After reading Brian Rosenthal’s New York Times front page article, “A Push for More Organ Donations is Putting Donors at Risk”. Donation and transplant expert Tom Mone, retired OPO and Hospital CEO submitted the following response:

Rosenthal’s article has a fundamental flaw: Organ Procurement Organizations (OPOs) do not determine if a patient has a terminal neurological injury, OPOs do not communicate the terminal nature of the injury and futility of continued care to the family, OPOs do not declare death prior to donation. Hospital MDs perform each of these actions who have nothing to do with donation.

OPOs DO strive to give every registered donor and family the chance to save other lives through donation IF the hospital’s attending MD declares the patient dead by neurological or cardiac criteria. And the OPO has no role in organ recovery until that death is declared. Only when the patient is declared dead based on hospital MD brain death testing or the DCD patient no heartbeat for five minutes does the OPO and its partner transplant MDs initiate organ recovery.

There are occasions when OPO staff anticipate that a potential DCD donor will not arrest within an hour and will not be able to donate, but choose to honor a family’s desire to try to help others through donation. Unfortunately, the ability to predict arrest of a patient that hospital MDs and family have determined to be terminally injured has always been challenging, with predictive tools being correct between 50% and 75% of the time, but the family’s wishes are honored and OPOs honor those families as Donors because they chose to give. Concluding, as Rosenthal does, that this is a sign of OPO failure is actually a sign of OPOs respect for families and registered donor wishes.

Rosenthal’s misunderstanding and/or unwillingness to share this reality speaks to his missing the critical separation of responsibilities based on the ethical requirement that OPOs are never involved in the declaring death of any donor.

Certainly on rare occasions hospital MDs err in assessment of a patient’s neurological status, but in most cases the decision to be an organ donor actually allows them to correct these errors because donation routinely requires 24+ hours from time of MD determination and conversation with families. This gives time for such errors as excess sedation or low body temperature that depress neurological function to resolve and if the patient’s function improves, the terminal diagnosis is reversed. However, If patients are not authorized for donation their MD and family routinely withdraw ventilation shortly after family request that they cease treatment…and patients expire without time for sedation to wear off and the discovery that the MD had erred…how many lives are lost this way? Rosenthal apparently never asks or didn’t tell us…choosing instead to erroneously blame OPOs that play no role in the diagnosis.

If there is a significant national problem it is with inconsistently defined hospital and MD policies and procedures guiding the determination of futile care and premature cessation of ventilation, but not with organ donation.

Some feel that the CMS OPO Final Rule and threat of decertification hanging over 60%+ of the nation’s OPOs creates pressures for rapid changes in OPO practices. Undoubtedly OPOs feel under pressure despite record setting performance for more than a decade. So, OPOs are being more assertive in reminding hospitals that CMS Hospital Conditions of Participation require hospitals to notify OPOs of possible donors and to ensure OPO staff have an opportunity to discuss donation. OPOs are also being more assertive in reminding hospitals and families that Donor Registries defined in the in law in all fifty states makes a person’s registration legally-binding. OPOs are working diligently to uphold these personal choices…and the law. Does this leave some hospital staff and some families uncomfortable, certainly, and this requires OPOs to double-down on professional and public education that reminds everyone that 1) OPOs have no formal role other than evaluation and stand back until death is declared, 2) the decision to donate is a personal choice that is respected in law just like a personal last will and testament, far more rigorous a standard than an Advanced Directive, 3) that OPOs will follow a potential donors legal wish and family wishes to try to make donation happen, only once a hospital MD has determined that the patient cannot recover, and 4) in the very rare cases that an MD errs, the decision to donate actually gives time to discover and prevent premature extubation and death of an overly sedated patient…as we saw in the Kentucky case where the donation decision likely saved this patient’s life.