure the safety of the tissue to be transplanted or used for research or medical education, as well as to ensure the safety of eye bank staff who may be exposed to a patient. Screening a patient with the hospital staff, the family, medical examiners, and autopsy technicians is only the beginning of the determination of donor eligibility that occurs. Preservation by strict procedure, testing of blood for a variety of pathogens using several different tests, follow-up on pre-mortem microbiological testing performed, and evaluation of tissue using two different microscopes are just some of the further activities that must occur to ensure safe tissue is available for transplantation.
It is critical that hospital staff refer a death to the OPO within 1 hour of cardiac death. Donation must occur within 24 hours, but preferably within 8 hours. For donation to be of use to the family in their grieving process, the donated tissue must be of a quality that is, to the best of our mutual abilities, useful to potential recipients. LifeNet Health and the Lions Medical Eye Bank and Research Center of Eastern Virginia both have staff that are compassionate and well-trained to handle the grim and daunting task of speaking to the families who have recently lost a loved one to offer donation without pressure. Both agencies respect the wishes of the next-of-kin throughout discussions about donation. Both agencies work toward a goal of recovering tissue, if a family chooses to donate, in the shortest timeframe possible.
Nursing staff is advised not to approach a family about donation ever. Unless nursing staff is trained as a “Designated Requestor,” CMS regulations forbid a donation approach. The main reason for this is that a determination of donor eligibility must be made before an approach for donation occurs. Second, every family deserves the option of donation to be presented by individuals knowledgeable in the subject and able to answer their questions about donation.
There is little regulation regarding deaths outside of the hospital setting. When a patient dies outside of a hospital and law enforcement is involved in the death reporting, law enforcement is, according to Virginia law, to refer a case. However, this practice is in its infancy. If a dying hospice patient indicated a desire to donate, anyone can refer the case. This includes hospice staff, family, or staff at the assisted living facility or nursing home, or even clergy. Though each family should be able to honor the wishes of their loved one or given an option to donate, a referral, followed by appropriate donor screening must occur first. It takes love and compassion from individuals who may not even have an association with the deceased to make this system work for those who die outside of a hospital.