Referral responsibilities and clinical triggers

Timely referral of patients who meet criteria as potential organ and tissue donors is required under CMS Conditions of Participation and Joint Commission standards. Hospitals are responsible for identifying patients who meet referral criteria and notifying the Organ Procurement Organization in a timely manner to ensure appropriate medical management and to allow donation decisions to be evaluated and honored.

Notify UW OTD of any mechanically ventilated patients whose death is imminent and who meets one or more of the following criteria:

• Glascow Coma Scale (GCS) of 5 or less due to illness or injury
• Family asks about or mentions organ donation
• Anticipated family discussions about end of life
• Patient has a Do Not Resuscitate (DNR) order

Refer all patients within 1 hour of cardiac time of death, including patients previously ruled out for organ donation by calling 1-866-894-2676.

Call UW OTD if a hospice or palliative care consult is ordered, grave prognosis given, before discussions about withdrawal of life-sustaining therapies, if comfort measures only orders are placed, of if brain death testing is planned.

Regardless of age, diagnosis, or registry status, referred patients must remain intubated, and hemodynamics maintained while UW OTD determines medical suitability.

Family donation discussions are collaborative work between UW OTD and the hospital care team.