
Watch Alexandra Glazier, JD, MPH CEO, New England Donor Services, discuss Why Gift Law Matters: The Law and Ethics of Donor Designation from the UNOS Region 6 Forum in Seattle, WA
We share the same goals as your care teams, and we’re aligned with the values of your hospital, too: we want to save lives, and we want to help families find comfort and meaning in a time of loss. Below, you’ll find information and guidance on the donation process and regulatory compliance, as well as ideas on how you can promote a culture of donation in your hospital.
If you find you have more questions that aren’t answered here, contact our Hospital Development team.
The ideas below can help you spread a donation culture well beyond the ICU. For more ideas, or to share what has worked at your hospital, contact our Hospital Development team.
The following checklist can help you ensure that you’re in compliance before Joint Commission, Health Department, CMS, and other audits.
The checklist below outlines some ways you can improve the donation process at your hospital:
Ensure an early donor referral call every time
Families are usually relieved to find out that their loved one has already declared their wishes with regards to donation, and that the decision has already been made. (In Washington state, for example, more than 75% of licensed drivers have already registered their wish to be a donor.) Families often feel an ethical duty to honor the expressed wishes of their loved one—since giving the gift of life to others, whatever their values or motive, may have been very important to the donor.
If a patient is not a registered donor the donation decision falls to their Legal Next of Kin (LNOK). There is a LNOK decision making hierarchy in every state. Please Click here for frequently asked questions regarding donation and the law, as well as the hierarchies for the states that we serve. LifeCenter Northwest and the hospital will always follow the hierarchy outlined by the state where the hospital is located.
In some cases, families may question their loved one’s designation, and at that point state laws must be followed so that neither LifeCenter Northwest nor your hospital can be held legally responsible for not honoring the patient’s designated wishes.
Below are some of the relevant regulations, but contact our Hospital Development team if you want more information on the legal issues surrounding donation. In general, we have found that in many cases when families question their loved one’s wishes, they just needed better timing or more information. For example:
Donor designation is a documented, legally binding commitment by an individual to make an anatomical gift—and just like a will or testament, it can only be revoked by that individual. Below you can find links to the Uniform Anatomical Gift Act (UAGA) for states in our region:
What are the Conditions of Participation (COP)?
COP is a Centers for Medicare & Medicaid Services (CMS) regulation that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries. The COP that covers organ and tissue donation is intended to increase organ donation and save lives.
All hospitals that receive Medicare reimbursement must identify and refer all deaths and imminent deaths to the Donor Referral Line (for LifeCenter Northwest, 888-543-3287).
Key points:
The COP requires hospitals to:
Does this mean every family will be approached with the option of donation?
Not necessarily. All referral calls are to be placed to the Donor Referral Line prior to approaching the family to evaluate medical suitability. This process ensures that families will only be approached with the appropriate options. For example, if the patient is unable to donate, there is no need to approach the next-of-kin. If donation is an option, the donation agency will facilitate approaching the family. The referral call and outcome must be documented in the patient chart.
Does this mean that all patient deaths must be reported to the Donor Referral Line, despite age?
Yes. All deaths and imminent deaths must be referred to the Donor Referral Line despite age and medical/social history. Calls are to be placed on all ventilated patients prior to withdrawal of support to preserve the option of organ donation.
Watch Alexandra Glazier, JD, MPH CEO, New England Donor Services, discuss Why Gift Law Matters: The Law and Ethics of Donor Designation from the UNOS Region 6 Forum in Seattle, WA
Every hospital across Alaska, Montana, North Idaho, and Washington has a dedicated Hospital Development Program Manager from LifeCenter Northwest.
That representative works to be a respectful, collaborative member of your team, and to help keep you up-to-date on policy and procedure changes relating to organ and tissue donation.