Your Captain Speaking: What to Say About Organ Donation

“Tammy, you are very experienced in organ donation and we know it does wonderful things for the lives in many people on the transplant list. Should we in EMS even bring up the topic with a patient or family? What should we say or more importantly, not say?” 

For EMS, there is a very positive view of organ donation but little to no instruction is received as either initial or continuing education. There are some significant gaps in our collective understanding.¹ Going over the basics is definitely in order. Organ donation actually covers a much wider range of human tissues than you might imagine. At the top of the list, many would identify kidney and heart transplants as contenders, but the list is much longer and includes liver, pancreas, intestines, lungs, bones, bone marrow, skin, and cornea transplants.² This is a very broad array of organs and tissue and one donor could potentially help multiple patients. As EMTs, we frequently transport patients with renal failure for dialysis. Many of you reading this could not even guess how many times you’ve done this type of transport in your career.  Many of those patients could have a much more normal life with a functioning kidney. That is not to say that all of them would be willing to undergo the surgery to receive a transplanted organ even if it was available.

So where do the donor organs come from? Basically, there are two categories and each has some significant legal/ethical considerations that we must be aware of. First up is Donation After Circulatory Death (DCD). This term refers to the patient who has suffered a catastrophic brain injury and may be near death except for mechanical interventions such as a ventilator, ECMO, or other devices and it has been decided, following a defined protocol, to withdraw life support.  Obviously, there is a limited time prior to the withdrawal of life support to consider the protocol and set up the donation process. To be blunt, organs are not recovered from these types of patients until after, as the name implies, circulatory death. There is a time of death established.  

It is possible to have an organ donated by a living person, legally and morally. There are brave and selfless people who have donated a kidney or part of their own liver to help another family member. There have been organ donations by a stranger to a patient in need.  This is an awesome demonstration of love and respect for another’s life. Tissue matching and consent all around are required. This is the exception to the vast majority of donations.  

Out of hospital death. This is where EMS works, but there are a multitude of reasons this is not currently a great source of organ donation. How about an example? EMS arrives on the scene to a gunshot wound (GSW) to the head and the patient is lifeless. No CPR is attempted according to protocol. As it is a crime scene, police and a coroner must be called. The clock has started and organs would need to be recovered with normally 60 minutes. This is not the “golden hour” we know in EMS, no connection between the two descriptions. Very little information is known about this patient, even their name, past medical history, or organ donation status. Even if we knew the exact time of the injury, the clock is simply not on our side for organ donation. According to an article on the US National Institute of Health (NIH), website stated: “4% of patients who died in ICU after OHCA (Out of Hospital Cardiac Arrest) led to organ donation.”³ 

Many of us know that the majority of OHCA patients brought to the emergency department are not transferred to the ICU as resuscitation is terminated in the ED. However, many organ donors are processed successfully in the Hospital Emergency Department!  Let’s assume that the patient in the ED has organ donation marked on his driver’s license and a family member objects.  Driver’s licenses are issued by state so if the patient is in a different state, things get a little more complicated. I’m not a lawyer, but a judge is likely required to override the patient’s wishes and during all of this, the clock is still running.  

Many of the obstacles are listed above but there is a brighter side: Who can be an organ donator?⁴

• Age limit? No limit to donating or signing up was a total surprise to me. One of the oldest donors was 92 years old from Texas and saved the life of a 69-year-old woman from a liver transplant. There is no minimum age with parental consent and donor potential if a minor.  

• Cancer history?  As long as it is not an “actively spreading cancer,” it may be possible. Each case would need to be individually evaluated, but not an automatic rejection. Corneas transplants are often possible. 

• Cost to donor family?  There is no cost to the donor or their family.  Medical treatment prior to donation will, of course, be incurred. Organizations that perform and coordinate organ and tissue donation rely on public generosity.  

• Social class or religious restrictions?  Any race, ethnicity, LGBTQ+, social class, etc, may register as a donor. Most major religions support donation but asking a religious advisor or clergy should quickly clarify.  

Short answer:  Anyone can sign up as an organ/tissue donor. No automatic exclusions. None. 

This next section is critical information to EMS.  First, check with your Medical Director, hospital policies, and state and local agencies and follow their policy and directives. From Organ Procurement and Transplantation Network Policies (.gov) directs: 

Prior to the OPO initiating any discussion with the legal next-of-kin about organ donation for a potential DCD donor, the OPO must confirm that the legal next-of-kin has elected to withdraw life-sustaining medical treatment. ⁵

Short version for EMS: DO NOT initiate the topic of organ donation to family members.  The reference above says the decision to withdraw medical treatment is made first, then an organ donation discussion can be initiated. We are not experts in this area so we should refer questions to the hospital coordinator.  

Likewise, at the hospital, the doctors and nurses should never bring the topic up for the same reason. There are good reasons, both ethically and legally for this practice.  For example, a family member could later feel that they were inappropriately being pressured into organ donation, that EMS or hospital was no longer trying to treat/save their family member, or that there was some financial motivation for EMS to bring up the topic of organ donation. Any and all of these can be misinterpreted and put the EMS organization as well as the EMTs in legal and ethical peril.  

Tangible takeaways for EMS to handle the situation: 

• A family member brings up the topic by saying “He’s registered as an organ donator.”  Less is more by saying “We’ll pass that along to the hospital” and that is totally appropriate to convey to the hospital.  

• A family member asks EMS “How does organ donation work?”  One answer might be: “There are coordinators at the hospital that can best answer your questions.” 

My friend and colleague, Tammy Camacho, works daily with organ donation with some 75 different hospitals in Texas and was the perfect resource to write this article with. Neither of us is a lawyer so start with your Medical Director for what to do and say to be legal and ethical. It is incredible how much good one donor can make for the lives of others. Consider your own organ registration and talk to your family about your decision. Register thru your individual state’s procedure could start with the internet search: “I want to be an organ donor.” 

Dick Blanchet, (Retired) BS, MBA, worked as a Paramedic for Abbott EMS in St. Louis, MO, and Illinois for more than 22 years. He was also a Captain with Atlas Air for 22 years on the Boeing 747 with more than 21,000 flight hours. As a USAF pilot for 22 years, he flew the C-9 Nightingale Aeromedical aircraft. A USAF Academy graduate with a Bachelor of Science degree, his Masters in Business Administration is from Golden Gate University.  

Tammy Camacho is a Quality and Compliance Auditor III for Southwest Transplant Alliance (STA) in Dallas, Texas. She also worked as a Surgical Coordinator and Triage Placement Coordinator for STA. Currently responsible for auditing 75 hospitals in the Organ Procurement Organization (OPO).  Tammy is finishing the final touches on her MBA in Healthcare Management.

1.  Emergency medical services knowledge and attitudes about non-heart-beating donors: Effect of an educational intervention, Sep 28, 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329276/ 

2.  NIH National Library of Medicine. MedlinePlus Organ Donation, Retrieved Jan 14, 2023, https://medlineplus.gov/organdonation.html#:~:text=Organ%20donation%20takes%20healthy%20organs,liver%2C%20pancreas%2C%20intestines%2C%20lungs 

3.  Organ donation after out-of-hospital cardiac arrest: a population-based study of data from the Paris Sudden Death Expertise Center, National Library of Medicine PMC PubMed Central, June 6, 2022, M. Renaudier, Y. Binois, [...], and Paris Sudden Death Expertise Center group, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9170852/ 

4.  “Who Can Donate”, Health Resources & Services Administration (HRSA),  Jan 16, 2023, https://www.organdonor.gov/learn/who-can-donate 

5.  OPTN: Organ Procurement and Transplantation Network Policies, 1/5/2023, page 33-34, https://optn.transplant.hrsa.gov/media/eavh5bf3/optn_policies.pdf