The Lewin Group, Inc. for
the Office of the Assistant Secretary for Planning and Evaluation
BACKGROUND
The purpose of this report is to provide an introductory analysis of state legislative actions related to organ and tissue donor registries. This analysis focuses on describing the current state legislation on donor registries, comparing legislation among the various states, and how such policies may enhance or hinder efforts to develop, modify, and link statewide donor registries.
Access to organ transplantation remains limited by the shortage of donated organs. In 1998, 16,945 individuals received cadaveric organ transplants. In that same year, only 5,791 deaths, out of an estimated potential of 8,000-15,000 donors, resulted in donation. Another 4,122 individuals were living donors, mainly of kidneys. Despite these contributions, 4,855 patients on waiting lists died while awaiting transplantation in 1998.
Major barriers to donation have included low rates of family consent to donation and missed opportunities to identify and refer all potential donors to procurement organizations so that families may be approached. Although the latest national Gallup survey indicated that 85 percent of Americans support organ donation for transplants, studies indicate that only about 50 percent of families consent to donating a loved one’s organs when presented with the opportunity. Most polls also indicate that knowledge of the decedent’s wishes to donate would positively influence the family’s decision to consent to donation. Moreover, a 1996 study of potential organ donors in hospitals found that in nearly a third of all cases, potential donors were not identified or no request was made to the family (Gortmaker et al. 1996). The number of potential eye and tissue donors far outnumbers potential organ donors, and many more families consent to donating eyes and tissues. Some state laws allow recovery of corneas with the consent of a medical examiner or coroner, without family consent.
Efforts to increase organ donation have included public and professional education and training of donation requestors, as well as various federal and state legislative measures (e.g., routine referral, the use of donor cards to indicate a preference for donation, and development of donor registries). In 1968, the National Conference on Commissioners on Uniform State Laws drafted the Uniform Anatomical Gift Act (UAGA), which established standards for organ donor cards, prohibited sale of organs, and designated attending physicians as custodians of donated tissues and organs. Every state had adopted the act by 1972.
Many state UAGAs provide that a wallet-sized donor card, signed by an individual of at least 18 years of age in the presence of two adult witnesses, is a legal instrument in permitting authorized medical personnel to remove organs and tissues after death. In many states, documentation of intent to become a donor (or conversely, to be a non-donor) is entered into a donor registry database. Under the appropriate circumstances, hospital and/or other procurement personnel are then able to access this database to determine a decedent’s donation wishes and, in principle, act upon those wishes as an advance directive.
Unfortunately, organ donor cards (or, similarly, the affirmative designation found on drivers’ licenses in many states) have not had a substantial effect on increasing the supply of organs and tissues available for transplantation. Although a donor card or a donor designation on a driver’s license meets the legal requirement of an advance directive, many health provider personnel are reluctant to rely solely on the donor card for authorization to remove organs for transplantation purposes. Instead, in response to public concern after the passage of many state UAGAs, many requestors have set a de facto precedent of seeking consent from families before donation takes place. Reasons commonly given for ignoring a valid donor document and seeking consent from the family include: respect for the family in their time of grief, the need for a donor medical and social history, fear of bad publicity, unease about litigation, and concern about whether the decision to sign a donor card is based on informed consent (Wright, 1998). As the organ and tissue donation process has evolved, the public has come to expect that a family’s consent will be sought as an essential step in the donation process. The result is that in current practice, signed donor documentation often does not ensure that an individual’s wishes will be carried out as an advance directive.
The United Network for Organ Sharing (UNOS) commissioned the "Advance Directives and Donor Card Effectiveness Survey Report" in June 1997 to "examine the feasibility and legal ramifications of enforcing the wishes of deceased individuals who possess validly signed and witnessed organ donor cards or other forms of advance directives" (Wright, 1998). Among other findings, the survey determined that hospital and organ procurement organization (OPO) staff attitudes toward the use of advance directives potentially undermine legislation enacted in this area. Results indicated that donation is rarely performed without consent of the next of kin, reflecting a hesitancy on the part of the medical community to use donor cards as advance directives. Wary attitudes on the part of the donation community or hospital staff could diminish the effectiveness of even the most rigorous donor registry efforts. Moreover, the study found that 60% of responding OPOs did not know whether a potential donor had directives, and 47% to 60% were found to rarely check for advance directives (i.e., any evidence of a deceased person’s donation wishes). In contrast to these results, substantial support among OPOs was demonstrated for the use of donor registries. Twenty-six percent of OPOs use a donor database, and another 26% would utilize one if it were created. Of those OPOs responding, 49% stated that a state or national registry would be a useful tool.
A broader issue related to donor registries is that in order for an intention to donate (evidenced by inclusion in a registry database) to be used as an advance directive, the decision to consent must be adequately informed. Guarantees must therefore exist ensuring that the individual signing a donor card or checking the affirmative box on a driver’s license application is doing so after having been provided all relevant information. Provision of accurate and comprehensive information to the individual at the time of donor document signing would, at least from a legal standpoint, diminish or eliminate the need for obtaining consent from the next of kin at a later time. Under these conditions, the family would be informed of the decedent’s wishes rather than being asked to consent.
METHODS
The Lewin Group conducted a thorough search for information about donor registries, advance directives, and informed consent (see Appendix A). Our search involved using the legislative search engine of the Health Policy Tracking Service of the National Conference of State Legislatures, search engines (if available) of individual states, and other sources via the World Wide Web. We also searched the DIALOG database (legislative and legal citations) for relevant articles in gray literature. Other sources included the Louisiana Organ Procurement Agency 1997 Report of State Legislation, covering state actions from the early 1990s to 1997, as well as documentation provided by registry representatives from the states in attendance of the conference, "Are Donor Registries Advance Directives?: Developing, Linking, Modifying Statewide Donor Registries," held in New Orleans, Louisiana, July 27-28, 1999 (see Appendix B). Lastly, the members of the Association of Organ Procurement Organizations were polled and solicited to submit copies of legislation each was utilizing to support development of local donor registries.
KEY FINDINGS
A number of key state actions have affected the development and modification of statewide donor registries in recent years, with most recent legislative efforts being directed primarily at increasing donation rates and addressing allocation issues. This section focuses on those state actions that most directly affect donor registries, which involve the following topic areas:
- Public awareness and education
- Registries as advance directives
- Informed consent
- Access to registry information
- Maintenance and technical aspects of registries
- Role of medical examiners
- Additional donor cards
- Evaluation of Registries
Appendix B provides a comprehensive listing of state efforts, arranged according to each of these topic areas.
Public Awareness and Education
Donor registries are often used as tools to increase public awareness and general knowledge regarding organ and tissue donation and transplantation. Four issues are related to the use of registries as public awareness tools: the method by which the message is conveyed, the choice of audiences to be targeted, evaluation of the success of awareness and education campaigns, and the development of public trust as a primary goal. Many states have taken actions to facilitate general awareness of organ and tissue donation, and to publicize the existence of the donor registry. Such actions include the following.
- States that provide the option of making a voluntary gift to fund donor awareness and educational programs at the time of driver’s license renewal include: Alabama, Colorado, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Kentucky, Maryland, Michigan, Missouri, Montana, Nebraska, Nevada, Ohio, Pennsylvania, South Carolina, Tennessee, and Texas.
- Arkansas, Louisiana, and Missouri have created multimedia donor awareness campaigns that use posters, television commercials, and radio advertisements.
- Florida and Missouri have created youth education programs in the secondary school system.
- Iowa allows county treasurers to collect funds for awareness grants.
- Louisiana and Michigan have educational sessions and registration information at many public events such as art and health fair booths, church programs, and driver’s education training.
- Ohio is considering implementation of an educational program that would automatically send donor information to individuals as a birthday card.
- Oregon sells special license plates to raise funds for donor awareness and education programs.
- Pennsylvania allows individuals to contribute to a donor awareness fund on income tax return forms.
- Louisiana has a statement of need in the state driver’s license manual.
Registries as Advance Directives
Registries as Advance Directives
For some states, one goal of donor registries is to provide medical and/or procurement personnel easy access to the donation wishes of brain-dead patients, thereby allowing such personnel to act on those wishes as an advance directive. The primary method by which individuals make their wishes known is by indicating a preference on a driver’s license or signing a donor card. In those states having a donor registry, this also enters that individual into the registry database. However, designation on a driver’s license or other donor documentation, or documented donation wishes in a state registry (if applicable), are rarely implemented as legally binding. This remains an important issue in a number of states, and many have taken legislative actions to affirm the legal strength of such documentation as advance directives. In most states, however, this issue remains unresolved.
- States with legislation that reaffirms a signed license as an advance directive or more specifically protects OPOs, hospitals, and tissue and eye banks in carrying out individuals’ advance directives without further consent include: Colorado, Connecticut, Delaware, Florida, Iowa, Illinois, Maryland, Missouri, Pennsylvania, and Tennessee.
- In 1996, California implemented legislation allowing hospitals to use a decedent’s organs, tissues, or corneas for transplantation without next of kin consent after a "reasonable," yet unsuccessful, search for the next of kin. In 1998, the state revised the law by requiring consent for corneal donation, but not for organs or tissues.
- Arkansas expanded the method of donation consent to include a documented telephone message witnessed by at least two people.
- States with legislation that officially created donor registries through the divisions of motor vehicles include: Arkansas, Connecticut, Delaware, Florida, Illinois, Louisiana, Missouri, New Jersey, Pennsylvania, and Tennessee.
- California created a donor registry through its Department of Health and Human Services.
- Colorado, Delaware, the District of Columbia, Illinois, Maryland, Pennsylvania, and South Carolina indicate willingness, but not a refusal, to donate on their licenses.
- Texas recently passed legislation to eliminate donor status from licenses.
- States with laws specifying a prioritized list of next of kin that may authorize an anatomical gift in the absence of a documented advance directive include: Arizona, Florida, Georgia, Maryland, South Carolina, Vermont, Virginia, Washington State, and Wisconsin.
- Utah requires that the next of kin sign a form indicating that they were asked to give consent to donation.
- Nebraska may eliminate the requirement for a witness when an individual is making an advance directive.
- South Dakota enacted a measure which requires law enforcement personnel having access to the decedent’s driver’s license to inform any person having lawful custody of the body of the decedent’s wishes regarding organ and tissue donation. This enactment expands South Dakota’s previous measures, which required law enforcement personnel to inform only the next of kin, the attending nurse, or the attending physician.
- Connecticut and Minnesota specify that an individual legally authorized to make health care decisions for the decedent prior to death (i.e., a health care agent) may give consent to donation.
- Tennessee requires law enforcement personnel to make a reasonable search for a decedent’s license at the scene of an incident.
- Texas law requires that all hospitals obtain consent from the next-of-kin even when there is a clear and valid advance directive to donate.
- In Utah, where the donee is defined as an "organ procurement entity," a law specifies that "the rights of the donee are superior to the interests of others." For example, if an anatomical gift is designated to a specific OPO, no other OPO can supersede the rights to that gift.
- South Carolina and Wisconsin have very similar legislation to that of Utah, but include OPOs, individuals, hospitals, and surgeons in the definition of the donee.
- Louisiana uses a common state consent form, requiring appropriate documentation and next-of-kin signature, which ensures that the next-of-kin was provided the option of donation; a copy of this document is provided to the next-of-kin.
Informed Consent
For both legal and ethical reasons, it is necessary that the public be properly informed regarding organ and tissue donation before individuals decide to become organ and/or tissue donors. Assurances that an informed consent process is in place strengthen the ability to use donor documentation as an advance directive. No state has yet established clear legal or ethical standards for the minimum amount of information necessary to consider the decision to donate an informed one. Instead, state actions have focused on the method by which the public is informed about the donation process, standards surrounding signing donor documentation (i.e., in the presence of a notary public), and assurances of supplying adequate information to those making a decision.
- California, Colorado, the District of Columbia, Illinois, Maryland, Michigan, Missouri, Tennessee, and Virginia provide pamphlets, display posters, and/or show looped videos about organ donation at the time of driver’s license renewal, when individuals are asked to be donors.
- The District of Columbia, Massachusetts, and Rhode Island have laws requiring that donor information be included with the driver’s license renewal notice sent to license holders.
- Rhode Island requires notary public approval on organ donation cards.
- Most states require an individual to be at least 18 years of age for an advance directive to be legitimate without a parent’s consent. However, New Mexico and Washington State have laws that allow an individual 16 years of age or older to make an anatomical gift without parent’s consent.
- Georgia reduces driver’s license fees for those who become donors.
- The Illinois and Maryland divisions of motor vehicles send out "thank-you" letters to individuals who agree to be donors, in part to confirm their donation decision.
- Louisiana provides both extensive training and a standardized consent form detailing the specifics of donation to division of motor vehicles personnel in the position to speak with the public about donation. Additionally, Louisiana verifies donor consent via a follow-up mailing reiterating information initially provided at the division of motor vehicles.
Access to Registry Information
Because access to registry information is closely tied to public concern over protecting privacy, access must be limited only to those with the proper authority to view the information. Further, a mechanism must be in place to confirm that those individuals accessing the registry database are authorized to do so. Universal agreement does not exist for who should have access to a state donor registry data, or the most efficient method for accessing information from the database. States concur that OPOs should have access, but the extent to which hospital staff, tissue and eye bank personnel, and law enforcement personnel should have access remains unresolved. Several types of state actions have been implemented addressing these issues.
- Arkansas, Florida, Georgia, Hawaii, Illinois, Louisiana, Pennsylvania, and Tennessee have passed provisions that ensure 24-hour access to the divisions of motor vehicles’ donor registries via a toll-free 800-number number or through the World Wide Web.
- In Indiana, registry information is accessible only to law enforcement personnel.
- In the District of Columbia and Maryland, OPOs are able to call the state police to check donor status 24 hours a day.
- In Missouri, OPOs and eye banks have only limited access to registry information.
Role of Medical Examiners
The responsibility of the medical examiner is to determine the cause of death by performing an autopsy on the decedent’s body. Medical examiners typically have a great deal of authority over the disposition of a body, and therefore have the potential to take a key role in the donation process. Only two recent state legislative actions have significantly addressed the role of medical examiners in the donation process. First, in New Jersey and in Texas, medical examiners are required to justify their decision to deny the use of certain organs for donation. This situation is particularly relevant in cases of infant death, in which the cause of death may be less clear, and necessitate further investigation of the body (e.g., Sudden Infant Death Syndrome or child abuse). A second legislative action involves the state of Iowa, where medical examiners are able to authorize donation without next of kin consent.
Additional Donor Cards
Two broadly categorized hard-copy methods of donor documentation currently exist to record an individual’s donation wishes. The first is a donor card, specifically designed to outline an individual’s donation wishes, and signed by the individual. The second method is designation on a state-issued driver’s license, usually noted on the front of the license in a conspicuous location. Thirty states currently use donor cards in addition to a driver’s license designation, while three states (California, New Jersey, and North Carolina) use donor cards in lieu of driver’s license designation. However, no recent legislation exists that significantly affects the use of donor cards.
Maintenance and Technical Aspects of Registries
A great degree of disparity currently exists regarding the developmental stages of state donor registries. While a small number of states have a well-developed registry, most states are in only a rudimentary stage of development of a computer-based registry database. The first step in developing a state donor registry is determining where the database is to be housed. Registries may be housed in the OPO, a division of motor vehicles, a state department of health, the state police, or a managed care organization. Compatibility between the various entities that will utilize the registry must be established as the second step to developing a registry – compatibility both in terms of how the information is stored in the database and the interfacing of hardware and software used to maintain the database. Finally, mechanisms must exist for keeping the database up-to-date, including purging those individuals that pass away or opt out, and entering new individuals that have joined.
Recent state legislative efforts that have addressed various parts of this process are outlined below. One innovative effort made by a small number of states is to include images of donor documentation in the registry database, which provides a visual representation of the potential donor’s handwriting, a potentially effective tool in helping next of kin to appreciate their loved one’s wishes. Other efforts include the following.
- The Arkansas State Revenue Department computer system downloads driver’s license information on a monthly basis to the state donor registry.
- In California, the registry enrollment form is posted on the state’s health and human services Web site.
- Florida law allows funds from a procurement trust fund to be allocated towards helping to maintain the state registry. The state’s registry contains images of donor wills and signatures.
- Georgia has an advanced technological registry that allows data to be entered via a computer keyboard, magnetic tape, or document scanners.
- A field is provided in the Illinois driver’s license database which links to the state registry database.
- The Louisiana registry database allows individuals to selectively designate specific organs and tissues to be donated and search for information about blood and marrow donation.
- The Michigan registry includes a captured image of signed donor cards.
- The Missouri Department of Health maintains the state’s registry.
- The Texas Living Bank National Registry has contracted with a private firm to develop and maintain its computerized registry database.
Evaluation
Evaluation is necessary to ensure that efforts to develop registries or improve other aspects of the donation process are effective and useful. Nine states are currently evaluating various aspects of the donation process. The common goal of these evaluations is to understand how well public education initiatives and donor registry programs are being implemented (i.e., process evaluation), and to determine if these efforts are effective at increasing public awareness, and ultimately, donation rates (i.e., outcome evaluation).
- Arkansas conducts ongoing analyses of donor registrant demographics and audience-specific effectiveness of the state’s television advertisement campaign.
- Hawaii enacted a law that, among other provisions, established an advisory committee on anatomical gifts within its department of health and requires hospitals to allow death record reviews.
- Louisiana recently passed two resolutions, one geared toward studying the feasibility of paying the bereaved family’s funeral expenses, and a second designed to study the impact of coroner activities on donation. In addition, the Louisiana OPO is funded by the National Institutes of Health (NIH) to conduct an analysis of division of motor vehicles data from the Louisiana State registry, to study a new consent model, and to track the effects of its multimedia advertisement campaign. Housing of the registry within the OPO facilitates tracking the impact of registering donors and use of the registry in actual donations.
- Missouri conducted the "Arc Survey," which probed public awareness regarding the donation process.
- North Carolina passed a law that directed the state’s department of health and human services to study the development of statewide donor registries. The state also is evaluating the effect of "postcard" reminders for driver’s license renewal that contain organ donation information.
- Ohio intends to measure the relationship between a general willingness to donate and public education.
- Rhode Island recently accepted a measure to extend a Special State House Commission that is in the process of studying organ donation.
- Texas passed a law creating a public task force that will report in December 2000 on issues relating to organ allocation.
- Virginia passed two resolutions, one stipulating the development of plans to increase public awareness of organ donation, and another requiring a Joint Commission on Health Care to look at other organ donation issues.
DISCUSSION
This section outlines implications of the recent applicable state legislative actions. In some cases, state legislative efforts may represent obstacles to the evolution of registries, although the majority of state actions are expected to enhance the development, modification, and possible linkage of state donor registries. This discussion also includes identification of issues related to the donation process that might be clarified with further state legislation (e.g., more clearly defining the functions of the registry, or developing minimum levels of information necessary to establish informed consent).
Potential Barriers and Solutions to the Development, Modification, and Linkage of State Registries
Public Awareness and Education
State legislation affects the development of registries through public education in three general ways: increasing opportunities to make a financial gift to donor awareness trust funds, expanding organ and tissue donation educational programs to schools and public events, and creating multimedia campaigns. Increased funds and wider educational efforts should increase the number of individuals aware of organ and tissue donation and augment the number of people who indicate a willingness to become a donor. Increased public awareness of donation and donor registries could potentially lead to greater state support and a more effective donor registry system. The success of these varying educational and public awareness programs should be evaluated to ensure an effective methodology and efficient use of resources.
Registries as Advance Directives
Many states only recently took the initiative to create donor registries intended to function as official documentation of advance directives. Most often housed in the state divisions of motor vehicles, registries are intended to officially represent the posthumous donation wishes of individuals, and therefore to be acted upon without further consent from next of kin. However, if the actual implementation of these more recently developed registries remains dependent upon seeking next of kin consent as it does in practice in other states, such donor registries will not serve effectively as advance directives.
Some states with existing registries have taken actions to strengthen their ability to use the registry as an indication of an advance directive. Though states have taken different approaches to this issue, a clear and definitive statement regarding the specific purposes of the registry (e.g., education, procurement, demographic tracking) is a necessary first step in providing direction for change. Legislation explicitly diminishing or eliminating liability of hospital and procurement personnel who carry out the advance directive may be more effective than legislation eliminating the necessity of next of kin consent. In this latter case, hospital and procurement personnel often will remain wary of litigation, even in cases of a clear and valid advance directive.
Two additional legislative categories exist that have proven to be important in strengthening registries as advance directives. First, a small number of states require law enforcement personnel to make a reasonable search for the decedent’s driver’s license (or other donor documentation) at the scene of an incident. These actions increase the likelihood that an individual’s wishes would be determined and acted upon (either as a donor or a non-donor), and reduce time wasted in trying to determine donation wishes at the hospital, when crucial personal documentation may already have been lost. While this legislation is more applicable to the donation process as a whole, it clearly demonstrates support for ensuring knowledge of a decedent’s donation wishes, indirectly bolstering prominence of a registry in the donation process. Second, three states stipulate that donee rights are superior to the interests of all others. This legislation reinforces the right of OPOs, hospitals, surgeons, and individuals to carry out the decedent’s designation of an anatomical gift. Ultimately, this legislative support of advance directives may provide a further incentive to develop state registries as an effective tool in demonstrating the wishes of the potential donor.
While many state actions help registries function as advance directives, three areas of legislation create potential barriers to this function. A number of state actions creating or expanding a prioritized next of kin list further reduce the effectiveness of donor registries by increasing the number of people who must be found and consulted by hospital or procurement personnel. This can reduce the strength of the stated advance directive in the registry, and may waste valuable time in the donation process. Because current practice often is to ignore valid donor documents and seek consent from the family, an expanded prioritized list would further hinder procurement personnel (i.e., OPO, eye and tissue bank, and hospital staff) from carrying out an individual’s wishes.
Two state actions in Texas present potential barriers to use of registries as advance directives. One law requires that all hospitals obtain consent from the next of kin even in cases in which the individual’s wishes to donate are valid and clear. This directly undermines the function of advance directives. A second measure eliminates the printing of donor status on drivers’ licenses. This action renders the donation process less transparent and efficient by making individuals’ wishes less accessible.
Informed Consent
State legislation has not clearly established legal or ethical standards for the minimum amount of information an individual needs prior to making the decision to become a donor or to remain a non-donor. Nonetheless, some states have taken action to increase the amount of background information that individuals must receive before they decide to become registered donors. Some state actions provide that looped videos, pamphlets, and posters be present at divisions of motor vehicles, designed to enhance the awareness of the lay public as a "captive audience" in the waiting rooms of licensing offices. In some states, division of motor vehicles personnel provide explanations regarding donation. However, these measures, which are not always properly or consistently implemented, may not provide adequate information to meet informally recognized legal or ethical standards of informed consent. Further efforts should be made to decrease the disparity of information given to grieving families in the consent process and that given to individuals considering becoming donors. This could increase expansion of state donor registries and enhance the strength of the advance directive.
A second broad issue also involves utilizing the driver’s license as a means to entering individuals into a donor registry. Driver’s license renewal cycles vary from every two years to the absence of a renewal requirement, although a common cycle is every four years. An optimal cycle to encourage consent to organ donation has not been determined, and it has not been demonstrated whether cycle length affects a new driver’s decision. However, a decreased renewal frequency has the effect of both decreasing the number of times that drivers will be asked to think about becoming donors, and opportunities for donation and donor registry information to provided to the public via division of motor vehicles offices, or through fact sheets included with renewal notice packets.
An additional concern is that most states offer an individual an opportunity to donate when they first get their driver’s license, typically at 16 years of age. Generally, the age at which individuals may legally donate is 18 years of age. Individuals are consequently forced to make decisions about donation before the issue is relevant to them and may not have the opportunity to change their decision until the renewal of their license, given a typical renewal period of 4 years. The discordance among obtaining a driver’s license, becoming a legal organ donor, and the driver’s license renewal period may pose a barrier to consent.
A number of states have taken actions that may provide some assurances that the registry process is based on informed consent. Extensive donation training programs for division of motor vehicles personnel improves the quality of information they provide to the public, increases their comfort level in discussing the topic of organ and tissue donation, and may even have the effect of making them active proponents of donation. Ultimately, training increases public education and results in a more informed registered donor pool. Finally, as a way of validating a donor’s wishes as accurate and informed, two states send thank-you letters to registered donors soon after they are entered into the registry to confirm their commitment to become a donor.
Access to Registry Information
The effectiveness of donor registries as advance directives depends in large part on the ease with which OPO, hospital, and law enforcement personnel are able to access the databases. State legislation stipulating 24-hour access, toll-free 800-numbers, and/or World Wide Web access eases access to registries, and furthers registry development. Many states currently do not have a 24-hour accessible registry, which could substantially diminishing registry utilization. General consensus exists in the procurement community that registry information must be readily accessible at all times if it is to be useful in the actual implementation of advanced directives.
Because protection of privacy remains a key public concern, this must be taken into account when developing legislation in the area of registry access. Potential measures to alleviate these concerns include clearly establishing the entities or individuals having access to the registry, ensuring transparency of the policies regarding access and who has access, and developing mechanisms to confirm that those accessing the registry information have a right to do so.
Maintenance and Technical Aspects of Registries
Further legislation is needed in those states with lesser-developed donor registries to diminish the disparity that currently exists in the degree of registry development. The majority of state registries operate at only a very basic level, while a small number have more developed databases. Many states do not have a registry at all.
Registry maintenance and technical support involves determining where the database is to be housed, ensuring compatibility between the various entities that will utilize the registry, and developing mechanisms for keeping the database up-to-date. Several recent pieces of state legislation in this area have focused on addressing various parts of this process, although innovative efforts such as including visual representations of donor documentation also have been made in a small number of states.
Finally, the cost of maintaining and supporting a donor registry could be substantial, and funding mechanisms need to be established for this process to advance. Costs include those for purchasing and upgrading hardware and software, and personnel to operate and maintain the database.
Role of Medical Examiners
Medical examiners have a substantial responsibility in investigating and reporting deaths, and therefore have the potential to take a key role in the organ and tissue donation process. Nevertheless, only a relatively limited amount of state legislation has been enacted recently to address this issue. Recent measures in New Jersey and Texas requiring medical examiners to justify any refusals of organ donation should significantly decrease this barrier to the use of registries. By requiring greater accountability on the part of medical examiners for these actions, this measure makes the process more transparent to procurement personnel.
Additionally, allowing a medical examiner to authorize donation (in lieu of next of kin consent) facilitates the donation process by decreasing the number of individuals that must be consulted to begin donation procedures and, further, represents a step toward implementation of advance directives. Legislation more specifically clarifying the role of medical examiners, such as that described here, can help to ensure that the responsibilities of examiners during the donation process are clearly defined.
Additional Donor Cards
Depending on the method by which additional donor cards are used in a state, this could represent either a barrier to increasing registered donors or a facilitative measure. If a state requires donor cards in addition to a driver’s license designation to adequately demonstrate decedents’ donation wishes, it becomes unclear if both are necessary to legally represent an advanced directive. A problem also arises if one piece of donor documentation (i.e., the donor card or the driver’s license) is changed at some point while the other remains unchanged. This could lead to ambiguity as to which document takes precedence in the event of brain death, or which designation is listed in the donor registry (i.e., which document information is recorded). The dual donor card-driver’s license designation represents a potentially significant barrier to the donor registry and the advanced directive by adding unnecessary and potentially ambiguous documentation.
Alternatively, additional donor documentation beyond designation on a driver’s license could facilitate entering more individuals into the donor registry. Many individuals may not carry a driver’s license, and would therefore be precluded from entering into the registry without an alternative means of donation designation. The donor card then offers an additional mechanism for entering into the state donor registry.
Evaluation
The common goal of evaluation of the donation process is to understand how well public education initiatives and donor registry programs are being implemented (i.e., process evaluation), and to determine if these efforts are effective at increasing awareness and, consequently, donation rates (i.e., outcome evaluation). Each of these types of evaluation should be consistently and repeatedly applied to the donation process and the donor registry. Evaluative mechanisms should be built directly into the system itself, by coding and tracking educational and awareness materials, and comparing rates of success.
Potential Solutions not Apparent in State Actions
While a substantial number of state legislative measures have been enacted in recent years covering most aspects of the donation process, donor registries, and advanced directives, some areas are in need of further legislation. These areas broadly include defining the functions of registries, analyzing and standardizing registries, applying statistical analysis to registry data, addressing ethical issues surrounding the donation process, addressing liability resulting from failure to act on advanced directives, establishing coordination guidelines between those involved in the process, and detailing technical issues related to donor registries. These topics are outlined in greater detail below.
- Each state needs to clearly define the major functions of its registry. These functions include, but are not limited to, public awareness and education, increasing the number of donors, collection of funds, easing the consent process, and the use of registry information as an advance directive.
- An analysis should be conducted of the key aspects of model state registry programs. Pennsylvania, for example, often has been cited for its innovative and effective program (Nathan, 1999). Further, if a standard model is provided to states that are still developing their registries, future linkage would be facilitated with increased uniformity across states.
- The collection and statistical analysis of each state’s registry data could provide insights into the effectiveness of public awareness and educational campaigns, and aid in determining which specific areas are in need of additional public awareness efforts.
- A more comprehensive consideration of the legal and ethical aspects of using a unilateral or bilateral advance directive should be conducted. For example, it may be determined that if a positive designation on valid donor constitutes a binding advanced directive, then the negative designation should be clearly and consistently interpreted as well.
- Further study and appropriate legislation should be devoted to clarifying whether failure to act on an advance directive leaves hospital and procurement personnel open to liability from potential recipients who do not receive organs.
- Additional efforts should be made to establish programs designed to promote coordination among primary care physicians, lawyers, hospitals, OPOs, and other entities and individuals relevant to the donation process.
- Further efforts should be made to develop computer registries for inter-state linkage and 24-hour access.
- Actions to standardize (on a statewide or nationwide basis) and legally verify consent documentation would lessen the liability of hospital and procurement personnel carrying out advance directives.
- Development, modification, and standardization of donor registries have potentially substantial cost burdens. Legislation should address funding mechanisms for these efforts.
- Consensus does not exist in the procurement community regarding the contents of donor registry databases. Further clarification of what should be included in the database may be appropriately addressed by state legislation.
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Nathan HM. Pennsylvania looks for answers to the organ donor shortage. June 10, 1999. PR Newswire.
National Attorneys' Committee for Transplant Awareness. Organ and Tissue Donation and Transplantation: A Legal Perspective. TransWeb. 1995. Accessed July, 1999.
Rothouse M, Kaiser E. Organ and Tissue Donation Issue Brief. June 24, 1999 update. National Conference of State Legislatures.
Wright DH. Survey Report: Advance Directives and Donor Card Effectiveness. UNOS. 1998.
APPENDIX A: Legislative SEARCH STRATEGY
Collection of the most recent state legislative information was conducted by using the legislative search engine of the Health Policy Tracking Service of the National Conference of State Legislatures, search engines (if available) of individual states, and other sources via the World Wide Web. We also searched the DIALOG database (legislative and legal citations) for relevant articles in gray literature. Other sources included the Louisiana Organ Procurement Agency 1997 Report of State Legislation, covering state actions from the early 1990s to 1997, as well as documentation provided by registry representatives from the states in attendance of the conference, "Are Donor Registries Advance Directives?: Developing, Linking, Modifying Statewide Donor Registries," held in New Orleans, Louisiana, July 27-28, 1999 (see Appendix B). Lastly, the members of the Association of Organ Procurement Organizations were polled and solicited to submit copies of legislation each was utilizing to support development of local donor registries.
To identify pertinent articles in the DIALOG database, we applied key search terms as described in the table below.
| Database Type | Database Names | Years | >Search Terms |
|---|---|---|---|
| DIALOG | MEDLINE; HealthSTAR; PROMPT; EMBASE; SciSearch; PASCAL; Periodical Abstracts Plustext; Social SciSearch; EMBASE ALERT; Newspaper Abstracts Daily; Biosis Previews; Sociological Abstr.; PAIS INT.; FEDRIP; Chem Bus NewsBase; Los Angeles Times; Pittsburgh Post-Gazette; State Tax Today | 1990-Present | ((organ ( ) allocat? or organ ( ) donation?) AND registr? AND (legislat? OR barr? OR solution?)) |
APPENDIX B: STATE ACTIONS AFFECTING DONOR REGISTRIES
| STATE | REMARKS ABOUT STATE ACTIONS | ORGAN DONATION INDICATED ON DRIVER'S LICENSE | ADDITIONAL DONOR CARDS | PUBLIC AWARENESS AND EDUCATION | REGISTRY AS ADVANCE DIRECTIVE | INFORMED CONSENT | ACCESS TO REGISTRY INFORMATION | MAINTENANCE AND TECHNICAL ASPECTS | ROLE OF MEDICAL EXAMINERS | EVALUATION |
|---|---|---|---|---|---|---|---|---|---|---|
| ALABAMA | >Encourages organ sharing across state lines | YES | 98 House Bill 527: Optional $1 gift to the Bobby McDowell Gift of Life Trust Fund for donation awareness | |||||||
| ALASKA | >No enacted legislation in recent years | NO | ||||||||
| ARIZONA | >Legislation emphasizes individual rights | YES | 98 House Bill 2156: Without advance directive, prioritized individuals may make an anatomical gift; removes need for consent after donor's death | |||||||
| ARKANSAS | >Donor information from OMS provided to OPO | YES | 97 Senate Bill 35: "Make Life Happen" multimedia donor awareness campaign | 99 Senate Bill 120: Allows documented telephone message as an advance directive; 97 Senate Bill 35: Created registry by giving OPO access to license information and by making clerks ask individuals to be donors | 97 Senate Bill 35: 24-hour access to database by OPO personnel | Driver’s license information is downloaded monthly from the State Revenue Department computer system* | Ongoing analysis of who is registered | |||
| CALIFORNIA | >"Pacemaker" and type of gift on donor card | NO | YES | 99 Senate Bill 771: Create registry through HHS; 98 Senate Bill 1403: Consent for corneal material; 96 7151.5: Hospital removal after attempted NOK search | 99 Senate Bill 771: Pamphlets about registries given at license renewal; 98 Assembly Bill 1225: Person between 15-18 years of age can make gift with parents consent | 99 Senate Bill 771: 24-hour-a-day access by OPO | 99 Senate Bill 771: Registry enrollment form shall be posted on the California HHS website | |||
| COLORADO | YES | 96 House Bill 1138: Optional $1 gift to donation awareness and educational fund | 98 Senate Bill 072: Eliminates witness of signatures; affirms donor wishes; affirms coroners authority to deny gift; "Y" on front of license | 96 House Bill 1138: Donation information must be available at driver license offices | ||||||
| CONNECTICUT | YES | 99 Senate Bill 1297: Appointed health decision maker for decedent can make gift; 98 Senate Bill 545: Anatomical gift made with document signed by donor; 98 House Bill 580: Donation indicated on driver's license; creation of DMV registry | ||||||||
| DELAWARE | YES | 98 House Bill 580: Created trust fund for donor education | 98 House Bill 580: With a valid advance directive, consent of the NOK is not necessary at the time of death; created DMV registry and only "Yes" appears on license | |||||||
| DISTRICT OF COLUMBIA | No new legislation in recent years regarding donor registries | YES | YES | "Organ Donor" printed on license | On-site education of DMV employees, brochures available at DMV and with mailed license renewal | Link to police department | ||||
| FLORIDA | >Multi-agency effort | YES | 97 732.915: Funding through Florida Organ and Tissue Donor Education and Procurement Trust Fund Youth education program | 99 Senate Bill 2228: Without advance directive, prioritized individuals may make an anatomical gift; 98 Senate Bill 304: Protects OPOs and hospitals in carrying out advance directive; 97 732.915: Establishment of DMV donor registry | 97 732.915: 24-hour web site access to certified hospitals and OPOs with password | 98 Senate Bill 304: Allows money from the procurement trust fund to help maintain registry Database contains donor wills and signature | ||||
| GEORGIA | >Registry in early stages | YES | 96 40-5-25: Optional gift to donation awareness and educational trust fund | 96 44-5-143: Without advance directive, prioritized individuals may make an anatomical gift | 96 40-5-25: Driver license fee reduction for donors | 24-hour access to authorized users | Advance technological database; magnetic tape, scanned document, and keyboard method of data entry | |||
| HAWAII | YES | YES | 99 House Bill 547: Optional $1 gift to donation awareness and educational trust fund | 99 House Bill 547: 24-hour access to database | 99 House Bill 547: Requires hospitals to allow death record review | |||||
| IDAHO | YES | |||||||||
| ILLINOIS | YES | 1993 Live & Learn Legislation : Created education trust fund | UAGA makes signed license effective without consent from NOK; Illinois Vehicle Code: Donor card on back of license; only "Donor" appears on card | Looped tapes, brochures, posters and countertop displays at the DMV; sends "Thank You" letters to participants | OPOs and coroners have 24-hour access via an 800 number | Additional data field in driver’s license database | ||||
| INDIANA | >Donor care for minors >Capture donation limit on file | YES | YES | 99 House Bill 1184: Optional gift to donation awareness and educational trust fund | Information available to law enforcement only | |||||
| IOWA | >"Medic Alert" and "Living Will" on license | YES | County Treasurer can collect funds for awareness grants administered by DPH | Durable power of authority over NOK | Medical Examiners can authorize donation if no NOK | |||||
| KANSAS | >Few recent actions | NO | ||||||||
| KENTUCKY | NO | 92 186.531: Optional $1 gift to donation awareness and educational trust fund | ||||||||
| LOUISIANA | YES | YES | Statewide television/print media campaign; registry awareness at many locations beyond DMV (e.g. church groups, heath fairs etc.) | Title 32 Section 410: Requires driver’s license officer to ask each license applicant whether they would like to be a donor | Extensive training for DMV personnel Registry available on the Internet | OPO only agency with access to the registry | Itemized listing of donation wishes | 99 Senate Concurrent Resolution 148: Study feasibility of paying funeral expenses DMV data to Louisiana Donor Registry; analysis funded by an NIH grant | ||
| MAINE | YES | |||||||||
| MARYLAND | YES | 98 Senate Bill 230: Created Organ and Tissue Donation Awareness Fund | 98 Senate Bill 230: Without advance directive, prioritized individuals may make an anatomical gift; driver’s license is a valid advance directive "Donor-Yes" printed on license | 98 Amoss Organ and Tissue Act: Allows 16-year olds to donate with parent’s co-signature Posters at DMV | OPOs can call the State Police to check donor status 24-hours per day Thank you cards given to participants | |||||
| MASSACHUSETTS | YES | YES | Law requires that organ donor program information be included in driver's license renewal notices | |||||||
| MICHIGAN | NO | 98 House Bill 4031 & 4062: Opportunity on state ID to make donation Public awareness at many places (e.g. church programs, health fairs etc.) |
98 House Bill 4031 & 4062: Receive registry information at license renewal | Captures picture of signed donor card | ||||||
| MINNESOTA | >Bill amends Living Will to include donation | YES | 99 Senate Bill 301: Choice to empower health care agent to make organ donation decisions | |||||||
| MISSISSIPPI | YES | |||||||||
| MISSOURI | YES | 96 194.302: Optional gift to Donor Awareness Fund TV and radio ads; secondary education |
96 194.302: Driver’s license is a legal advance directive without NOK consent; creation of registry/database | Pamphlets given out at driver’s license renewal | OPOs and Missouri Lion’s Eye Bank have limited access | Department of Health maintains registry | The Arc Survey on general public awareness about the donation process | |||
| MONTANA | >Examiners must ask each applicant | YES | YES | 99 House Bill 454: Provides voluntary check-off on vehicle registration for a donation to support public awareness | ||||||
| NEBRASKA | NO | 99 Legislative Bill 147: Optional $1 gift to Organ and Tissue Donor Awareness Education Fund | May eliminate requirement for witness when making advance directive | |||||||
| NEVADA | >Examiners must ask each applicant | YES | YES | Optional gift to organ donation education fund | 93 451.555: A gift from a donor less than 18 requires approval by one witness and one parent/guardian | |||||
| NEW HAMPSHIRE | YES | YES | ||||||||
| NEW JERSEY | YES | YES | 99 Assembly Bill 2623: Donation status indicated on driver's license electronically | Requires medical examiners to justify their refusal of donation | ||||||
| NEW MEXICO | YES | 95 24-6A-2: An individual who is 16 years of age or older may make an anatomical gift without parent's consent | ||||||||
| NEW YORK | NO | |||||||||
| NORTH CAROLINA | YES | YES | Decedent’s wishes have priority of the NOK | 97 House Bill 1197: Study the establishment of a statewide registry of persons with advance directives E valuating "post card" type renewal reminder for driver's license |
||||||
| NORTH DAKOTA | YES | YES | ||||||||
| OHIO | >Automated systems prompts inquiry >Fee to file willingness to donate with county clerk | YES | 96 2108.15/4507.231: Optional $1 gift to support Second Chance Trust Fund Intent to have birthday card education program | Intent to measure relationship between the intent of donation and targeted areas | ||||||
| OKLAHOMA | >Participation rate up since supplemental card stopped | NO | ||||||||
| OREGON | > New legislation authorizes donor card | YES | NO | A special license plate raises funds for education | ||||||
| PENNSYLVANIA | YES | 96 8618/ 8621: Donation to Organ Donation Awareness Trust Fund can be made on income tax return form; 94 Act 102: Optional $1 gift to support Organ Donation Trust Fund | 94 Act 102: Consent is not necessary with advance directive; establishment of donor registry; only "Yes" appears on card | 24-hour access via 800 phone number at DOT | ||||||
| RHODE ISLAND | YES | YES | 98 House Bill 7797: Information on the state registry will be sent to each person renewing a license Notary required on Organ Donor Card |
99 House Bill 6192 : Commission to study "All aspects of Organ Donation" | ||||||
| SOUTH CAROLINA | YES | 99 House Bill: Optional $1 gift for Organ Donor Program | 44-43-330: Without advance directive, prioritized individuals may make an anatomical gift; 99 House Bill: Organ status indicated on license | 44-43-330: Rights of the donee are paramount to all others | ||||||
| SOUTH DAKOTA | >"Medic Alert", "Living Will" and "Power of Attorney" on driver's license | YES | 99 House Bill 1146: Law enforcement personnel with access to license must inform NOK of decedent's advance directive | |||||||
| TENNESSEE | >File shows blood type | YES | YES | 96 Public Chapter 83: Optional $1 gift for Organ Donation Education | 97 Warner Act : With signed driver’s license no further consent is needed; requires reasonable search for license by law enforcement personnel; 90 Public Chapter 775: Created donor registry through license | Brochures and posters at driver’s license renewal | 90 Legislation: 24-hour access to registry by authorized personal | |||
| TEXAS | >Stopped using supplemental Organ Donor Cards | YES | NO | 99 Senate Bill 673 : Optional $1 fee at License renewal to fund the Anatomical Gift Educational Program | 97 Senate Bill 952 : Removal of donor status; 86 Legislation: Requires all hospitals to ask NOK for consent even with an advance directive | Contracted technical support | Require medical examiners to justify their refusal of donation | Passed a law creating a public task force that will report in December 2000 on issues relating to organ allocation | ||
| UTAH | YES | YES | 96 26-28-9: Rights of the procurement entity are superior to the interests of others NOK must sign form saying they were offered donation | |||||||
| VERMONT | YES | YES | 98 5271: Unless the decedent has an advance directive, prioritized NOK can make a gift | |||||||
| VIRGINIA | YES | 96 32.1-290.1: Unless the decedent has an advance directive, prioritized NOK can make a gift | 99 House Bill 2670: Requires organ donation brochure to be given out at license renewal 16-year olds can donate with guardian’s signature |
99 Senate Joint Resolution 453/454: Plan to increase organ donation awareness and examine donation issues | ||||||
| WASHINGTON | > Provisions for organ donation medal | YES | 97 68.50.500: Unless the decedent has an advance directive, prioritized NOK can make a gift | Minimum age for choosing to be a donor is 16 years of age | ||||||
| WEST VIRGINIA | YES | |||||||||
| WISCONSIN | YES | 96 157.06: Unless the decedent has an advance directive, prioritized NOK can make a gift; rights of the donee (OPO, individual, hospital, surgeon) are superior to the interests of others | ||||||||
| WYOMING | YES |
APPENDIX C: Summary of Conference: "Are Donor Registries Advance Directives?: Developing, Modifying, and Linking Statewide Donor Registries." New Orleans, Louisiana, July 27-28, 1999
This summary provides an overview of the issues, key points, and findings of the July 27-28, 1999, conference on addressing the question of whether inclusion in a donor registry represents an advanced directive. As an accompanying theme throughout the two days, conference attendees were asked to deliberate on developing, linking, and modifying statewide donor registries. The substantive foundation of the conference was current or pending state legislation pertaining to donor registries.
While the question of whether a donor registry constitutes an advanced directive was posed as a major consideration for the conference, several other pertinent issues arose during the course of discussion. These issues included, but were not limited to:
- Design and use of a donor registry
- Ethical and legal considerations regarding informed consent
- Evaluation of registry development efforts
The first day of the conference consisted primarily of recovery agency personnel detailing for the group their efforts in the area of developing and modifying their respective donor registries. Some discussion regarding the issues of advanced directives, informed consent, potential uses of donor registries, and legislation evolved from these presentations, although lengthy discussions on these topics were reserved for the second day.
During the course of the conference, participants called into question the feasibility of linking donor registries in a way that involved electronic connections between the various databases. Trying to link registries in this fashion was thought to be impractical due to both the substantial cost of such an effort and the differing developmental stages of each of the state registries. Instead, the group deliberated on a less integrated approach involving a system of increased accessibility between states. The group agreed that, if a system of increased accessibility among state registries is implemented, three factors must be considered:
- Establishing specific purposes (e.g., education, procurement, and/or demographic tracking) each state has for the donor registry;
- Establishing consensus on a set of guidelines for accessing the database; and
- Assuring proper authorization for those accessing the information.
A more detailed description of major areas of conference discussion is provided below. This does not include summaries of state-by-state programs.
Design and use of the Donor Registry
Although design and use of donor registries varied considerably among different states, participants identified a common set of "typical" uses for a registry. These included:
- Education and public awareness (especially to facilitate informed consent)
- Increasing the number of donors in the registry
- Collection of funds
- Easing the consent process (by allowing recovery personnel access to registry information for use during the donation request)
- Use of registry information as an advanced directive
Different states emphasize each of these uses to varying degrees, including states that emphasize only one aspect, e.g., education. A major distinction was made between states using the registry to aid in both education and procurement, and others that use the registry exclusively for educational purposes. Participants emphasized that not all registries were developed with all of these functions in mind, and states should not be forced to alter the goals of their registry. This variation has implications for any attempts at linking registries. The group also addressed the ethical issue of using the registry database as a means to solicit funds for its support. No clear consensus evolved from this discussion, however.
Public Awareness and Education
Approach to Public Awareness and Education. Public awareness and education consists of several broad issues. First among these is the type of message that should be conveyed to the public, or more precisely, the "level" of information. A progressively focused public awareness campaign may consist of an initial introduction of the topic of donation, followed by an effort to develop public knowledge of the donor registry, concluding with a campaign to encourage people to sign up in the registry, and describe how to do so. A more complex model, such as the transtheoretical model of communication (See www.uri.edu/research/cprc/transtheoretical.htm), may be more appropriate for education and awareness campaigns. The specific media used to disseminate the message may include television, spots preceding movie showings, literature distributed at health and wellness fairs, or the World Wide Web. The approach taken will largely depend on the audience being targeted: professionals, young people, specific socioeconomic groups, or some other specified group.
Targeting Key Groups. An important target audience includes those individuals on the front lines of the registry process, that is, personnel in departments of motor vehicles, licensing offices, or elsewhere where the public might come into contact with agents who may be charged with providing information about the registry. Conference participants emphasized the importance of educating such personnel about ways to clearly explain the benefits of donation to the lay public, present the option to become part of the donor registry in a positive light, and even to become proactive proponents of the donor registry.
Tracking and Evaluation. The success of varying methods of education and awareness building can be tracked via the same system used to disseminate the information. Coding public education and awareness literature (i.e., coded to the location where it was distributed) and tracking which methods are used in which circumstances, and determining which methods are most successful in those areas, can provide the procurement community with valuable evaluative information. In one area, for example, tracking data may show that distribution of materials at a house of worship has a greater effect on increasing donor registry participation compared to materials distributed at a sporting event. The recovery community can then use this information to alter and refine their approaches as appropriate.
Public Trust. Finally, the group emphasized that paramount among the purposes of public education is to develop and maintain public trust. This is facilitated by recovery agencies and policy makers being forthright and transparent about their policies and activities, and educating the public about not only the donation process, but the procurement community as well. Putting a "human face" on the donation process may help people to feel more comfortable with joining the donor registry.
The Registry as an Advanced Directive
Legality. The group agreed that in most states, designation as a donor on a driver’s license or other donor documentation is legally binding. In spite of this legal directive, it is rarely implemented as such due to hospitals’ and recovery agencies’ fears regarding legal action or bad publicity resulting from a negative family reaction. A related point is that, by ignoring advanced directives, hospitals or procurement personnel leave themselves open to liability from potential recipients who do not receive organs. Case law on this issue would help to clarify the appropriate actions on advanced directives, and perhaps have an impact on the underlying public and professional expectations related to donation and advanced directives, cited by many as a necessary first barrier to overcome.
Unilateral versus Bilateral Directives. A distinction was made between a unilateral and a bilateral advanced directive. Many conference participants consider that, if the positive designation on valid donor documentation is considered a binding advanced directive, then the negative designation should carry equal weight and be respected. That is, if "yes" means yes, then "no" means no. This is not always the case, however, and in some states, families of deceased individuals who indicated a negative designation on their driver’s license are still approached by procurement personnel. Further, wording of the donor registry question on the driver’s license registration or renewal form may be somewhat ambiguous, e.g., asking individuals if they would like to become part of the registry rather than asking more directly if they would like to become a donor. In some states, the designation of "No" is not noted on the driver’s license or in the registry database, while in all cases the designation of "Yes" is noted.
Ethics of an Advanced Directive. Ethical implications of these approaches were discussed by the participants. It was pointed out that a negative designation might not always be an informed decision on the part of the decedent and that the family should therefore be consulted. Not all participants agreed on this point, and it remains an unresolved issue. Some of the group also felt that certain wording of the question, or omission of negative donation wishes while positive designations are noted, could lead to ambiguity that could be perceived as unethical.
Legislation. Regarding the question of whether further legislation is needed to bolster usage of the registry as an actual advanced directive, the group concurred that the 1987 amendment to the Uniform Anatomical Gift Act (UAGA) was meant to do that, but has not had a substantial effect. Further legislation, if enacted, should include efforts to make donation gifts irrevocable, and should provide immunity for those carrying out advanced directives and organ, tissue, and eye procurement. A further step may be to enact sanctions against medical personnel not adhering to the advance directive. States that have made particular progress on implementing the registry as an advanced directive include Tennessee, Pennsylvania, Illinois, Texas, Florida, Colorado, Arizona, and Virginia.
Two Definitions of "Advanced Directive." Two slightly differing definitions of the term "advanced directive" were presented, with differing potential implications. In one case, an "advanced directive" is the stated intent of an individual in life to donate his or her organs and tissues after death. A broader definition of "advanced directive" is legal documentation outlining an individual’s wishes in the case of incompetence by death. These wishes could include a "Do Not Resuscitate" order that could preclude donation wishes, if both were included in an advanced directive.
Informed Consent
Much of the discussion concerning informed consent dealt with two main questions:
- What is the minimum amount of information necessary for legal purposes to qualify as informed consent?
- What is the minimum amount of information necessary for moral/ethical purposes to qualify as informed consent?
The group generally concurred that legislation (i.e., the established legal minimum) on the first point is somewhat more straightforward. For many of the participants, the question of what qualifies as informed consent is tied closely to the positive donor designation on a driver’s license, which is a document whose primary function does not concern organ donation, but whose ownership is regarded as essential to many people, as opposed to a donor card, which signifies its holders specific intent to donate. The environment of the division of motor vehicles or the license office is not always conducive to informing individuals about donation, particularly when they are there for another purpose and are inclined to hasten their departure. The question arose as to whether a checked "Yes" box on a license renewal form can be ethically considered informed consent. A fact sheet provided on the back of the consent form to become a donor may be enough to be considered truly informed consent.
Driver’s Licenses
In many states, the primary method of developing registries and presenting to the public the option to become part of the donor registry occurs through driver’s license renewal. This has several implications, which include the following:
- The issue of whether this presentation of the option constitutes informed consent.
- The way in which the question of whether an individual would like to join the registry is asked (i.e., as a question on the renewal form or verbally by department of motor vehicles or license office staff).
- The specific wording of the question, or the underlying tone of the individual asking the question (for example, asking the question in the negative rather than the positive, i.e., "You don’t want to donate your organs, do you?").
- The renewal cycle of the driver’s license, as renewals occur at less frequent intervals (States represented at the conference varied in renewal times from four to twelve years.)
- A mechanism for reaching those individuals who may not have a license (given that the primary method for entering individuals into the registry in most states is by utilizing driver’s license registration and renewal).
The group agreed that the process should start with universal eligibility by including in the registry anyone of sound mind, legal age, etc., even if other factors (e.g., the medical/social history) eventually preclude them from becoming donors at the time of death.
Maintenance and Support/Technical Aspects
The group raised several technical issues related to maintenance and support of a donor registry, many of which proved integral to considerations about linking and modifying state registries. These are listed below.
Housing of the Registry. The first consideration in developing and/or linking donor registries is determining where the registry is, or should be, housed. Registries may be housed in any of several entities, including an OPO, a division of motor vehicles, a state department of health, the state police, or a managed care organization.
Compatibility. Once the determination of where the registry is to be housed is made, linkage between the recovery agencies and the registry database site must be made, including ensuring compatibility of hardware and software.
Information Maintenance. There must also be a mechanism for keeping the database up to date (i.e., purging those who are deceased or have opted out and adding those who have joined), and a mechanism to quickly and accurately search for individuals in the database.
Cost and Funding. Several participants pointed out that the cost of such a database could be substantial. Costs include purchasing the hardware and software, personnel to operate and maintain the database, and purchasing or buying the rights to upgraded hardware and software. Options for collecting funds include state allocation, grants, donations, or special tax increases.
Access to Registry Information
Recovery agency personnel and hospital personnel who may be involved in the organ, tissue, or eye recovery process need to be able to quickly access the donor registry information. The group noted that criteria for who should have access to the registry database must be established. Additionally, once established, proper authorization should be assured by developing a system to validate that those attempting to access the system have a right to do so.
The method by which the information is accessed merits further consideration. Several options exist, including using a toll-free 800-number, the World Wide Web, or a direct method of accessing the database independent of the Web. Other discussion topics in this area focused on managing the data in the registry or public entry into the database, and included the following.
- The database should be accessible at all times.
- A clear public entry/access to sign up or to opt out of the registry must exist.
- Registries should be viewed and maintained as an information clearinghouse.
- Procedures to ensure data integrity must exist.
- Data fields and formats must be uniform between states.
- In the case of linking service areas, clear guidelines for use and access should be established.
Evaluation
The need for ongoing evaluation arose throughout the conference. Two types of evaluation were identified for the purposes of developing, modifying, and possibly linking donor registries. These two types are:
- Process – How well is the program being carried out?
- Outcome – Is the chosen program proving to increase donation?
The group repeatedly emphasized that both types of evaluation needs to be applied to all aspects of donor registries, and the ways in which registries may be used. For example, if the stated goals of implementing the registry are to increase public awareness or the number of donors, then the registry should be evaluated accordingly. Ideally, evaluative aspects of the registry could be built directly into the system itself, for example by coding distributed materials, tracking them, and comparing these data to the actual results of the effort (e.g., survey results or number or register donors). The group also suggested clearly establishing that tracking and monitoring registry efforts is not equivalent to evaluation of those efforts. Finally, an important aspect of evaluation is determining the cost-effectiveness of developing, maintaining, and utilizing a donor registry, and this should not be overlooked.
Appendix D: Directory of Resources
Three major sources and contacts give insight into the relevant issues surrounding the development of each state’s donor registry: state legislation, OPO directors, and sometimes other contacts within OPOs who specifically work with donor registries. The three sources are listed below.
State Legislation
The status of recent legislation affecting donor registries can be searched on the Internet at each state’s legislature web page. Each of these web pages can be accessed at www.ncsl.org/public/sitesleg.htm#sites.
OPO Directors and Contacts
Alabama
Charles Patrick, III,
Executive Director
Alabama Organ Center
301 South 20th Street, Suite 1001
Birmingham, AL 35233
Phone: (205) 731-9200
Fax: (205) 731-9250
Alaska
Diana Clark, Executive Director
LifeCenter Northwest
2553 76th Avenue SE
Mercer Island, WA 98040-2758
Phone: (206) 230-5767
Fax: (206) FAX-LIFE (329-5433)
Arizona
John M. Cremin, Jr.,
Executive Director
Donor Network of Arizona
3877 North 7th Street, Suite 200
Phoenix, AZ 85014
Phone: (602) 222-2200
Fax: (602) 222-2202
Arkansas
Michael Manley, Executive Director
Arkansas Regional Organ Recovery Agency
1100 N. University Avenue, Suite 200
Little Rock, AR 72207
Phone: (501) 224-2623
Fax: (501) 372-6279
California
Phyllis Weber, Executive Director
California Transplant Donor Network
55 Francisco Street, Suite 510
San Francisco, CA 94133-2115
Phone: (415) 837-5888
Fax: (415) 837-5880
Janet Kappes, R.N., Executive Director
Golden State Donor Service
1760 Creekside Oaks Drive, # 160
Sacramento, CA 95833
Phone: (916) 567-1600
Fax: (916) 567-8300
Rudolph Morgan
Lifesharing Community Organ Donation
3665 Ruffin Road, Suite 120
San Diego, CA 92123-1871
Phone: (619) 292-8750
Fax: (619) 560-5945
Robert Mendez, M.D., CEO
Southern California Organ Procurement Center
2200 West 3rd Street, 2nd Floor
Los Angeles, CA 90057
Phone: (213) 401- 1204
Fax: (213) 413 - 2216
Colorado
Patricia Brewster, President, CEO
Donor Alliance, Inc.
3773 Cherry Creek North Drive, Suite 601
Denver, CO 80209
Phone: (303) 329-4747
Fax: (303) 321-1183
Connecticut
Deborah Savaria, Assistant Supervisor Northeast OPO & Tissue Bank
Hartford Hospital
P.O. Box 5037
Hartford, CT 06102-5037
Phone: (860) 545-2256
Fax: (860) 545-4143
Florida
Jean Layne, R.N., Director
LifeLink of Florida
409 Bayshore Blvd
Tampa, FL 33606
Phone: (813) 348-6308
Fax: (813) 348-0571
Liz Lehr, Director
LifeLink of Southwest Florida
409 Bayshore Blvd
Tampa, FL 33606
Phone: (813) 348-6308
Fax: (813) 348-0571
Chuck McCluskey, Director
(Shands Hospital)
University of Florida OPO
P.O. Box 100163
Gainesville, FL 32610-0286
Phone: (352) 395-0632
Fax: (352) 338-9886
Tim Jankiewicz, Executive Director
TransLife/Florida Hospital
2501 North Orange Avenue, Suite 40
Orlando, FL 32804
Phone: (407) 303-2474
Fax: (407) 303-2473
Leslie Olson, Executive Director
University of Miami Organ Procurement Agency
1150 Northwest 14th Street Suite 208
Miami, FL 33136
Phone: (305) 243-7622
Fax: (305) 243-7628
Georgia
Bobbi Beatty, Executive Director
LifeLink of Georgia
3715 Northside Parkway
100 Northcreek, Suite 300
Atlanta, GA 30327
Phone: (404) 266-8884
Fax: (404) 266-0592
Hawaii
Robyn Kaufman, M.P.H., Executive Director
Organ Donor Center of Hawaii
1000 Bishop Street, Suite 302
Honolulu, HI 96813
Phone: (808) 599-7630
Fax: (808) 599-7631
Illinois
Jarold Anderson, President/CEO
Regional Organ Bank of Illinois, Inc.
800 South Wells Street, Suite 190
Chicago, IL 60607
Phone: (312) 431-3600
Fax: (312) 803-7643
Indiana
Mr. Lynn Driver, President/CEO
Indiana Organ Procurement Organization, Inc.
429 N Pennsylvania Street
Suite 201
Indianapolis, IN 46204
(317) 685-0389
(317) 685-1687
Iowa
Suzanne Conrad, Executive Director
Iowa Donor Network
2732 Northgate Drive
Iowa City, IA 52245
Phone: (319) 337-7515
Fax: (319) 337-6105
Kansas
Rob Linderer, Executive Director,
Midwest Transplant Network
1900 West 47th Place, Suite 400
Westwood, KS 66205
Phone: (913) 262-1666
Fax: (913) 262-5130
Kentucky
Paul O'Flynn, Executive Director
Kentucky Organ Donor Affiliates
106 East Broadway
Louisville, KY 40202
Phone: (502) 581-9511
Fax: (502) 589-5157
Louisiana
Kelly Ranum, Interim Director
Louisiana Organ Procurement Agency
3501 North Causeway Boulevard, Suite 940
Metarie, LA 70002-3626
Phone: (504) 837-3355
Fax: (504) 837-3587
Maryland
Mr. Marion Borowieki
Transplant Resource Center of Maryland
1540 Caton Center Drive, Suite R
Baltimore, MD 21227
Phone: (410) 242-7000
Fax: (410) 242-1871
Massachusetts
Richard Luskin, Executive Director
New England Organ Bank
One Gateway Center, Washington Street Newton, MA 02158-2803
Phone: (617) 244-8000
Fax: (617) 244-8755
Michigan
Thomas Beyersdorf
Transplantation Society of Michigan
2203 Platt Road
Ann Arbor, MI 48104
Phone: (313) 973-1577
Fax: (313) 973-3133
Minnesota
Susan Gunderson, Executive Director
LifeSource, Upper Midwest Organ Procurement Organization, Inc.
2550 University Avenue West Suite 315
South St. Paul, MN 55114-1904
Phone: (612) 603-7800
Fax: (612) 603-7801
Mississippi
Kevin Stump, Executive Director
Mississippi Organ Recovery Agency
12 River Bend Place, Suite B
Jackson, MS 39208
Phone: (601) 933-1000
Fax: (601) 933-1006
Missouri
Dean Kappel, President/CEO
Mid-America Transplant Services
1139 Olivette Executive Parkway
St. Louis, MO 63132
Phone: (314) 991-1661
Fax: (314) 991-2805
Nebraska
Karen Risk, Administrative Director
Nebraska Organ Retrieval Systems, Inc.
5725 F Street
Omaha, NE 68117
Phone: (402) 733-4000
Fax: (402) 773-9312
Nevada
Ken E. Richardson, Executive Director
Nevada Donor Network, Inc.
4580 South Eastern Avenue, Suite 33
Las Vegas, NE 89119-6105
Phone: (702) 796-9600
Fax: (702) 796-4225
New Jersey
Joseph Roth, Executive Director
New Jersey Organ & Tissue Sharing Network
841 Mountain Avenue
Springfield, NJ 07081
Phone: (973) 379-4535
Fax: (973) 379-5113
New Mexico
Laurie Garretson, Executive Director
New Mexico Donor Services
2715 Broadbent Parkway NE, Suite J
Albuquerque, NM 87107
Phone: (505) 843-7672
Fax: (505) 343-1828
New York
Elaine Berg, Executive Director
New York Organ Donor Network
475 Riverside Drive, Suite 1244
New York, NY 10115-1244
Phone: (212) 870-2240
Fax: (212) 870-3599
Mark Simon, CEO
Upstate New York Transplant Services
165 Genessee Street, Suite 102
Buffalo, NY 14203
Phone: (716) 853-6667
Fax: (716) 853-6674
Frank Taft, Director
Center for Donation and Transplant
218 Great Oaks Boulevard
Albany, NY 12203
Phone: (518) 262-5606
Fax: (518) 262-5427
Bill Morris, Regional Director
Finger Lakes Donor Recovery Network
Corporate Woods Brighton
Building 120, Suite 180
Rochester, NY 14623
Phone: (716) 272-4930
Fax: (716) 272-4956
North Carolina
Lloyd Jordan, Jr., Executive Director
Carolina Organ Procurement Agency
702 Johns Hopkins Drive
Greenville, NC 27834
Phone: (252) 757-0090
Fax: (252) 757-0708
William Faircloth
LifeShare of the Carolinas
P.O. Box 32861
Charlotte, NC 28232-2861
Phone: (704) 548-6850
Fax: (704) 548-6851
Lisa Cooper, Executive Director
Carolina LifeCare
Greentree Centre II
1551 West brook Plaza Drive
Suite 200
Winston-Salem, NC 27103
Phone: (336) 774-4450
Fax: (336) 774-6591
Ohio
Debbie May-Johnson, Executive Director
LifeBanc
20600 Chagrin Boulevard, Suite 350
Cleveland, OH 44122-5343
Phone: (216) 752-5433
Fax: (216) 751-4204
Michael Phillips, Executive Director
Life Connection of Ohio (Toledo)
1545 Holland Road, Suite C
Maumee, OH 43537-1694
Phone: (419) 893-4891
Fax: (419) 893-1827
Burton J. Mattice, Executive Director
Life Connection of Ohio (Dayton)
1100 S. Main Street, Suite 204
Dayton, OH 45409
Phone: (937) 223-8223
Fax: (937) 223-8955
Linda Jones, CEO
Lifeline of Ohio Organ Procurement Agency, Inc.
770 Kinnear Road, Suite 200
Columbus, OH 43212
Phone: (614) 291-5667
Fax: (614) 291-0660
David D. Lewis, Executive Director
Ohio Valley LifeCenter
2925 Vernon Place, Suite 300
Cincinnati, OH 45219-2425
Phone: (513) 558-5555
Fax: (513) 558-5556
Oklahoma
Robert Turner, Director
Oklahoma Organ Sharing Network |
5801 North Broadway, # 200
Oklahoma City, OK 73118
Phone: (405) 840-5551
Fax: (405) 840-9748
Oregon
Michael Seely, Executive Director
Pacific Northwest Transplant Bank
2611 Southwest 3rd Avenue, Suite 320
Portland, OR 97201-4952
Phone: (503) 494-5560
Fax: (503) 494-4725
Pennsylvania
Brian Broznick, Executive Director
Center for Organ Recovery & Education
Ride Park
204 Sigma Drive
Pittsburgh, PA 15238
Phone: (412) 963-3550
Fax: (412) 963-3564
Howard M. Nathan, Executive Director
Gift of Life Donor Program
2000 Hamilton Street, Suite 201
Philadelphia, PA 19130-3813
Phone: (610) 543-6391
Fax: (215) 557-9359
Puerto Rico
John Campbell, Director
Lifelink of Puerto Rico
409 Bayshore Blvd
Tampa, FL 33606
Phone: (813) 348-6308
Fax: (813) 348-0571
South Carolina
Nancy A. Kay, Director
South Carolina Organ Procurement Agency
1064 Gardner Road, Suite 105
Charleston, SC 29407
Phone: (843) 763-7755
Fax: (843) 763-6393
Tennessee
Judy Shipman, Executive Director
Mid-South Transplant Foundation, Inc.
910 Madison Avenue, Suite 805
Memphis, TN 38103
Phone: (901) 448-4588
Fax: (901) 448-8126
Lawrence Cochran, Executive Director
Tennessee Donor Services
1714 Hayes Street
Nashville, TN 37203
Phone: (615) 327-2247
Fax: (615) 320-1655
Texas
Samuel Holtzman, Executive Director
LifeGift Organ Donation Center
5615 Kirby Drive, Suite 900
Houston, TX 77005
Phone: (713) 523-4438
Fax: (713) 737-8100
Patrick Giordano, Executive Director
Texas Organ Sharing Alliance
8122 Datapoint Drive, Suite 1150
San Antonio, TX 78229
Phone: (210) 614-7030
Fax: (210) 614-2129
James Cutler, Executive Director
Southwest Transplant Alliance
3710 Rawlins, Suite 1100
Dallas, TX 75219
Phone: (214) 522-0255
Fax: (214) 522-0430
Utah
Tracy C. Schmidt, President
Intermountain Organ Recovery Systems
230 South 500 East, Suite 290
Salt Lake City, UT 84102
Phone: (801) 521-1755
Fax: (801) 364-8815
Virginia
Bill Anderson, President & CEO
LifeNet
5809 Ward Court
Virginia Beach, VA 23455
Phone: (757) 464-4761
Fax: (757) 464-5721
Janice Leland, Executive Director
Virginia's Organ Procurement Agency
1527 Huguenot Road
Midlothian, VA 23113
Phone: (804) 330-0800
Fax: (804) 330-0595
Lori Brigham, Executive Director
Washington Regional Transplant Consortium
8110 Gatehouse Road, Suite 101-West
Falls Church, VA 22042
Phone: (703) 641-0100
Fax: (703) 641-0211
Washington
Diana Clark, Executive Director
LifeCenter Northwest
2553 76th Avenue Southeast
Mercer Island, WA 98040-2758
Phone: (206) 230-5767
Fax: (206) 230-5806
Wisconsin
Paul Volek, Director
Wisconsin Donor Network
9200 West Wisconsin Avenue
Milwaukee, WI 53226
Phone: (414) 257-5002
Fax: (414) 259-8059
Robert Hoffman, Executive Director
University of Wisconsin Hospital and Clinic
Department of Surgery
600 Highland Avenue
Madison, WI 53792
Phone: (608) 263-1341
Fax: (608) 262-9099
Other Resources
Legacy Donor Foundation
Louise M. Jacobbi, Director
1100 Poydras Street Suite 1500
New Orleans, LA 70163
Association of Organ Procurement Organizations
One Cambridge Court
8110 Gatehouse Road, Suite 101
West Falls Church, VA 22042
(703) 573-AOPO
(703) 573-0578