Organ Donation
The UK operates an opt-out (deemed consent) system for organ donation since 2020, managed by NHS Blood and Transplant, with specialist nurses in organ donation approaching families to discuss donation after death is confirmed.
Key Facts
Deemed consent (opt-out) system introduced in England in May 2020 (Organ Donation (Deemed Consent) Act 2019 — 'Max and Keira's Law') Adults are deemed to have consented to organ donation unless they have opted out or are in an excluded group Excluded groups: under 18s, those lacking capacity, those not ordinarily resident in England for ≥12 months, those in excluded relationships Even with deemed consent, families are always consulted and their views given significant weight Approximately 7,000 people are on the organ transplant waiting list at any time; approximately 400 die each year waiting Specialist Nurses in Organ Donation (SNODs) lead family conversations and coordinate the donation process Donation after brainstem death (DBD) and donation after circulatory death (DCD) are the two pathways Living donation is possible for kidney (most common) and partial liver transplantation
Overview
Key Facts
Organ donation saves approximately 3,500 lives per year in the UK. The shift to an opt-out system aims to increase donation rates and reduce the gap between supply and demand. Healthcare professionals play a key role in identifying potential donors and supporting families.
Legal Framework
- Organ Donation (Deemed Consent) Act 2019: opt-out system for England
- Human Tissue Act 2004: regulates removal, storage, and use of human tissue; Human Tissue Authority oversees
- Similar legislation: Wales opted out in 2015; Scotland in 2021; Northern Ireland in 2023
- Living donation: regulated under Human Tissue Act; requires independent assessment and HTA approval for non-directed donation
Opt-Out System
- All adults deemed to consent unless they: opted out on NHS Organ Donor Register, are in excluded group, or appointed a representative who objects
- Family is always consulted and involved
- 'Deemed consent' does not override family objection in practice
Types of Organ Donation
- Donation after Brainstem Death (DBD): brainstem death confirmed on ventilator; organs maintained by cardiovascular support until retrieval
- Donation after Circulatory Death (DCD): death confirmed after cessation of circulatory function; organs retrieved rapidly after death
- Living donation: kidney (most common), partial liver; requires HTA-approved assessment
Organs and Tissues That Can Be Donated
- Organs: kidneys, liver, heart, lungs, pancreas, small bowel
- Tissues: corneas, skin, bone, tendons, heart valves, blood vessels
Clinical Presentation
Identifying Potential Donors
- Any patient whose death is anticipated in ICU/critical care and who may be suitable for donation
- Patients with catastrophic brain injury where brainstem death testing is being considered
- Patients where withdrawal of life-sustaining treatment is planned (potential DCD)
- Referral to SNOD should occur when death is anticipated, regardless of donation status
Brainstem Death Testing
- Two senior clinicians (one must be a consultant; neither involved in transplant)
- Performed twice with an interval
- Tests: absent pupillary response, absent corneal reflex, absent vestibulo-ocular reflex, absent motor response to central stimulation, absent cough reflex, apnoea test
- Legal time of death: first set of tests
Approach to Family
- SNOD-led conversation (collaborative requesting)
- Explore patient's wishes, beliefs, values
- Check NHS Organ Donor Register
- Explain donation options
- Provide time and support for family decision
- Even with opt-out, donation will not proceed against family's wishes in practice
Differential Diagnosis
| Pathway | Criteria | Process |
|---|---|---|
| DBD (brainstem death) | Confirmed brainstem death on ventilator | Maintain organ perfusion → retrieval in theatre |
| DCD (circulatory death) | Planned withdrawal of treatment; death anticipated | Withdraw treatment → confirm death → rapid retrieval |
| Living donor (kidney) | Healthy adult, voluntary, assessed | HTA assessment → nephrectomy → transplant |
| Tissue donation | Any death (wider eligibility than organ) | Corneas, bone, skin, heart valves within 24-48h of death |
Diagnosis / Investigation
Pre-Donation Assessment
- Blood group, tissue typing (HLA)
- Virology screen: HIV, hepatitis B/C, HTLV, CMV, EBV, syphilis
- Assessment of organ function: U&Es (kidneys), LFTs (liver), ABG/CXR (lungs), echo (heart)
- Donor history: malignancy, infection, high-risk behaviours
- Brain death testing (for DBD)
Allocation
- National Organ Allocation Policy (NHS Blood and Transplant)
- Prioritised by: clinical urgency, waiting time, HLA match, sensitisation
- Super-urgent listing for life-threatening conditions
Management
Healthcare Professional Responsibilities
- Refer all potential donors to SNOD (mandatory referral policy in most trusts)
- Support family conversations alongside SNOD
- Maintain potential donor on organ support until retrieval (DBD)
- Ensure accurate documentation of brainstem death testing
- Provide bereavement support to families
- Be aware of cultural and religious considerations around organ donation
Ethical Considerations
- Respect for autonomy (patient's expressed or deemed wishes)
- Non-maleficence (no harm to living donors)
- Justice (fair allocation of scarce organs)
- Dead donor rule: organ retrieval must not cause the death of the donor
- Opt-out: balances increasing donation with respecting individual choice
- Religious views: most major religions support donation; some individuals may object
Referral Criteria
- Refer all patients where death is anticipated in ICU/critical care to SNOD
- Living donor assessment: refer to transplant centre
- Complex cases (e.g. known objection vs family wishes): SNOD and clinical ethics
Prognosis
- Organ transplant survival: kidney 1-year graft survival >95%; liver >90%; heart >85%
- Approximately 3,500 organ transplants performed annually in UK
- Approximately 400 people die each year waiting for a transplant
- Opt-out system expected to increase donation rates by 20-25% over time (based on Welsh experience)
- Living donor nephrectomy: mortality risk approximately 1 in 3,000; long-term kidney function well-preserved
- Each organ donor can save or transform up to 9 lives (organs) and benefit up to 50 people (tissues)
Other Relevant Information
Deemed Consent (Opt-Out) System Summary
| Status | Donation Proceeds? |
|---|---|
| Opted in (on register) | Yes (with family consultation) |
| No decision recorded (deemed consent) | Yes (with family consultation) |
| Opted out (on register) | No |
| Excluded group | No deemed consent; explicit consent needed |
| Family objects (despite deemed consent) | In practice, donation unlikely to proceed |
Religious and Cultural Views
| Religion | General Position |
|---|---|
| Christianity | Generally supportive |
| Islam | Most scholars supportive; some require explicit consent |
| Judaism | Generally supportive (pikuach nefesh — saving life) |
| Hinduism | Generally supportive; individual decision |
| Sikhism | Generally supportive |
| Buddhism | Generally supportive; individual decision |