Have you seen the movie Return to Me?
It’s an early 2000’s romantic comedy featuring David Duchovny (Bob in the movie) and Minnie Driver (Gracie). The movie is set in Chicago. It’s cute and clever featuring this ridiculous cast of old men who run an Irish-Italian restaurant which sets the stage for an eventual meet-cute for the main couple (Bob and Gracie). Within the first few moments of the movie, the wife of Bob dies in a car accident. We are then introduced to Gracie, a young woman who has end-stage heart failure and is in desperate need of a heart transplant. Fortunately, Bob’s now deceased wife is an organ donor and Gracie is the lucky recipient.
What I love about this movie is how it captures two sides of the organ donation experience. We get to observe Gracie’s serious condition as she waits in the hospital, hoping for the right match.
But really, there are at least three perspectives of organ donation—the health care workers involved in the process.
As a nurse, I cared for several patients who were brain dead, in the midst of the organ donation process. It’s a phenomenon I call “the living dead.” The death certificate of the patient lists the time a patient is declared brain dead by the neurologist. (There is an entire criteria and series of tests a patient must undergo for this to happen.) However, the nurse cares for the patient for an additional 24-48 hours following the brain death declaration during the organ matching and procurement process. While it’s odd to care for “the living dead” you know that somewhere, six to eight patients are getting the call for which they’ve been waiting. There’s a match and that patient is about to get a new chance at a normal life, less constrained by machines and hospital admissions.
In the movie, Gracie’s grandpa gets the call that an organ is available and it’s a beautiful portrayal of what I imagine it’s like after caring for the “living dead.” The emotional juxtaposition of this experience is indescribable, and I’ve always felt privileged to play a small part.
What is organ donation?
Approximately every eight minutes, a patient is added to an organ donation list. At any given time, there are over 100,000 people waiting for an organ. These patient conditions have a range of acuity. For example, a patient can be on the kidney transplant list for years while receiving regular dialysis, waiting for an organ. In other cases, a patient needing a heart or lung transplant may not be able to leave the hospital due to the severity of their condition.1
There are three ways people can donate organs:
Donation after cardiac death (DCD): the patient’s heart has stopped, and they are dead
Brain death: a patient who has irreversible brain damage who meets neurological criteria
Living donor: one kidney, lung, and a part of the liver, pancreas, and intestine can be transplanted by a living donor. For more information on this process, check out Living Organ Donation | organdonor.gov
Organ donation is regulated by the federal government under the Department of Health and Human Services (HHS). In 1984, the National Organ Transplant Act became federal law. This law made it illegal to sell human organs and established a national registry for organ matching—the Organ Procurement and Transplantation Network (OPTN). The OPTN ensures organs are donated and allocated fairly.2 United Network for Organ Sharing (UNOS) was awarded the OPTN contract and continues to coordinate organ donation today.
A few years later (1986), the Required Consent law required hospitals to develop a policy that would allow families the opportunity to donate the organs of their deceased loved ones in hopes that the number of organ donors would increase. In 1998, the Centers for Medicare and Medicaid Services (CMS), issued a rule that all hospitals who receive reimbursement from Medicare or Medicaid must refer all deaths or approaching deaths to their local organ procurement organization (OPO). Generally, this means that an OPO must be notified anytime a patient is admitted with a low Glascow Coma Score (GCS—a common measure of neurologic response).3
When the OPO is notified of a patient meeting criteria, they follow along to watch the patient’s progress. If the patient progresses to brain death or cardiac death, the organization is notified (by nursing staff) and comes to the hospital to discuss donation options with the family.
History of Brain Death and Organ Transplant
In 1962, the first successful kidney transplant from a deceased donor was documented in the US. The first successful kidney transplant from a brain-dead donor was documented in 1963, and the first heart transplant from a deceased donor occurred in 1967.
In 1968, there were two major milestones in the organ donation process. First, the Uniform Anatomical Gift Act (UAGA) was passed which established a uniform donor card as a legal document of organ donation in all fifty states (this is often indicated on a driver’s license). The UAGA has been revised twice since the original legislation, each time with the hope of increasing the number of organ donors by making it easier for people to indicate if they would like to be a donor.4
Second, the first definition of “brain death” (defined as irreversible coma) was developed by the Harvard Ad Hoc Committee and became the basis for “brain death” laws in all fifty states.5 To be clear, there has been extensive debate surrounding this definition since it was established, but the bioethics surrounding brain death and organ donation are outside the scope of this piece.
In 1981, the Uniform Determination of Death Act (UDDA) became federal law and defined death as the “irreversible loss of blood flow and breathing or irreversible loss of all brain activity and functions.” It is limited to legal definition of death, but not the ethical considerations. Because health care is usually determined by each state, the UDDA was designed to provide uniform legislation for the states to follow. The UDDA also attempted to align the legal definition of death with established medical standards in light of advancements in medical technology. With those advancements in technology, medical providers are able to maintain patient’s breathing and circulation without brain activity using a variety of machines and medication.6
There is a scene in Return to Me that gets me misty every time I watch. Bob, wearing a blood-spattered tuxedo, walks into his home after his wife’s death. Clutching his broken arm to his chest, Bob sinks to the floor, his back against the door as he sobs, acknowledging his wife’s death for the first time. The grief of the scene is palpable and a sobering reminder that even though there is a gift within organ donation, there is intense loss as well.
A few months ago, a patient was admitted to my intensive care unit with a severe brain injury. After neurosurgery evaluated the patient and determined there were no interventions available that would save the patient, we had to tell the family. As a nurse practitioner, I sometimes must deliver hard news to families as was the case with this situation. I always try to present the information as simply and kindly as I can, but there’s no easy way to tell a family their loved one is going to die shortly. This particular situation was especially tough, and the raw grief expressed from the primary family member is burned in my brain.
Ultimately, the patient’s condition progressed to brain death. The appropriate parties were notified, and the patient ended up becoming an organ donor. The organ donation network always sends a lovely follow-up letter, and at least six patients received an incredible gift from this patient. Somewhere, that family’s grief lingers while it’s intermingled with the knowledge that their loved one changed the lives of several strangers.
Matching Donors and Recipients
The process of matching organs and donors typically takes a few days. First, the donor goes through a wide range of testing and detailed health history record gathering. Second, the donor is evaluated for several different levels of health risk.
Here’s a sample of the policy from the first round of risk evaluation.7
The host OPO is responsible for evaluating each potential donor in order to obtain the following information:
1. Arterial blood gas results
2. Blood type determination and reporting according to Policy 2.6: Deceased Donor Blood Type Determination and Reporting, including sub-typing for blood type A donors
3. Chest x-ray
4. Complete blood count (CBC)
5. Electrolytes
6. Serum glucose
7. Urinalysis, within 24 hours before cross clamp
The risk evaluation and safety profile is extensive and it’s all detailed here.
Once it’s clear that the organs are healthy and everything is checked, re-checked, and then checked again, recipients are identified.
OPTN describes the factors in the matching process8
“First, a transplant hospital evaluates and accepts a patient for a deceased donor transplant. The hospital then lists that patient with the Organ Procurement and Transplantation Network’s (OPTN) national computer network. The network links all donors and transplant candidates.
Organ procurement organizations (OPOs) identify potential deceased donors and get consent for donation.
When the OPO knows what organs are to be matched, it enters information into the OPTN system.
The system then matches the organs with patients in need.
For each organ, the matching program sets the order of people to receive transplant offers.”
Once a recipient is identified, all the medical data gathered from the donor is sent to the recipient’s medical team for evaluation. Among the considerations is the body size of both parties. For example, if your donor is a short woman (like me!) and the top recipient is a tall person, my organ is probably not a good fit for, say, a six-foot seven male. Our blood vessels and body cavity size are too different. In that case, my organ would go to the next eligible patient where the organ is a good fit.
Once a recipient is identified and the organs removed from the donor, the clock starts ticking. Kidneys are generally transplanted within 36 hours; liver, pancreas, and intestinal organs within 12 hours; and hearts and lungs within 6 hours. That means the surgeons removing the organs have to remove the organs, fly or drive to the hospital where their recipient patient is waiting and prepped, conduct their own testing, and place the new organ into a recipient all within a short time frame.9
The logistics are mind-boggling and it’s incredible to watch the front-end (the donor side) unfold.
Like any good romantic comedy, Bob and Gracie meet at the fortuitously named O’Reilly’s and fall in love. The rest is romantic comedy gold. Turns out, hearts are always supposed to be together and organ donation made that possible.
You can find more information about the organ donation process here.
Information about Organ, Eye, and Tissue Donation | organdonor.gov
History and NOTA - OPTN (hrsa.gov)
Donation & Transplantation History | organdonor.gov
Uniform Anatomical Gift Act - Wikipedia
How Harvard Defined Irreversible Coma - PubMed (nih.gov)
What is the Uniform Determination of Death Act (UDDA)? - FindLaw
Patient safety - OPTN (hrsa.gov)
Learn about the donor matching system - OPTN (hrsa.gov)
Learn about the donor matching system - OPTN (hrsa.gov)
This is so interesting and informative! Thanks for all the care you took to write it and the care you provide your patients!