Organ Transplant Network Loosens Rule Separating Care Teams From Donation Staff

The nation's organ transplant system is revising a long-standing safeguard meant to protect potential donors, a move its supporters say will boost donations and reduce errors, while critics warn it could endanger patient care.

The Organ Procurement and Transplantation Network, which runs the U.S. transplant system, will relax a strict firewall between the doctors and nurses working to save a patient and the team waiting to procure that patient's organs. Under the old rule, no one from the procurement team was supposed to speak with family members until after they had made the painful decision to let a loved one go. The barrier was meant to prevent pressure that could alter a patient's care, and to reassure families that clinicians were doing everything possible.

The network's board of directors voted Aug. 20 to change the rule as part of new guidelines for donation after circulatory death. That type of donation follows the withdrawal of life-sustaining care and now makes up about half of all organ donations. The guidelines take effect Nov. 18. According to the new policy, they "allow discussions for organ donation to take place once end of life discussions are taking place with the potential deceased donor's agent."

Dr. Raymond Lynch, director of transplantation at the Health Resources & Services Administration, the federal agency that oversees the network, defended the change in an interview with NPR. He said insisting on a bright line without attention to what happens on either side of it gives "a false sense of security." The revisions also aim to prevent past errors, including cases in which patients who were still alive were wheeled into operating rooms for organ removal.

Besides allowing donation teams to approach families sooner, the policies make it easier to pause organ retrieval if anyone suspects something is wrong, and they standardize other protections, such as testing used to determine death. "Documentation, clear coordination, deference to the primary healthcare team and consequences, that's what keeps patients safe," Lynch said. He added that the change is intended to keep retrieval teams from being brought in too late to complete needed tests and preparation. When that happens, he said, the family loses a memory of helping their loved one donate, the patient loses the choice they made, and people on the waiting list lose a chance at a lifesaving organ.

The stakes are high. More than 109,000 Americans are waiting for a transplant, according to the agency, and about 12 die each day because of the organ shortage.

Critics say the change crosses an ethical line. They argue it could subtly pressure families and caregivers to end care and blur the distinction between the team trying to save a patient and the team seeking organs, deepening distrust in the system. Dr. Lainie Ross, a bioethicist at the University of Rochester, called it "a very important bright line." She said she is "horrified to think that families will feel pressured. They'll feel manipulated."

Dr. Claire Morgan, a transplant surgeon on the network's Patient Affairs Committee, said she supports more transplantable organs but fears families "may be pressured to make that decision too quickly." Lois Shepherd, a University of Virginia law and bioethics professor who opposed the change as a member of the working group behind the guidelines, said it is part of developments that are "blurring lines" and weakening patient safeguards.

The Association of Organ Procurement Organizations, a trade group, endorsed the change. In public comments, it said families considering withdrawing life support must be told how the donor evaluation process may affect timing, and that many have been frustrated to learn of the impact after arranging for relatives to be present. "Waiting until the family has made the decision is too late," the group said. Its president, Allison Erickson, said in a written statement that donation depends on public trust and that donor families deserve to fully understand each stage of the process.