抄訳 USAのドナーコーディネーターの論文「潜在的臓器提供者の判定と照会および臓器提供の承諾:成功率を上げるための青写真」

"Determination and Referral of Potential Organ Donors and Consent for Organ Donation: Best Practice--A Blueprint for Success", Ronald N. Ehrle, Teresa J. Shafer, and Kristine R. Nelson, Critical Care Nurse, Volume 19, Number 2, April, 1999.

2003.09.29. abstracted and translated by てるてる


About the Authors

Ronald N. Ehrle, RN, BSN, CPTC, is the managing director of the North Texas office of the LifeGift Organ Donation Center in Fort Worth, Tex. Teresa J. Shafer, RN, MSN, CPTC, is the executive vice president and chief operating officer of the LifeGift Organ Donation Center in Fort Worth, Tex. Kristine R. Nelson, RN, MSN, CPTC, is the executive director of Life Banc in Cleveland, Ohio.

Ronald N. Ehrle, Teresa J. Shaferは、テキサス州の臓器調達機関 (OPO, Organ Procurement Organization) のドナーコーディネーターである。Kristine R. Nelsonは、オハイオ州のOPOのドナーコーディネーターである。(*註1)

LifeGift Organ Donation Center
Life Banc


The time is long overdue for the collective healthcare community to take a serious look at the dilemma facing everyone involved in organ and tissue donation and transplantation: the organ shortage. Preliminary data from the United Network for Organ Sharing indicate that organ donation in the United States did not increase from 1996 to 1997 (Figure 1), and the number of transplants increased only 1% during that period.1,2 One person on the waiting list in the United States dies every 2 hours. What do these statistics, so often quoted, mean? Consider the following: Of the more than 60 000 patients currently waiting for an organ transplant in this country, about 20 000 will receive a transplant, 35 000 will continue waiting while the disease progresses, and 5000 will die2 (Figure 2).


As the struggle to eradicate the organ shortage continues, donation and transplantation professionals can look back at earlier, more idealistic days, when they thought that the solution was "just over the next hill." Unfortunately, that next hill was a mountain. Twenty years, hundreds of professional and public education campaigns, and a number of legislative initiatives later, the summit is still not in sight. Perhaps the most important and positive lesson that has been learned from this experience is that there is no quick solution; there are no easy answers to the organ shortage.


This article deals with the 2 most limiting factors in organ donation today: (1) failure to determine which patients are potential organ donors and lack of referral of those patients to the organ procurement organization (OPO) and (2) refusal of patients' families to consent to donation.

(1)患者が潜在的ドナーであることを識別するのに失敗し、臓器調達機関 (OPO, Organ Procurement Organization) への照会がないこと

Referral of Potential Organ Donors

National estimates of the number of potential organ donors vary widely, from 5000 to 29 000.3 More recently, the number of medically suitable potential donors was estimated at 13 700.4 The ideal organ donor has an irreparable brain injury, is relatively young, is a trauma patient who is otherwise medically well, and has excellent multiorgan function. Donors who fit these criteria are becoming more and more uncommon because of demographic changes in the US population.5 As the organ shortage has continued, restrictions on donor criteria have been greatly relaxed.6-11

Improved automobile restraint systems and helmet and seat-belt laws have greatly decreased the number of fatal motor vehicle accidents in the past few years, with a concomitant decrease in the number of organ donors among persons who have died under these circumstances. In fact, from 1988 through 1996, the number of organ donors whose circumstance of death was a motor vehicle accident decreased 29%. During the same period, the number of donors whose cause of death was listed as cerebrovascular accident increased 57%. This increase and the relaxed restrictions on donor criteria led to an astounding 611% increase in the number of donors more than 55 years old for the same period.2 These events are but a few of the reasons that the growth in the waiting list has outstripped the supply of organs (Table 1).

Critical care nurses are often responsible for recognizing potential organ donors and then making a referral to their local OPO.13 According to current estimates, 27% of the medically suitable organ donors in the United States are never recognized as potential donors.4 This percentage is alarming in light of the widening gap between the number of patients waiting for transplants and the number of patients who donate organs. The absence of accurate and consistent determinations of which patients are potential organ donors by critical care nurses and physicians has been one of the greatest barriers to increasing organ donation.


Several recent studies14-16 have indicated that hospital staff members and physicians consistently do not recognize certain patients as potential organ donors and thus do not notify the OPO so that a thorough evaluation can be done.14-16 Reasons why hospital staff do not recognize which patients are potential organ donors and refer these patients to the OPO include lack of knowledge about the criteria for organ donation, reluctance to spend the time to get the OPO involved, and uncertainty about how to initiate the donor referral process.


Several attempts have been made to increase hospital referral rates. In the mid to late 1980s, many states passed "required request" legislation that "required" hospitals to ask the next of kin of every potential organ donor to consent to donation unless the patient was medically unsuitable, the family was too emotionally traumatized to be asked, or prior objections to organ donation had been made by the patient.17,18

病院の照会率を上げるために幾つかの試みがなされたことがある。1980年代後半には、多くの州が、"required request"法を通した。これは、次の場合を除いて、すべての潜在的臓器提供者(ポテンシャルドナー、"potential organ donor" )の近親者に臓器提供の承諾を打診することを、病院に「要請する "required" 」法律である。要請が免除されるのは、患者が医学的に不適合であるか、家族が打診されることによって情緒的にあまりに深く傷つくか、患者が前もって臓器提供に反対の意思を示している場合である。

In 1986, the federal government followed with the Omnibus Reconciliation Act, which required hospitals to have processes in place to ensure that all families of potential donors are offered the option of donation.19 The state laws did not have any penalties for failure to comply with required request laws; however, the federal law had the stipulation (although it was never realized) that Medicare and Medicaid funds could be withheld from hospitals that did not comply with required request laws. Despite these sincere efforts by the various state and federal governments, growth in organ donation did not materialize because of the failure to determine which patients are potential donors and, therefore, the failure to refer potential donors, as well as failure to approach all families for donation, even when the patient was a potential donor.

1986年、連邦政府は、Omnibus Reconciliation Actを通して、病院は、すべての潜在的ドナー(ポテンシャルドナー、"potential donor" )の家族に、臓器提供の打診を確認する手続をしなければならないと定めた。州法は、"required request"法に従わなかった場合の罰則がなかった。しかし、連邦政府の法律では、メディケアとメデイケイドの基金が病院から引き上げられるという罰則が付いた(まだ実行されたことがないけれども)。これらの真摯な努力にもかかわらず、臓器提供を増加させることは失敗した。それは潜在的ドナーを識別できなかったからで、それゆえ、潜在的ドナーを照会できず、すべての家族に臓器提供を働きかけるということが、できなかったからである。

Why has the current system not produced the desired results? Although most research in this field has focused on OPO performance20-23 and OPO and hospital programs,24-27 the reality is that the donation system is dynamic, not static, and for any real increases to occur, the OPO and the hospital must have a close, positive, responsive, and simple (user-friendly) system.


Referral systems should be automatic and simple. Donors are lost when hospital staff with limited knowledge of the acceptance criteria for organ donors inappropriately "rule out" potential organ donors as medically unsuitable. Retrospective reviews of the records (charts) of patients who have died while in the hospital indicate that a surprising number of potential donors are not evaluated by OPO staff for this reason. The reasons given for the determination of unsuitability, if any reason is noted in the chart, are many and include age, use of vasoactive drugs, disease (ie, diabetes), cardiopulmonary respiration, and positive cultures.

照会システムは自動的で単純でなければならない。ドナーは、病院のスタッフが、ドナー適合の診断基準について限られた知識しかないと、医学的に適合する潜在的ドナーから不適切に除かれてしまう。("rule out") 患者のカルテを遡及的に調査してみると、驚くべき数の潜在的ドナーが、この理由で、OPOに評価されずにいることがわかっている。

Any patient with a significant and potentially life-threatening injury to the head, whether caused by trauma, an intracerebral hemorrhage, or an anoxic event, should be referred to the OPO as early as possible for evaluation as a potential organ donor. This practice allows the OPO to evaluate the situation and apprise staff members early on about whether the patient is a potential donor. Currently, few medical contraindications to donation are absolute (Table 2). Indeed, the only typical feature of a potential donor today is brain death, and with the increased use of nonheart-beating donors in the United States, even brain death is not necessarily typical anymore.30


Early referral is also key to success in recovering transplantable organs for potential recipients. If an OPO receives a referral from the critical care nurse well after brain death has occurred, decreases in end-organ function will already have taken place. If the OPO is called in only well after the signs of brain death are present, the donor who might have had 5 to 7 organs suitable for donation and transplantation may by that time have only 1 or 2 suitable organs.


Experts have begun to question whether it is reasonable to expect nurses and physicians to keep pace with all of the changes taking place in donation and have developed and implemented systems (sometimes required by law) that do not rely on hospital staff to screen potential donors.


Several states, led by Pennsylvania,31 have passed "routine notification" legislation to address the problem of failure to determine which patients are potential donors. This legislation simply requires that all deaths or deaths that are imminent within a hospital be referred to the Medicare-certified OPO. In other areas of the United States, the OPO, in collaboration with area hospitals, has voluntarily adopted a policy of routine notification.

Pennsylvaniaと、それに続く幾つかの州で、"routine notification"法を通過させた。それは、患者が潜在的ドナーであるかどうかを識別することに失敗する問題を解決するためである。この法律は、病院にいるすべての死者と死が迫っている者とはメディケア公認のOPOに照会するということを単純に要請している。USAの他の地域では、OPOは、地域の病院と協力して、自発的に routine notification の方法を採用している。

Reports from an OPO in Pennsylvania indicate substantial increases in organ as well as tissue and eye donation in the 3 years since implementation of routine notification. Specifically, organ donation in this OPO service area increased 40%,32 while for the same period, donation for the rest of the nation increased only 7.7%.33 Similarly, an OPO in Texas, a state that does not have routine notification laws, worked with its hospitals to voluntarily implement routine notification and experienced a 12% increase in organ donation for the 2-year period after the implementation, an increase that was 352% greater than the national growth in organ donation.34

PennsylvaniaのOPOの報告によると、臓器・組織の提供は、routine notificationを実施してからの3年間でかなり増加した。特に、このOPOがサーヴィスの対象としている地域では、臓器提供が、40%増加した。一方、同じ時期に、USAの他の地域では、7.7%しか増加しなかった。
同じように、TexasのOPOでは、州がroutine notification法を採用していないが、病院が自発的にroutine notificationを実施して、2年間で臓器提供を12%増加させた。

Largely because of reports such as those just mentioned, the Health Care Financing Administration issued Hospital Conditions of Participation for Medicare and Medicaid on June 22, 1998, which required all US hospitals to adopt a routine notification policy effective August 21, 1998: "The hospital must have and implement written protocols that: . . . it must notify, in a timely manner, the OPO . . . of individuals whose death is imminent or who have died in the hospital."35 These new regulations, in essence, require all acute care hospitals to notify their local OPO of all hospital deaths.

Hospital Conditions of Participation for Medicare and Medicaid が、1998年6月22日に、Health Care Financing Administrationを制定したので、すべてのUSAの病院は、1998年8月21日から、routine notificationを採用しなければならなくなった。「すべての病院は、以下に記述せる手順を採用しなければならない。病院で死期が迫っている者または死者は、OPOに、適時、通知しなければならない。」この新しい法律は、本質的に、すべての急性期治療病院に、地域のOPOへ死者を通知することを要請している。

Routine notification ensures that a person who is familiar with the most current criteria on donation will evaluate every death. If followed consistently, a policy of routine notification would make it virtually impossible for the hospital not to refer all potential organ donors.

routine notificationによって、最も新しい臓器提供の診断基準をよく知った人間が、すべての死者を評価できる。routine notificationの政策に従えば、病院は、すべての潜在的ドナーを照会しないでおくことは不可能になる。

The role of critical care nurses in referring potential donors is of key importance in actualizing the provision of these new regulations. Once it has been determined that a patient has not had a survivable neurological event and that brain death is imminent, the OPO must be contacted. The OPO needs time to work with nurses and physicians to evaluate the patient's eligibility as an organ or tissue donor. Once death has been declared and the OPO has been determined that the patient is a suitable donor, a plan to approach the family to request consent for donation is created.


Request for Consent

Family refusal to provide consent for donation is the most common reason that organs of medically suitable potential donors are not recovered. According to estimates, 35% of the medically suitable organ donors in this country do not donate because the family of the potential donor refuses to consent to donation.4 Although personnel in the donation and transplantation community would like for all families to consent to donation when approached, these personnel understand and respect that not all families will donate. However, the healthcare community can improve the way in which families are approached for donation and can decrease the number of families who refuse. A recent study36 of donor and nondonor respondents showed that approximately one third of the nondonor respondents would not make the same decision again-that is, they would instead agree to donate.


Why do public opinion polls indicate that 86% of Americans would be inclined to donate if asked,37 yet only 40% to 50% actually says yes when approached?33 Do Americans say they would donate because it is the right thing to say at the time, or is the way in which families are approached so unfeeling that they are turned off to the idea of donation? In a report38 from one pediatric intensive care unit, parents of children who died suddenly in the unit said that the difficulty experienced at the time of their child's death revolved around the abrupt impersonal, formal staff reactions and the lack of communication. Both OPO staff and hospital staff must be very sensitive to a family's communication needs at such stressful times.


Consent for donation is considered by many to be the true outcome measure of efforts of hospitals and donor programs to increase organ donation.39 In the past 2 decades, literally hundreds of articles have been written on the topic of organ and tissue donation. Most of these studies focused on the period before anyone's family member was brain dead and provided limited baseline information only. In more recent studies, researchers have begun to examine the situational and the demographic variables that correlate with an increase in donation.



When to Approach

The answer to the question of when to approach is usually: not yet! Unfortunately, nurses often indicate a need to rush in, offering the option of donation before the family has been able to comprehend that the family's loved one is dead.42 It is easy to imagine the kind of message that is sent to families when they are approached about donation before being informed that their loved one has died. This type of premature approach validates the fear, often verbalized by the general public, that hospitals are more concerned about obtaining organs than they are about saving patients' lives. A premature approach can hurt both the donor's family and waiting recipients.


The timing of the request-when the request is made-is one of the most critical elements of the family request protocol. First and foremost, the request for donation must be decoupled if at all possible. The premise behind decoupling is that the family must first acknowledge that death has occurred before the subject of donation is introduced. For the most part, families are making an unfamiliar journey when a loved one dies. Family members have no clear idea about what is coming next or what role they will play. Generally speaking, family members do not outwardly verbalize that their loved one has died. Nurses should be attuned to signs that indicate that the family is finding it difficult to cope with the death of its loved one. Such signs might be denial of the seriousness of the illness or injury, disagreements between family members, or pressure for treatment at all costs.


When families comment that their loved one "never wanted to be kept alive on machines," "this is no kind of life," "he's not there," or "he never wanted to live like this," they may be beginning to understand the grave prognosis. Nurses should use these comments as opportunities to ask questions in order to better understand what the family knows and understands and what family members want to know. In addition, family discussion of do-not-resuscitate orders may indicate that the family is beginning to understand that death is imminent. However, these comments should not be used as an indication that the family is ready to talk about donation.


Procurement professionals are often asked how much time should elapse before the subject of donation is introduced. Ideally the answer should be, "However much time the family needs." Unfortunately, the clinical status of the potential donor, the number of patients in the treatment unit, and economics do not always allow procurement professionals and hospital staff to practice in the ideal. Families who have been informed about the possibility of brain death and who have had this information reinforced up to the time of actual pronouncement of brain death are at a different stage than are those families who are told about brain death for the first time when the physician tells them the results of the cerebral blood flow study or apnea test.


The latter family will need more time and explanation about their loved one's hospitalization and prehospitalization period before the topic of donation is introduced. Explanations of the various clinical and diagnostic tests for brain death before and after such tests are performed, as well as of the cause of brain death, are essential to help families understand brain death.


Some families have commented that visual aids such as simple drawings have helped them understand brain death. Nurses know that in highly charged emotional situations, assimilation of information is often imperfect, and therefore, repeated explanations of the situation may be needed. Families may use the terms that have been explained to them, but healthcare professionals should exercise caution in assuming that family members understand such terms.


The amount of time between the conversation surrounding brain death or pronouncement of death and the request for donation depends on the events and the nature of communication between the staff and family members up to this point. Results of one study63 indicated that consent for donation occurred 71% of the time when the conversation was decoupled, as opposed to only 47% of the time when the conversation was not decoupled. In another study44 of the consent process, a 78% consent rate was reported when donation was discussed after notification of death.

ある研究によると、臓器提供の承諾は、死亡宣告と臓器提供の要請との間に時間がおかれていたときには、71%, 反対に同時だったときには、47%である。別の研究では、死を認めた後で臓器提供について話をすると、78%の承諾率だったという。

Where to Approach

A patient and his or her family have the right to consideration of privacy.64 Nurses are advocates for patients and often try to provide a private area for families who are receiving serious news or discussing highly personal issues. It is therefore distressing that many families are approached about donation in a crowded waiting room; in the hallway outside the patient's room; at the nurses' station; or, worse yet, at the patient's bedside. It is self-evident that the conversation surrounding donation should take place in a quiet, private setting (Table 5).


Many families are aware of organ donation, but the family members are often not knowledgeable about organ donation. Family members are more likely to disclose and ask questions in a private setting. If donation is a possibility, a private area should be found and prepared for the family. This simple but critical intervention can increase donation by 24%.63




註1: "Organ Procurement Organization, OPO"は、病院にコーディネーターを派遣し、臓器"organ"や組織"tissue"を受け取り、移植センターに届ける民間非営利団体である。

各地域ごとのOPOの代表が集まった連絡協議会が、"Association of Organ Procurement Organizations, AOPO"である。

USA全体の移植センターを結んで臓器・組織の公平な分配と流通を図る民間非営利団体が、"UNOS:United Network for Organ Sharing"である。

UNOSは、"National Organ Transplant Act, NOTA"に基づいて、"The Organ Procurement and Transplantation Network, OPTN"を統括運営する。OPTNは連邦議会が設立した機関で、USA全体の移植待機患者の登録情報を蓄積している。

註2:この論文は、1999年に発表されているので、臓器不足などのデータは、それ以前のものである。現在は、臓器の不足は更に進行している。 UNOSのサイトの最初のページには、臓器移植待機患者数と、半年ごとの移植件数と臓器提供件数が標示されている。

Waiting list candidates 82,786 as of today 4:31am
Transplants January - June 2003 12,513 as of 09/26/2003
Donors January - June 2003 6,464 as of 09/26/2003


「脳死・臓器移植」専用掲示板過去ログハウス 2001年05月07日〜05月13日



スペインの移植コーディネーター(Transplant Coordinator, T.C.)
てるてる翻訳 2000年12月29日、2001年1月4日改訂

"transplant community" の二つの意味
てるてる著 2001年4月23日