STANDARD 26: Organ, Tissue, and Eye Donation/Procurement

26.1 General

1. If applicable the healthcare organization shall have written policies and procedures to address its organ procurement responsibilities.

2. The healthcare organization shall have a written agreement with an Organ Procurement Organization (OPO). At a minimum, the written agreement shall address the following:

a) written agreements with at least one tissue bank and at least one eye bank;

b) the criteria for referral of donor eligible entities;

c) donor eligible entities to include patients facing of "imminent death";

d) appropriate definition of "timely notification";

e) OPO responsibility to determine medical suitability for organ donation;

f) method by which the tissue or eye bank shall be notified regarding potential donors;

g) provision for OPO notification of each individual death or donor availability in accordance with the terms of the agreement;

h) resolution and mutual agreement related to training programs and tissue and eye bank requirements;

i) OPO, tissue bank, and eye bank access to the healthcare organization’s death record information in keeping with and agreed upon schedule;

j) the ability of the healthcare organization to relieve members of the organ recovery team from the credentialing process and subordinate this requirement to the OPO to qualify individuals performing organ recovery;

k) required intervention within the healthcare organizations so as to maintain harvest organ viability.

3. The healthcare organizations shall develop a written procedure to notify the OPO of every death or imminent death in the healthcare organization. This notification shall occur prior to the donor removal from life support systems. It shall also occur in a timely manner approved by the medical staff and the needs of the OPO.

NOTE 1 When death is imminent, OPO notification must consider multiple human factors in the decision to initiate organ harvest. These factors include needs and desires of the family, the healthcare organization resource availability, concerns, and recommendation of the medical staff regarding donor organ safety and possible other ethical issues.

4. The healthcare organization shall ensure, in collaboration with the designated OPO, that the family of each potential donor is informed of its options to donate organs, tissues, or eyes, or to decline to donate.

5. The healthcare organization in concert with its medical staff, the OPO, and other relevant authorities shall ensure that the donor material in consideration is free from any human health hazard or communicable disease endangering any potential recipient.

6. The individual designated by the healthcare organization to initiate the request to the family shall be an organ procurement representative or a designated requestor.

7. The healthcare organization shall retain and maintain documented information regarding harvest and organ donor activities as determined as necessary and essential to this service efforts.

NOTE 2 The definitions of "imminent death" and "timely notification" should be defined and agreed upon by the OPO and the healthcare organization.

NOTE 3 For purposes of these standards, the term "organ" means a human kidney, liver, heart, lung, or pancreas.