Consideration of organ and tissue donation after death should become a normal part of end-of-life care in all areas of NHS Borders. This will be facilitated by identification of potential donors, and timely referral to Specialist Nurses in Organ Donation (SNOD)/ Tissue Donor Coordinators. The Human Tissue (Scotland) Act 2006 places a duty on certain healthcare workers, mainly SNODS/SRs/TDCs to make inquiries about a potential donor and their last known views on Organ and tissue donation with the nearest relative. Organ and tissue donation is an infrequent but important activity within NHS Borders. The health board works in partnership with NHS Blood and Transplant (NHSBT) and the Scottish Government to deliver the national strategy for organ donation. In the UK this is guided by the current strategy document Organ Donation and Transplantation 2030: Meeting the Need, along with the Scottish Government document Donation and Transplantation Plan for Scotland: 2021 – 2026. Priority 3 of this plan states “We want to continue to ensure that, wherever possible, anyone who would have wanted to donate can have that decision respected when they die”. It is important therefore that all parts of the hospital support donation.

Organs suitable for donation and transplantation include but are not limited to heart, lungs, liver, kidneys, pancreas and small bowel.

General Medical Council (GMC) guidance advocates that: “If a patient is close to death, and their views cannot be determined, you should be prepared to explore with those close to them whether they had expressed any views about organ or tissue donation, if donation is likely to be a possibility. You should follow any national procedures for identifying potential organ donors, and in appropriate cases, for notifying the regional Specialist Nurse – Organ Donation.”

Current guidance states that “although donation occurs after death, there are steps that health professionals may need to take before the death of the patient if donation is to take place.” This policy covers such steps and in the case of clinical triggers, action that might take place even before the inevitability of death has been recognised.

Tissue only donation can be facilitated by the Scottish National Blood Transfusion Service who are the primary provider of tissues for therapeutic use in Scotland. Anyone who dies in hospital has the potential to become a tissue donor as unlike organ donation, tissue donation can take place up to 48 hours after death for heart tissue and tendons and within 24 hours for eye donation. Organ donors may also be able to donate tissue.

Tissue donation after death includes the potential of donating life-saving heart tissue and skin and life-enhancing tendons and corneas.

1. Identification of potential donors by the doctor in charge, by means of clinical triggers, must initiate discussion with the SNOD at the time the triggers are met. See Appendix 2.
   
   
2. Identification should be based on the following criteria, while recognising that clinical situations vary, in accordance with timely identification and referral of potential donors. (A strategy for implementation of best practice NHSBT (2012)):
   
   
   1. Any patient with a potentially devastating neurological injury that is expected to be non-survivable.
   2. A decision is made to perform neurological death tests.
   3. The intention to withdraw life sustaining treatment in patients with a life-threatening or life limiting condition which will, or is expected to, result in circulatory death. In this context, examples of life sustaining treatment are positive pressure ventilation and/or inotropic drugs.
      
      
3. Patients may present in areas outside of critical care units e.g. emergency department, who are receiving positive pressure ventilation, but a decision may have been made to withdraw life sustaining treatment.
   
   
4. When appropriate, the patient should be made clinically stable for a period of prognostication. The patient should be moved from the emergency department to a Critical Care area, in line with the national Emergency Department strategy.
   
   
5. Provided this period of assessment is in the patient’s best interests, life-sustaining treatments should not be withdrawn or limited until the patient’s wishes around organ donation have been explored and the clinical potential for the patient to donate has been assessed in accordance with legal and professional guidance.
   
   
6. Where a patient has the capacity to make their own decisions, staff should obtain their views on, and seek authorisation for, organ donation.

1. All patients in whom neurological death is the suspected clinical diagnosis should have neurological death testing performed.
   
   
2. Discussion with the Procurator Fiscal for those patients who would fit the criteria for a reportable death and in addition, if the clinician or SNOD is uncertain if the death meets reporting criteria.
   
   
3. The patient is assessed by the SNOD and if they are a suitable potential donor, the Duty to Inquire (DTI)must be carried out with the family/nearest relative to determine the patient’s most recent views regarding organ and tissue donation.
   
   
4. The approach to the family must be planned on an individual basis, with due regard given to issues of culture and belief. The standard of best practice is that the family approach should be a collaborative effort between senior medical staff and the SNOD/SR, see Appendix 3.
   
   
5. If the family supports the patient’s latest views/shows no known unwillingness to donation, organ support continues, authorisation is obtained and donation proceeds. If the family state unwillingness as the latest known view of the patient, or they themselves do not wish to proceed with organ or tissue donation, end of life care planning should continue as per local policy.

1. The intention to withdraw life sustaining treatments in patients with a life threatening or life limiting condition, which will, or is expected to, result in circulatory death should initiate discussion with the SNOD.
   
   
2. Discuss with the Procurator Fiscal those who would fit the criteria for reportable death and in addition if the clinician or SNOD is uncertain.
   
   
3. The patient is assessed by the SNOD and if they are a suitable potential donor, the DTI must be carried out to determine the patient’s last known views regarding organ and tissue donation.
   
   
4. The approach to the family must be planned on an individual basis, with due regard given to issues of culture and belief. The standard of best practice is that the family approach should be a collaborative effort between senior medical staff and the SNOD/SR, see Appendix 3.
5. If the family supports the patient’s last known views/shows no unwillingness to donation, life sustaining treatment continues, authorisation is obtained and donation proceeds. If the family state an unwillingness as the last known view of the patient, or they themselves do not wish to proceed with organ and tissue donation, life sustaining treatment is discontinued and end of life care planning should continue as per local policy.
   
   
6. Withdrawal of life sustaining treatment should occur according to normal unit practice, with the practicalities guided by the SNOD and retrieval team. A clinician should be readily available throughout the period of withdrawal to enable prompt confirmation of death, accompany the patient and SNOD to theatre where s/he will be required to confirm with the retrieval surgeon they have pronounced life extinct. Should there be cardiothoracic organs accepted for transplantation, then withdrawal of life sustaining treatment must take place in the anaesthetic room adjacent to the intended operating theatre. The clinician confirming death should be available throughout the period of withdrawal and an anaesthetist available for potential reintubation and anaesthetic support until lung retrieval is complete.

1. There may be an opportunity for children and infants with a life-limiting or life-threatening condition of any age to be considered for organ or tissue donation. 
   
   
2. While many of the donation options and processes offered to children are similar to those offered to adults, additional consideration is required around donation in children or infants. In particular, a paediatrician/paediatric intensivist should be involved when considering withholding or withdrawing life sustaining treatment or diagnosing death using neurological criteria. This will require discussion with a tertiary paediatric centre.
   
   
3. If a child is subject to child protection concerns or Procurator Fiscal involvement then the following key professionals must be notified: -
   • Lead Paediatrician for Child Protection
   • Child Protection Advisor
   • Investigating Police Officer.
   • Procurator Fiscal
   • Forensic Pathologist
     
     There may still be a possibility to consider donation even in these cases and a referral should be made to the SNOD.
     
     
4. Many parents and families take a great deal of comfort from knowing that through donating their child’s organs or tissue, other people’s lives were saved or enhanced. Even if donation is not possible, it may be reassuring for families to know that this option was explored.

1. Families of all deceased patients in NHS Borders should be offered the option of tissue donation as part of normal end of life care.
   
   
2. There is an unmet clinical demand for some tissue in Scotland. One Tissue Donor has the potential to help 11 people regain a normal life after illness or injury.
   
   
3. Access to Tissue Donor Co-ordinators is available in NHS Borders. Their remit is to provide education for clinical staff and furnish them with the skills to approach suddenly bereaved families to offer tissue donation as part of the end-of-life care pathway.
   
   
4. There are also close links with the ITU through SNOD collaboration in departmental education of clinical staff to identify potential donors of tissues as part of the organ donation programme as well as for those patients that die where organ donation is not possible.
   
   
5. This close relationship with the SNODs and collaboration in donor identification and assessment ensures the potential for both organs and tissues are maximised for the patients that become organ donors. There is a Tissue Donor Co-ordinator on call in Scotland 24/7 on 07623 513987 and they are happy to provide donation advice to Healthcare Professionals.
   
   
6. In order for tissue donation to progress, the donor will need to be transferred to a dedicated mortuary retrieval suite in Edinburgh to ensure safety of the tissues. Eye only donation can be progressed on site at the Borders General Hospital.
   
   
7. To refer a tissue only donor-see Appendix 1.

1. All deaths within Critical Care areas and Emergency Departments are audited to identify any areas of the service that require improvement. Local data forms part of the national data set to allow comparison of activity. Operating theatre responsibilities are as described in Appendix 4.
   
   
2. Compliments and complaints can be reported in the first instance to the embedded SNOD and CLOD. The process for formal reporting of complaints can be found in NHS Borders Complaints Management Policy or the NHS Blood and Transplant Incident Submission System on the Organ Donation Team (ODT) Microsite.

1. NHS Borders will continue to support National Organ Donation Campaign activity through digital channels and press.
   
   
2. People involved in organ donation may wish to share their story in the public domain as is their right. In choosing to do so the privacy of NHS staff should be respected and no names, photos or other person identifiable information of NHS staff should be shared without consent. If you have any questions in relation to patient stories, please contact the communications and engagement team: communications@borders.scot.nhs.uk
   
   Staff are reminded that any approaches to them by media, either direct or indirect (e.g. via a family) must be referred immediately to the communications and engagement team.
   
   In some cases, NHS Borders may proactively seek patient stories about organ donation. All initial approaches should go through the CLOD and/or SNOD, and there should be no direct approaches to patients or their family members from the communications and engagement team in this regard.

1. Spiritual Care is one form of additional support offered to patients, visitors and staff when people are facing the challenging consequences or repercussions of illness or sudden trauma.
   
   
2. Research[1] suggests that the opportunity for patients and family members to ‘talk about what is on their minds’, with someone who is not a member of the clinical staff, can be of significant benefit.  Staff themselves may also appreciate the chance to talk through cases that have been particularly demanding, in terms of energy, clinical or ethical judgment, as well as personal resonance; not to mention communicating with a range of people in complex and highly emotional situations.
   
   
3. With their considerable experience of being with people who are dying or who are dealing with life-threatening conditions or, maybe asking some of the fundamental questions about life’s meaning and purpose, what it means to be human and to face one’s own mortality, the Spiritual Care Team in NHS Borders is well equipped to offer this kind of support around the time when organ donation is being considered. 
   
   
4. Some people will wish to explore their concerns in the context of their own cultural or faith background.  Others will value the opportunity for similar conversations and ritual without reference to belief.  Chaplains are experienced in being able to offer non-judgmental supportive listening to all; as well as help create a safe place for difficult but honest conversation.
   
   
5. The Care Advisor/Chaplain Service offers 24/7 support and can be contacted during office hours on01896 826564and out of hours through BG Switchboard.

(Adapted from Approaching the families of potential organ donors: Best practice guidance (2013). NHSBT.)

The approach to the nearest relative of a patient that is potentially in a position to be considered suitable for organ donation can be challenging. The following appendix of the NHS Borders organ donation policy is intended as a guide for clinicians and to provide some explanation to the policy. For a more thorough explanation read the documents referenced in the policy.

1. Emphasis is placed on a collaborative effort between senior medical staff and SNOD/SR.
   
   
2. An individualised approach is planned at the initial meeting between consultant, ITU nurse and SNOD/SR where unique clinical and family issues will guide the forthcoming discussions. The SNOD/SR must carry out the DTI with the nearest relative to determine the patient’s latest known views regarding organ and tissue donation. This will ensure that donation does not proceed where it would be against a person’s wishes. Occasionally, and only when necessary, the initial discussion between consultant and the SNOD will take place by phone. The SNOD/SR will endeavour to attend when required, however if this is not possible they will hold a discussion with the appropriate healthcare worker talking through what is required for the DTI.
   
   
3. Referrals to the regional Organ Donation Services Team do not automatically proceed to donation. When alerted to a possible organ donor, the SNOD/SR may contact transplant recipient centres to ascertain if organ donation is possible and what may be offered. If the clinical condition of the patient is such that no recipient centre considers donation possible, then organ donation cannot occur. Every effort must be made to ascertain this information before families are told that withdrawal is inevitable to avoid confusion at a crucial stage of the family’s grieving. Early contact with the SNOD/SR reduces this risk.
   
   In cases of DCD donation:
   
   
4. For the purposes of the following flow chart the “end of life” discussion refers to the final discussion in which the family is informed that withdrawal of life sustaining treatments is inevitable. It is recognised that clinicians may have had multiple discussions with family members at which withdrawal of therapy is mentioned as a possibility prior to this. The planning meeting with the SNOD/SR should take place prior to the “end of life” discussion. It is strongly recommended that the SNOD/SR is present at this meeting and introduced as “a specialist nurse” but not as an organ donation nurse or an ITU nurse. This is so both family and SNOD/SR have met before organ donation is mentioned. This will benefit both and facilitate achievement of the patient’s interests.
   
   
5. A gap between the “end of life” discussion and the duty to inquire is advantageous in order to allow futility to be accepted by the patient’s relatives. unless the relatives raise the subject of donation themselves.

Organ donation is an infrequent but important activity within NHS Borders. The board works across site in partnership with NHS Blood and Transplant (NHSBT) and the Scottish Government to deliver the national strategy for organ donation.

In the UK this is guided by the current strategy document Organ donation and Transplantation 2030: Meeting the Need and the Scottish Government document Donation and Transplantation Plan for Scotland: 2021 – 2026. Priority 3 of this plan states “We want to continue to ensure that, wherever possible, anyone who would have wanted to donate can have that decision respected when they die”.  It is important therefore that all parts of the hospital support donation. The operating theatres are a key part of that.

Organ Donation occurs in two ways -

Donation following death by neurological criteria (DNC)

In donation following death by neurological criteria, the patient will have undergone neurological death tests and will have been declared dead by neurological criteria, however the heart will still be beating and the lungs mechanically ventilated. It is more likely in this scenario that the patient will proceed to full cardiothoracic and abdominal organ retrieval. It is often possible to give an approximate time of when theatre access will be required in this situation.

Donation following circulatory death (DCD)

In DCD, the heart has stopped beating and the patient is moved quickly to theatre following 5 minutes of asystole. Normothermic regional perfusion (NRP), an in situ perfusion facilitated with the help of extracorporeal organ support may be used in DCDs. DCD Heart and lungs are increasingly being retrieved along with abdominal organs. following a planned withdrawal of treatment, including extubation. The time to death cannot be easily predicted but if more than 3 hours after extubation then retrieval is likely to be stood down.

The closest available National Organ Retrieval Services (NORS) teams will attend to perform the retrieval surgery. There may be requests from the SNOD/SR or accepting centres for pre-death procedures to be carried out on the patient. Some of these may have conditions that must be met before these procedures can be carried out. The attending SNOD/SR will have this information in relation to the Human Tissue (Scotland) act 2019.

 Location of Retrieval at the Borders General Hospital:

1. DNC retrieval will take place in the Main Theatre suite.

1. DCD retrieval will take place in the Main Theatre suite.

Theatre Priority

Elective Work

The aim is for organ retrievals to take place overnight so conflict with elective work is unusual, however, if this does occur then elective work may need to be rescheduled. Organ Donation should take priority over elective work in NHS Borders. If in doubt the final decision should be made by the Clinical Director for Anaesthetics and the Clinical Director for the affected surgical specialty, in discussion with the Medical Director if necessary.

Emergency Work

DCD usually requires the presence of a local senior anaesthetist until death is confirmed, the patient has been transferred to theatre and following cardiothoracic organ retrieval.

DNC may conflict with emergency work. Anaesthesia should be provided by the on-call Anaesthetist. Where conflict arises over access to theatre the on-call Consultant Anaesthetist should decide on priority. The option of opening another theatre should be considered.

Operating theatre responsibilities

1. The donor hospital (i.e. the BGH) will provide a fully equipped operating theatre for the retrieval procedure, including appropriate anaesthetic equipment and drugs to support the donor.
2. The donor hospital is responsible for the safe transfer of the donor to the operating theatre.
3. The donor hospital will provide an anaesthetist to support donation during the retrieval procedure after neurological death and when cardiothoracic organs have been accepted for transplantation following DCD withdrawal.
4. The donor hospital will provide a suitable member of staff, such as a qualified theatre nurse and/or operating department practitioner, who is familiar with the theatre facilities and the whereabouts of the surgical and anaesthetic equipment, instruments and drugs which may be needed by the retrieval surgeons and/or anaesthetist.
5. This/these individual(s) will remain in theatres during the retrieval procedure to provide assistance to the scrub nurse (provided by the retrieval team) and the anaesthetist, and assist the SNOD with the final act of care.