Close
About
FAQ
Home
Collections
Login
USC Login
Register
0
Selected
Invert selection
Deselect all
Deselect all
Click here to refresh results
Click here to refresh results
USC
/
Digital Library
/
University of Southern California Dissertations and Theses
/
The emotional and psychological response of healthcare providers involved in organ procurement: a literature review with practice recommendations for certified registered nurse anesthetists
(USC Thesis Other)
The emotional and psychological response of healthcare providers involved in organ procurement: a literature review with practice recommendations for certified registered nurse anesthetists
PDF
Download
Share
Open document
Flip pages
Contact Us
Contact Us
Copy asset link
Request this asset
Transcript (if available)
Content
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT
THE EMOTIONAL AND PSYCHOLOGICAL RESPONSE OF HEALTHCARE PROVIDERS
INVOLVED IN ORGAN PROCUREMENT: A LITERATURE REVIEW WITH PRACTICE
RECOMMENDATIONS FOR CERTIFIED REGISTERED NURSE ANESTHETISTS
by
Nicole Christine Creef
A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE
May 2021
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT ii
The following manuscript was contributed to in equal parts by Nicole Creef, Margaret Lynch,
and Michelle Tovani.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT iii
Dedication
We would like to dedicate this work to all those involved in organ transplantation: the families
whose loved ones have given the gift of life, health care providers who have held patients’ and
families’ hands, aided in procurement and implantation, and witnessed the celebration and
devastation that surrounds this unique procedure, and all those who have advocated, researched,
and paved the way to make organ donation what it is today.
We would also like to dedicate this work to Dr. Charles Griffis: our mentor, professor, and
friend. He leads by example, both in his quality of care and quality of character. Thank you for
demonstrating what it looks like to be a truly exceptional anesthesia provider and human being.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT iv
Acknowledgements
Our research team would like to thank the authors listed in our references who provided a
base for this literature review. We would also like to acknowledge our faculty chairs, Dr.
Elizabeth Bamgbose and Dr. Charles Griffis, for their continued mentorship and provision of
expert opinion throughout this process. Finally, we would like to thank our families, who have
been patient and supportive throughout the completion of this project.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT v
Table of Contents
Dedication ................................................................................................................................. iii
Acknowledgements ................................................................................................................... iv
Abstract ..................................................................................................................................... vi
Chapter 1 ................................................................................................................................ 1
Introduction ........................................................................................................................ 1
Research Question and Statement of Specific Aims............................................................. 2
Background and Significance .............................................................................................. 2
Chapter 2 ................................................................................................................................ 9
Literature Review ............................................................................................................... 9
Chapter 3 .............................................................................................................................. 19
Methods ............................................................................................................................ 19
Chapter 4 .............................................................................................................................. 21
Results .............................................................................................................................. 21
Specific Aim #1 ............................................................................................................ 21
Specific Aim #2 ............................................................................................................ 21
Specific Aim #3 ............................................................................................................ 22
Specific Aim #4 ............................................................................................................ 23
Chapter 5 .............................................................................................................................. 24
Discussion ........................................................................................................................ 24
Recommendations---Executive Summary.......................................................................... 25
Conclusion ........................................................................................................................ 28
References ................................................................................................................................ 30
Appendix A: Proposed Research Design ................................................................................... 34
Appendix B: Recruitment Script ............................................................................................... 37
Appendix C: Demographic Data and Semi-structured Interview Guide ..................................... 39
Appendix D: Literature Review Flow Chart .............................................................................. 41
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT vi
Abstract
Certified Registered Nurse Anesthetists (CRNAs) participate in organ procurement
procedures involving the harvest of organs from brain-dead donors. These cases are challenging
for many reasons. Patient management, which is well documented in anesthesia literature,
involves ensuring accurate determination of brain death and the irreversibility of the fatal
condition, administration of multiple medications, fluid management, and temperature
maintenance in an effort to maintain organ perfusion and minimize warm ischemia time. These
cases differ entirely from the usual experiences of anesthesia management. CRNAs are trained to
assess patients for risks of anesthesia, yet the brain-dead patient is no longer viable; to maintain
life, yet the brain-dead patient’s life support will be discontinued in the course of organ
procurement. This investigation of evidence examines current research regarding the emotional
and psychological effects of participation in organ procurement procedures in populations of
healthcare providers who work closely with CRNAs in order to describe the likely responses of
CRNAs to these procedures. A set of recommendations are presented to guide future research
regarding preparation of nurse anesthetists who participate in organ harvest cases.
Key words: organ procurement, anesthesia, OR nurse, organ transplantation, anesthesiologist
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT vii
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 1
Chapter 1
Introduction
The role of an anesthesia provider in organ procurement is laden with complexity. Corr
and Coolican (2010), emphasize while education and knowledge are critical in the technical
aspects of organ transplantation, equally critical are education and knowledge related to
bereavement, grief, and mourning. The success of organ procurement surgeries depends on
accurate physiologic and pharmacologic protocols as well as timely procurement of organs for
donor recipients (Morse, 2017). Emotions experienced by nursing personnel involved in organ
procurement have been described as rewarding; yet many acknowledge the impact it can have on
a healthcare professionals’ personal well-being (Smith, Leslie, & Wynaden, 2016). Evidence
continues to emerge regarding the emotional impact of organ procurement on perioperative
nurses. Less explored are the emotional implications endured by healthcare providers, in
particular anesthesia providers such as Certified Registered Nurse Anesthetists (CRNAs) who
participate in the organ procurement process (Kentish-Barnes et. al, 2017). Surgeons,
anesthesiologists, and CRNAs are exposed to the same psychologically triggering situation.
Published literature describing surgeon and anesthetist involvement in organ procurement
provides hundreds of studies regarding techniques and best practices, yet few regarding
emotional impact. Recommendations have been made for anesthesia providers involved in non-
heart-beating cadaver organ donation to undergo specific palliative care training (VanNorman,
2003). It is imperative CRNAs are emotionally and mentally prepared to harvest organs in the
operating room (OR) if necessary (Faircloth, 2017). This paper aims to provide a summary of
current literature regarding the emotional and psychological impact of organ harvest case
management on healthcare providers who work closely with CRNAs in the same perioperative
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 2
milieu. Based on inferences drawn about the likely impact on CRNAs, recommendations will be
made to effectively prepare CRNAs to cope with the demands of organ harvest cases, and
provide suggestions for future research.
Research Question and Statement of Specific Aims
The authors pose the following questions: What is the likely emotional and psychological
impact upon CRNAs of participation in solid organ procurement procedures, how might CRNAs
be better prepared to cope with these stressful experiences, and how might this phenomenon be
researched in the future?
The specific aims of this paper are to:
1. Describe the role of the CRNA in organ procurement case management.
2. Review current literature regarding psychological and emotional experience and
effects of participation in organ procurement procedures for perioperative medical
personnel.
3. Based upon review of the existing literature for perioperative personnel, discuss
the ethical, emotional and psychological issues that Certified Registered Nurse
Anesthetists are likely to face during the management of organ procurement cases
4. Suggest approaches for future research regarding the emotional and psychological
response of CRNAs involved in organ procurement.
Background and Significance
Brain death, first referred to as ‘coma depasse’, was described as early as 1959 by two
neurophysiologists, Pierre Mollaret and Maurice Goulon (Elkins, 2009). In 1967, the first human
heart transplant was performed in South Africa by Dr. Christiaan Barnard in Cape Town, South
Africa. The heart of a traumatic brain injury patient was transplanted into a patient suffering
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 3
from severe cardiac failure. During that time, law stated a patient was considered dead when
he/she was declared so by a physician (Cooper, 2018). To avoid any medico-legal implications,
Dr. Barnard allowed cardiac death to occur before procurement of the patient’s organs, which
took approximately six minutes following removal from life support (Cooper, 2018). Shortly
after this historic transplant, the Ad Hoc Committee of the Harvard Medical School to Examine
the Definition of Brain Death issued a report redefining brain death. The report defined brain
death as a “permanently non-functioning brain,” and also provided diagnostic criteria to aid in
the determination of brain death (Anderson, Becker, & Vagefi, 2015).
In the early 1970s, a formal legal definition of brain death was instituted and Kansas
became the first state to legally recognize brain death as a form of legal death, setting the
precedent for the rest of the United States (Elkins, 2009). The 1981 President’s Commission set
forth the guidelines for determining brain death; the resulting legislation is known as the
Uniform Determination of Death Act (UDDA) and has been adopted verbatim by thirty-eight
states (Nikas et al., 2016). Nine other states have also adopted the UDDA, however with the
explicit qualification that the neurological criteria for death may only be used when a patient’s
cardiopulmonary functions are maintained through artificial means (Nikas et al, 2016). The
remaining three states have adopted their own legislation pertaining to determinants of brain
death (Nikas et al., 2016). Each healthcare institution has its own applicable policies and
procedures, in compliance with local law and is guided by the standards set forth by the
American Academy of Neurology in the determination of brain death (Anderson et al., 2015).
In 1984 the National Organ Transplant Act was signed into law when the federal
government determined a need for oversight for organ procurement and transplantation (Morse,
2017). In response to the Organ Transplant Act of 1984, the Organ Procurement and
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 4
Transplantation Network (OPTN) was formed. It is operated by the United Network for Organ
Sharing (UNOS), a nonprofit organization under federal contract (Morse, 2017). The goal of
UNOS is to ensure effective and efficient allocation for organ sharing in a national system.
Donation after brain death (DBD) is the most common source of allograft transplant. If a
patient has suffered irreversible neurologic devastation and is suspected to meet the criteria for
the declaration of brain death, and if it is deemed appropriate by physician and next of kin or
legal guardian, then the patient’s treating physician may identify this patient as a potential DBD
organ donor (Anderson et al., 2015). Eligibility for DBD is determined based on the patient’s
other medical conditions or comorbidities. If at least one organ is viable for procurement and
donation, the patient is considered a utilizable organ donor (Anderson et al., 2015).
Another legally recognized organ donor category is described as donation after cardiac
death (DCD). However, these patients must meet strict criteria and are declared dead and eligible
for organ donation based on cardiopulmonary criteria and underlying severe illness or trauma
deemed non-recoverable by medical providers (Anderson et al., 2015). In the case of DCD, the
patient’s family or legal guardian(s) must first decide to withdraw care. Once care is withdrawn,
cardiopulmonary function ceases, and resuscitative efforts are withheld. There is then a five-
minute waiting period to ensure autoresuscitation does not occur before proceeding with
pronouncement of death by a physician unrelated to the donation team and the procurement
process (Anderson et al., 2015).
The anesthesia provider plays a pivotal and complex role in the organ procurement
process, regardless of the donor’s status of brain death or cardiac death. Many organ
procurement procedures take place in the community or rural hospital setting where CRNAs may
act as the sole anesthesia providers (Morse, 2017). The CRNA must meticulously balance the
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 5
physiologic processes within the brain-dead donor in collaboration with, and following
recommendations from the UNOS team, requiring shared control of interventions (Morse,
2017).
Each aspect of physiological management requires specific and unique interventions to
ensure the procurement of viable organs for donor recipients in the presence of hemodynamic
instability and cardiac dysfunction that become imminent after the declaration of brain death
(Anderson et al., 2015). The CRNA must ventilate the patient, maintaining perfusion and
oxygenation so physiologic function is maintained until all organs dependent upon circulatory
blood flow are removed (Anderson et al., 2015). Fluid administration and vasoactive
pharmacologic intervention must be administered within strict parameters, often set by the
UNOS procurement team, considering how each can potentially have negative consequences on
certain organ systems. The CRNA must have an astute understanding of the requirements for
precise management of physiological parameters in order to ensure allograft viability and
survival (Morse et al., 2017).
Administration of neuromuscular blocking agents and analgesia are also part of the
anesthesia providers’ role during procurement. Neuromuscular blocking agents are provided to
optimize surgical conditions during procurement (Anderson et al., 2015). Despite the diagnosis
of brain death, somatic responses to surgical stimuli mediated by spinal cord reflexes remain
intact, necessitating the need for neuromuscular blockade. Anesthesia and analgesia
administration is a more controversial issue regarding the involvement of the anesthesia provider
in the procurement process. In a 2003 randomized, controlled, double-blinded trial researchers
administered 7mcg/kg of fentanyl and an equal volume of placebo (0.9% sodium chloride) to
determine the effects of fentanyl administration on catecholamine release in 15 brain dead
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 6
donors (Fitzgerald, Hieber, Schweitzer, Luo, Oczenski, & Lackner, 2003). Their findings
indicate that the administration of fentanyl did not suppress the catecholamine release elicited by
painful stimulus during the organ procurement process; in particular during skin incision and
sternotomy (Fitzgerald et al., 2003). The researchers cite multiple factors possibly contributing to
the variability seen in their results including: deficits at the receptor level inhibiting the function
of catecholamines, hypothermia and acidosis, vasomotor tone dysregulation, and
microcirculatory maldistribution, which are common hemodynamic dysfunctions that occur after
brain death (Fitzgerald et al., 2003).
However, Young and Matta (2000) argue that anesthetists in charge of the clinical
management of brain-dead donor may experience distress in not administering analgesia to this
patient population. They posit three arguments for this assumption. First, there are virtually no
circumstances in which surgery with muscle relaxation is not accompanied by analgesia
and/or anesthesia and this leads to an almost psychological compulsion to provide these
interventions as anesthesia providers. Next, anesthesia providers may find distress in not treating
the hypertension and tachycardia that accompanies the procurement procedure, which are most
likely reflexes at the spinal level, however there is no EEG monitoring during the procedure to
confirm this (Young & Matta, 2000). Finally, the authors suggest, death should be viewed as a
process and not a single event and that our limited understanding of death should demand
caution before assuming that anesthesia is not required to prevent suffering (Young & Matta,
2000).
The most commonly accepted ethical principle relating to organ procurement is the “dead
donor rule” (Sade, 2011). This principle is based on two ethical concerns: first, that patients must
not die by organ procurement and second, that the patients must be dead before organ
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 7
procurement (Katznelson & Clarke, 2018). The dead donor rule has been part of much debate in
regard to the anesthesia providers role during organ procurement, centering on the idea that part
of anesthesia care is always the relief of pain and suffering. Some providers believe it would be
distressing to families to know their loved ones were treated with anesthetics and pain
medication during organ procurement as it has been deemed that the BDD is not capable of
feeling pain (Katznelson & Clarke, 2018). Others may view the provision of anesthesia and
analgesia as a violation of the dead donor rule and believe it may promote distrust of medical
providers involved in the organ procurement process (Katznelson & Clarke, 2018). While the
chances of the BDD experiencing pain during the procurement process is believed to be nil due
to brain death and destruction of the somatic sensory system, it is recommended by some in the
anesthesia and ethical community that a cautionary way of dealing with analgesia administration
is the most ethically sound approach to managing anesthesia care for the BDD (Katznelson &
Clark, 2018). The administration of analgesia would fulfill the anesthesia providers’ ethical duty
to do no harm in the view of those practitioners who adhere to this belief. There has been an
ongoing discussion amongst providers with the view that the administration of pain medication
should be done in transparency to the families of donors so as to maintain trust in the medical
profession (Katznelson & Clarke, 2018).
Thus, the anesthesia care provided to brain dead donors for organ procurement is fraught
with challenging issues. The goal of organ procurement is to provide physiological support until
circulation ceases, which is the absolute antithesis of anesthesia care for any other surgical
patient population and is in opposition to the training and goals of CRNAs (AANA, 2018). The
intraoperative management of these cases requires precise management of physiological
parameters by the anesthesia provider, while in close collaboration with the organ procurement
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 8
team, potentially leading to conflicts in management. The final act of every other anesthetic is to
safely awaken a patient whose life has hopefully been improved. However, the final act of each
organ procurement case is removing all life support, which usually would signify the loss of life,
yet in these cases, means prolonging and improving life for multiple other patients. It is
reasonable to speculate that this mix of impactful issues may affect the CRNA anesthesia
provider profoundly, and have a similar effect reported in the extant literature by other members
of the perioperative organ harvest team requiring specific coping measures.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 9
Chapter 2
Literature Review
This literature review will consider research relevant to the specific aims of this study.
Though scant extant literature on the emotional and psychological reactions of CRNAs to organ
procurement were discovered, investigations of perioperative personnel including physician
anesthesiologists and perioperative nurses were reviewed. Since CRNAs work closely with
physician anesthesiologists, and provide the same anesthesia care, and since CRNAs come from
a nursing background similar to perioperative nurses, it is reasonable to speculate that the
experiences of all these members of the perioperative care team are similar during organ
procurement procedures and that these investigations provide a suitable background to
support recommendations to prepare CRNAs to deal with emotional and psychological
reactions to this shared situation.
This literature review begins with an article described as a “historical overview of organ
donation and procurement” (Morse, 2017, p.386). According to this author, the history of organ
procurement procedures is important to understand due to the potential ethical complexities of
the situation of caring for a brain-dead donor (BDD) patient (Morse, 2017). As previously
elucidated, organ transplantation began and evolved in the early 20
th
century, culminating in the
initiation of federal oversight with the Organ Transplant Act of 1984, followed by the
establishment of OPTN and UNOS. There are multiple complex aspects of organ harvest
procedures including: determining which organs from which donors are suitable for transplant;
verifying legal brain death and irreversibility of the fatal condition; and clinical management of
the BDD in the face of deteriorating cardiopulmonary function, loss of temperature control and
neurological instability and coagulopathy development. During the organ procurement
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 10
procedure, the CRNA begins by assuring proper diagnosis of brain death, followed by the
maintenance of donor organ perfusion and minimizing warm ischemia time (time from cessation
of perfusion to cold organ preservation), through administration of drugs such as vasopressors
and fluids. Physiological goals include: maintaining oxygen saturation > 95%; systolic blood
pressure > 100 mm Hg; mean arterial pressure > 70 mm Hg; and central venous pressure > 12
cm H2O. Morse (2017) maintains that anesthetic and analgesic drugs are not required, but
muscle relaxants are needed to neutralize spinal reflexes. Anesthesia care is terminated after the
proximal aorta is cross-clamped.
The task of processing equivocal ethical issues surrounding these cases further increases
the emotional and psychological impact. Katznelson and Clark (2018) examined the precise role
of the anesthesia provider during organ procurement in considering the dead donor rule. The
same authors note that other physicians argue administering pain medication to the BDD would
only serve to negatively sway the public’s already fragile opinion of organ donation as this could
cause doubt that the patient is actually dead prior to organ procurement. The ethical lines have
only become more blurred as donations from patients suffering irreversible cardiopulmonary
arrest have increased (Katznelson & Clark, 2017). In considering ethical dimensions of organ
procurement care, VanNorman (2003) recommends the anesthesia provider must assure her or
himself all required medical determinations of death have been made prior to participation in
organ procurement and withdrawal of life support, if this task falls within his or her purview
during an organ procurement case.
The ethical concerns associated with organ procurement may be even more complex
when considering procurement following cardiac death. Results from a semi-structured interview
by Zaneta Smith (2019) describes distress and personal anguish felt by perioperative nurses
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 11
involved in these types of cases. These emotions were reported to be exacerbated when
withdrawal of treatment occurred within their view or when the donor was young. Many nurses
reported concern regarding the inability to provide a peaceful environment for the family during
the withdrawal period when for the ultimate purpose of organ donation, life-sustaining measures
are discontinued, cardiopulmonary function ceases, and the patient is pronounced dead.
Participants found it particularly difficult watching distressed families say urgent, succinct
goodbyes to their loved ones without privacy during the ‘stand down’ period, a mandatory two to
five-minute window following cardiac death prior to the official declaration of death. Instead,
loved ones frequently had their final moments amidst a cold, loud, exposed, sterile OR
environment. Perioperative nurses reported feeling unsure of how to support the family and
anxious regarding lack of ‘appropriate’ end-of-life care, particularly because the OR setting does
not see death as frequently as other locations such as the ICU. As the anesthesia provider and
perioperative staff watched and waited for cardiac death, nurses reported emotions related to
perceiving the situation as assisted suicide or euthanasia. This sense of personal anguish, stress,
and guilt is compounded by the unpredictable timing of donor death, which frequently did not
proceed as planned. For donor organs to be viable death must occur within 60-90 minutes,
followed by the ‘stand down’ period. Interviewees described experiences when life support was
removed, yet the patient began to breathe again; gasping, heart weakly beating, while the family
and OR staff alike stood by, waiting, watching, tormented by the guilt-ridden hope that the
potential donor would die within the required timeframe so that their deaths have the opportunity
to give new life. Sometimes these patients survived the timeframe by a matter of minutes; other
times it was days. Regardless, the experience of witnessing the pain felt by the would-be donor
family and recipients left a lasting impression.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 12
Gazoni et al. (2012) performed an extensive survey of anesthesia providers in the United
States regarding the impact of perioperative catastrophes on anesthesiologists. Though
perioperative catastrophe usually occurs to a viable patient, parallels can be drawn to the organ
harvest situation, in that both types of experiences are unexpected, stressful, high stakes, and
either may (during catastrophe) or will result in patient death (during organ harvest). Results
suggested 77% of anesthesia providers felt that their ability to provide anesthesia following an
emotionally traumatic event was compromised, while 34% felt compromised “a lot”. Fifty one
percent of the providers felt compromised for 24 hours, 27% for a week, and 19% indicated that
they felt they’d never recovered. The sensation of allowing death might be considered
catastrophic to many healthcare providers; particularly the anesthesia provider who is frequently
charged with extubating the patient and ending life support measures during organ harvest.
Studies regarding perioperative nurses’ experience in organ procurement highlights many
themes; including preoperative considerations, intraoperative stress and experiences, post-
mortem care, and perceptions of available support, and coping mechanisms (Gao et al.,
2016). The procurement process is frequently lengthy, takes place during non-traditional work
hours accompanied by decreased resources, is extremely time sensitive and involves various
surgical teams; resulting in an environment with high potential for stress (Wang & Lin, 2009). In
2009, Wang and Lin sought to explore the experiences and feelings of perioperative nurses
during the process of organ procurement in Taiwan. The researchers used a semi-structured
questionnaire during face-to-face interviews with six senior perioperative nurses who had been
working for greater than three years (Wang & Lin, 2016). This qualitative data was analyzed
using content analysis, and themes from these semi-structured interviews indicated that the
perioperative nurses’ first experience with organ procurement was unforgettable and full of
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 13
tension, stress, confusion, conflict, and guilt (Wang & Lin, 2016). Another finding was one of
contradictory feelings the nurses experienced in the sense that the death of the donor was not
natural and was unlike the death of a patient with a specific illness. This study also found certain
coping mechanisms adopted by the nurses to deal with their feelings pertaining to organ
procurement. One such coping mechanism was distancing themselves from work, which is seen
as a self-protection mechanism from psychological trauma and is a practice among the nursing
profession in general. According to Wang and Lin (2016), this alone proves professional help is
needed in the workplace to deal with issues arising during stressful work experiences, and
greater emphasis should be placed on this issue.
Regehr, Kjerulf, Popova, and Baker (2004) examined the attitudes of operating room
(OR) nurses towards organ donation and their experiences participating in these procedures
through in-depth qualitative interviews. Fourteen OR nurses from a large urban trauma center
volunteered to participate; all participants were female registered nurses. Their years of nursing
experience ranged from 3.5 years to greater than 25 years, OR experience from 2 to 20 years, and
years of cadaveric organ retrieval procedures by each nurse from to 2 to greater than 20 years
(Regehr et al., 2004). Personal feelings of distress and negative attitudes towards the issue of
organ donation were elicited during the interviews (Regehr et al., 2004). It was evident that
nurses who participated in this study were profoundly affected by the experience, many in a
negative way. Organizational factors stemming from strained relationships within surgical
teams, concerns about the well-being of the patient and their families, and exposure to death and
trauma added to the nurses’ distress and overall attitude about organ donation in relation to
themselves and their family members. Some reported, after seeing how the procedure is
performed and their perceived disrespect of the donor on the part of the various surgical teams
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 14
that they would not want to donate their organs or the organs of their loved ones (Regehr et al.,
2004). Coping mechanisms utilized by these nurses included focusing on the technical aspects
of their jobs, avoiding thoughts of the patient and their families, focusing on the life or lives that
will be saved by the transplants, and using prayer as a way of seeking closure on the life of the
donor.
A research study by Perrin, Jones, & Winkelman (2013) sought to provide a platform for
Australian nurses to describe their involvement in organ procurement procedures. Interview
questions were developed based on Perrin’s own expertise and experience as a perioperative
nurse and administered in the form of semi-structured interviews to seven Australian nurses who
had participated in at least two organ procurement procedures in totality. Three themes emerged
from information obtained in regard to their experience with organ procurement: existential
issues, coping strategies, and support for each other (Perrin, Jones, & Winkelman, 2013). Nurses
described coming face to face with their own mortality. After the question “What does it mean
to be dead?” (Perrin et al., 2013, p. 794) was posited, nurses described struggling to rationalize
that the breathing donor patient with a beating heart they were taking care of was in fact
dead. Several nurses described feelings of isolation when trying to illustrate the gravity of their
experiences to those who had not been in similar situations. Participants had developed an array
of strategies to cope with the emotional demands of their job. Many nurses mentioned needing
to find purpose in their work. These nurses tended to respond to workplace stress by “taking the
stress home” (Perrin, et al., 2013). In accordance with the fast-paced turnover associated with the
perioperative setting, participants often found solace in immediately returning to work in another
operating room following the commencement of an organ procurement procedure. Every nurse
interviewed described supporting fellow staff members as an effective way of
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 15
coping. Experience with organ procurement, stage of organ procurement surgery, and proximity
to the donor body warranted varying degrees of support according to these nurses. Seasoned
nurses took it upon themselves to support more novice staff and those working directly with the
transplant surgeons and thus the donor body, in particular the scrub nurse, who they felt
experienced increased amounts of stress in an already uniquely demanding environment.
According to a grounded theory study completed by Smith, Leslie, and Wynaden (2016),
organ procurement cases are ad hoc in nature (done only when needed or necessary), leading to
the more haphazard assignment of staff members who are less familiar with the procedure.
Unfamiliar procurement teams can further inhibit ability to establish normal team dynamics and
impact team support within the OR, resulting in a lack of rapport and trust, as well as feelings of
isolation (Smith et al., 2016). According to these investigators, in seeking to explore the levels
of support provided to perioperative nurses during organ procurement surgery, nurses felt they
lacked support within the operating room organization, support from the surgical team, and
access to external professional counseling resources. The authors suggested healthcare
organizations should acknowledge the personal impact organ procurement has on participating
nurses and provide suitable resources for referral. Smith et al. (2016) found implications for both
education and clinical practice. These include team building activities to strengthen the
relationships of external and hospital based surgical teams, increased education and training
through mock procurement simulation activities, and increasing awareness for the need of
support and open communication among surgical team members and hospital management
teams. The authors also emphasized the importance of timely access to debriefing and counseling
sessions that are available during an employee’s work hours (Smith et al, 2016).
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 16
A study of perioperative nurses involved in organ procurement cases by Carter-Gentry
and McCurren (2004), found several themes associated with decreasing the distress associated
with procurement cases. The study consisted of a semi-structured interview guided by open-
ended questions in which data was analyzed using a constant comparative analysis approach. The
researchers identified themes and developed a categorization scheme and coded data according
to category (Carter-Gentry & McCurren, 2004). The common themes found among the
perioperative nurses included not visualizing the patients’ face, the presence of additional tubes,
and case management by the anesthesia care provider (which lessened required interactions of
the perioperative nurses with the donor). These things enhanced the perioperative nurses’ ability
to detach themselves from the procedure (Carter-Gentry and McCurren, 2004). The fast-paced,
task-focused structure of organ procurement cases allowed nurses to desensitize themselves,
completing steps with a nearly robotic sense about them. Intraoperatively, participants in this
study felt anger associated with the inability to help the patient, which was exacerbated if the
patient had previously been cared for in the OR prior to organ transplantation; and if the patient
was young. Perioperative nurses involved in the study felt that they have experienced a role
reversal: rather than working to save a life or enhance recovery, they were working with an
already deceased patient to remove vital organs (Carter-Gentry and McCurren,
2004). Perioperative nurses interviewed agreed the task of cleaning the donor’s body and
transporting them to the morgue was the most difficult part of the procedure and elicited feelings
that they found difficult to cope with.
The potential impact of participation in organ harvest cases by CRNAs could be
conceptualized as provoking moral distress. Utilizing Wilkinson’s Moral Distress Model, an
exploratory, descriptive study was undertaken to determine the incidence, level, and
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 17
consequences of moral distress in CRNAs (Radzvin, 2011). Radzvin (2011), in her review of the
concept in CRNAs, utilizes a model of moral distress first described by Judith Wilkinson (1988),
in which moral distress is defined as “the psychological disequilibrium and negative feeling state
experienced when a person makes a moral decision but does not follow through by performing
the moral behavior indicated by that decision”. The author states that nurses are often faced with
moral and ethical dilemmas while performing their jobs. In order to understand the scope and
quintessential essence of moral distress in nurses, Wilkinson developed the Moral Distress
Model. The inability to implement what is believed to be the proper moral or ethical course of
action can lead to moral distress in nurses, whether obstacles to implementation are real or
perceived. Moral distress can manifest itself physically as well as psychologically. Extrapolating
components of this moral distress model to the organ harvest situation as it has been described
here-in, impactful psychological reactions from involved CRNAs seems quite possible. In the
organ harvest situation, CRNAs are required to abandon the usual anesthetic goal of saving an
individual, while being forced to witness the death of the person receiving care.
In an effort to enhance awareness and education about the processes and issues of organ
donation among medical students, Essman and Lebovitz (2005) created a six-part lecture series
regarding donation education, offered to medical students at a local university. They state that
though content regarding organ donation and transplantation is increasing in nursing curricula,
very little research exists regarding physicians. The intervention instituted by the study consisted
of a six-part lecture given to medical students, which included education on pathophysiology,
clinical evaluations, and evaluation of brain death. Additionally, students received a two-hour
lecture by a bioethicist regarding ethical dilemmas and complexities associated with organ
procurement and donation. The final class consisted of a two-hour question and answer with
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 18
families of organ donors and those who received organ transplants. A survey conducted at the
end of the curriculum indicated satisfaction, and students stated that they would recommend this
class to others. Based on their findings, the authors suggest, since increased understanding of
organ donation through nursing school education has directly affected nursing attitudes, and
experiences, and has led to the positive influence the profession has had on the organ donation
process, similar interventions may have a beneficial effect on medical students as well.
Corr and Coolican (2010) describe the importance of understanding bereavement, grief,
and mourning for those participating in organ procurement. Though aimed at “transplant
professionals who participate in organ donation and transplant”, insights were shared that
appeared relevant to perioperative nursing and anesthesia personnel. Education and knowledge
are imperative for the technical skills held by these providers, however equal emphasis should be
placed on education and knowledge pertaining to the psychological aspects of the procurement
and transplant process. Corr and Coolican (2010) argue to effectively engage with bereaved
individuals, as well as to be able to process situations of grief and mourning, transplant
professionals should seek opportunities to provide themselves with tools and resources to allow
them to fully understand what they and the individuals they serve are experiencing. They go on
to discuss the importance of a well-developed and up-to-date understanding of bereavement,
grief, and mourning. The International Work Group on Death, Dying, and Bereavement states,
“Education about death, dying, and bereavement should be required, distinct, and substantive
part of the core education of all health care and human services professionals,” (Corr &
Coolican, 2010, p. 169).
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 19
Chapter 3
Methods
A thorough literature search was conducted using the PubMed, CINAHL, Embase, and
Google Scholar databases. Inclusion criteria mandated that resources be full text, available in the
English language; pertain to anesthetic management, discussion of ethics, healthcare provider
perceptions, and attitudes about organ procurement; and have been published between 2000-
2019. Exclusion criteria eliminated non-full text resources, resources published in a language
other than English, resources focused on organ transplantation versus organ procurement,
resources pertaining to family perception, animal subjects, and brain death outside of the
operating room as this step is kept separate from organ procurement. In order to increase the
number of results, subject term searching was utilized in the PubMed, CINAHL, and Embase
databases. The terms “organ procurement” AND “anesthesia OR nurse” were put into the
advanced search builder. Following Embase’s recommendations, the subject search (“organ
transplantation” AND “anesthesiologist OR nurse”) was used. One hundred and ninety-seven
full text articles resulted in PubMed, one hundred articles resulted in CINAHL, and one hundred
and eighty-four full text articles resulted in Embase.
A PubMed search approach for similar articles used snowballing based on the reference
list associated with an article identified as timely, seminal, and well informed,
entitled: “Clinicians’ perception and experience of organ donation from brain-dead patients”
(Kentish-Barnes et al., 2017). Duplicates were removed and articles pertaining to family
perceptions and those involving animal subjects were excluded. Twenty-three records were
identified through snowballing and screened for eligibility. Two resources from the American
Association of Nurse Anesthetists’ website were identified, screened, and referenced in this paper
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 20
following a google search of “ethics in nurse anesthesia”. In addition, twenty-seven full-text
articles were ultimately included in the literature review (see Appendix D for Literature
Flowchart).
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 21
Chapter 4
Results
Specific Aim #1
The authors’ first aim was to describe the role of the CRNA in organ procurement case
management. In order to assure appropriate BDD treatment and allograft protection, the CRNA
must have an astute knowledge and understanding of the organ procurement process (Morse,
2017). It is imperative certain hemodynamic parameters are maintained throughout the
procedure, as guided by the UNOS representative, and that the CRNA work in collaboration with
the multidisciplinary procurement teams. As mentioned in previous sections, administration of
neuromuscular blockade provides optimal surgical conditions for the procurement of organs.
Administration of analgesia to the BDD is still debated among anesthesia providers and should
be left to the discretion of the provider (Katznelson & Clarke, 2018). Anesthesia care is
terminated upon the cross-clamping of the proximal aorta (Morse, 2017). In regards to organ
procurement from the non-heart beating organ donor, withdrawal of life-sustaining measures
generally occurs within the intensive care unit, however occasionally will occur in the operating
room. The role of the anesthesia provider for this specific patient population includes
discontinuation of life-sustaining medications such as vasopressors and inotropes and the
discontinuation of ventilatory support (Van Norman, 2003). After a five-minute waiting period to
ensure autoresuscitation does not occur, death is pronounced, and the procurement process
begins.
Specific Aim #2
The authors’ second aim was to review current literature regarding psychological and
emotional experience and effects of participation in organ procurement procedures for
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 22
perioperative medical personnel who work closely with CRNAs. According to the robust
literature review described above, emotions elicited in perioperative nurses--- and likely
experienced by the anesthesiologists and CRNAs working with them--- consisted of guilt,
anxiety and stress attributed to lack of familiarity with the surgical staff and procedures,
isolation, tension and strained relationships within the surgical team, anger associated with
inability to help the deceased donor, isolation, a sense of role reversal related to the perception
that they have allowed a patient to die in the OR, and a perceived level of disrespect in the
surgical teams’ treatment of the donor during procurement (Carter-Gentry and McCurren, 2004;
Katznelson and Clark, 2018; Perrin, Jones, & Winkelman, 2013; VanNorman, 2003). Another
common theme was difficulty in accepting a breathing patient with a beating heart as deceased,
contributing to feelings of conflict and moral distress (Perrin et al., 2013).
Specific Aim #3
Based upon review of the existing literature for perioperative personnel, the authors’ third
aim was to discuss the ethical, emotional and psychological issues CRNAs are likely to face
during the management of organ procurement cases. An extensive literature search yielded no
results pertaining directly to CRNAs, however multiple resources described the emotional and
psychological experiences of perioperative nurses involved in organ procurement (Carter-Gentry
and McCurren, 2004; Gao, W. et al., 2017; Perrin et al., 2013; Regehr, C. et al., 2004; Smith, Z.
et al., 2015 & 2016; Smith Z. 2019; and Wang, J., & Lin, C., 2009). Additionally, a study
published in the AANA Journal concluded that CRNAs experience moral distress in their
practice in a similar manner to the previously established moral distress experienced by
registered nurses (Radzvin, 2011). CRNAs begin their nursing careers at the bedside and often
have overlapping responsibilities with their perioperative nurse colleagues, it is reasonable to
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 23
speculate they may have similar ethical, emotional and psychological experiences in response to
participation in organ procurement.
Specific Aim #4
The fourth aim of this paper was to suggest approaches for future research regarding the
emotional and psychological response of CRNAs involved in organ procurement. A preliminary
study establishing the presence, or lack thereof, of negative emotional sequelae associated with
organ procurement procedures is required before additional research is undertaken. Assuming
CRNAs experience similar psychological responses to organ procurement as perioperative nurses
and anesthesiologists, additional research to assess efficacy of specific interventions in relieving
these negative responses can be addressed.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 24
Chapter 5
Discussion
Despite an extensive literature search, studies related to the emotional and psychological
responses of CRNAs participating in organ procurement procedures were not found. However,
the literature pertaining to perioperative nurses and their emotional and psychological responses
to participating in organ procurement procedures was robust; and limited literature was found
addressing the ethical challenges of physician anesthesiologists to organ harvest case
management, likely to produce the same emotional and psychological responses. Due to lack of
information regarding emotional impact on the target population, the authors suggest it is
reasonable to speculate that the emotional responses of CRNAs would be similar to those of the
perioperative nurse population when caring for this particular patient population because of the
shared humanistic nursing training, and required cooperation as a team in organ harvest case
management. While the responsibilities are vastly different, the core values of nursing including
human dignity, integrity, autonomy, altruism, and social justice remain. Likewise, because
physician anesthesiologists and CRNAs provide the same service, responses to organ harvest
case management is likely to be similar. This discussion will focus on the shared experiences
with perioperative nurses and CRNAs.
CRNAs and perioperative nurses experience overlapping responsibilities as it pertains to
caring for the traditional OR patient, such as ensuring patient comfort, proper patient
identification, verifying safe positioning to prevent nerve damage, and implementing measures to
maintain normothermia. When caring for a traditional surgical patient, their goal is the same: to
provide safe and compassionate care throughout a specific surgical procedure, while in the end,
improving the patient’s condition and overall well-being. While the goal of surgical management
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 25
in organ procurement is similar in the sense of providing safe and compassionate care, the end
result is much different than the traditional surgical patient in the fact that the end result of organ
procurement is physiological death of the donor. Reactions among perioperative nurses
pertaining to organ procurement procedures included feelings of distress, anger, and isolation.
Many perioperative nurses also reported negative attitudes toward organ procurement, a feeling
of role reversal, strained relationships within surgical teams, concerns about the well-being of the
patient and their families, and a lack of support from the OR organization and surgical teams. It
is understandable that these reactions and feelings would exist because of the characteristics and
nature of organ procurement procedures. As CRNAs are caring for these patients alongside the
perioperative nurses, it is our inference that CRNAs will experience similar feelings and
responses towards organ procurement.
Recommendations---Executive Summary
It is imperative research be conducted with anesthesia providers to identify the
psychological and emotional impact of participation in organ procurement, as described by the
providers themselves. In order to address this gap in knowledge, the initial intent of this paper
was to complete a qualitative, descriptive study in which CRNAs were interviewed in order to
gain insight into the emotional and psychological effects of providing anesthesia during organ
procurement. Due to the Novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV
2), the authors were unable to complete the study as planned. In order to facilitate future
research, the authors have provided the proposed research design and semi-structured interview
guide (Appendix A, Appendix C).
Due to current lack of research on this topic concerning CRNAs, the authors undertook a
systematic review of the relevant existing literature on topics related to the specific aims of this
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 26
study: the role of the CRNA in organ procurement; moral and ethical issues in organ
procurement medicine; and responses of other perioperative personnel who work closely with
CRNAs in the same milieu of organ procurement. Based upon this review, the authors propose
implementing recommendations found to be beneficial for the mental health of perioperative
nurses in care settings involved in organ procurement. These recommendations fall into two
categories: education and support and fall into two categories: education and support and may be
modified when further research is performed to help direct specific measures to address the
CRNA population.
As noted by Essman and Lebovitz (2005), increased understanding of organ donation has
been associated with improved attitude and experience with organ procurement. Smith et al.
(2014) emphasized that the importance of education and preparation to assist in procurement
procedures from a perioperative context is an area that is still lacking, not only among nurses, but
among health professionals in general. In regard to the CRNA population, it can be argued that
implementing a more in-depth overview of the organ procurement process within the core
curriculum of nurse anesthesia educational programs would be beneficial (Essman and Lebovitz,
2005). The emphasis of the added curriculum content pertaining to organ procurement should not
only emphasize the physiology and management of the procedure, but should also include
information on death, dying, and bereavement, as organ harvest cases, by nature, involve the loss
of a life to a family somewhere, along with grief and sorrow (Corr and Coolican, 2010). Certified
Registered Nurse Anesthetists are key members of the perioperative team and may interact with
family members and other team members when transporting patients to or receiving patients in
the operating room suite. Such training will prepare CRNAs to provide appropriate emotional
support in these emotional situations.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 27
The discussion and understanding of complex moral and ethical issues surrounding organ
harvest will be helpful additions to nurse anesthesia training. As previously elucidated in the
discussion of the dead donor rule (Sade, 2011), organ procurement must only be performed on
deceased patients, and no patient should die as a consequence of organ procurement. This rule is
consistent with the AANA Code of Ethics: “#1. Responsibility to Patients: CRNAs preserve
human dignity, respect the moral and legal rights of health consumers, and support the safety and
well-being of the patients under their care” (AANA Code of Ethics, 2005). Section 1.2 of the
AANA Code of Ethics states, “The CRNA protects the patient from harm and is an advocate for
the patient’s welfare” (AANA Code of Ethics, 2005). In regard to the non-heart beating organ
donor, it is imperative that anesthesia providers are educated on the legal, ethical, and medical
issues pertaining to such procurement procedures (Van Norman, 2003). CRNAs should not
undertake such duties without adequate knowledge and training of the aforementioned issues.
Certified Registered Nurse Anesthetists caring for organ procurement donors have a moral and
ethical duty to assure that the patient has been found to be brain dead, or suffers cardiac death,
which has been certified according to institutional, state and national definitions of these states,
to prevent any harm or suffering.
In their research, Smith et al. (2015) exposed the importance and need for specialized
education and professional development opportunities for perioperative nursing health
professionals participating in organ procurement procedures. Nurse anesthesia educational
programs may also consider introducing their students to UNOS as a way to facilitate education
for future participation in this type of surgical procedure. Students may benefit from online
introduction to UNOS content to better familiarize themselves with the organ procurement
process from beginning to end. Lectures from UNOS representatives could also be beneficial in
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 28
informing students on how donors and recipients are chosen, how representatives interact with
donor families, the collaboration between the anesthesia provider and the UNOS representative
in the perioperative setting, and how UNOS representatives manage their own grief and stress.
Recommendations for support begin with recognition by the healthcare organizations of
the personal impact organ procurement has on participating nurses and the importance of
providing suitable resources in a timely manner (Smith et al., 2016). Carter-Gentry & McCurren
(2004) suggest specific interventions to mitigate the emotionally taxing and stressful nature of
organ procurement procedures for perioperative nurses. Based upon this review, interventions
recommended by this team of investigators include: increasing exposure to the procurement
coordinator, introducing student registered nurses---and in the case of graduate nurse anesthetist
training---student registered nurse anesthetists (SRNAs) to organ recipients, increasing education
on death and dying in the curriculum of nursing, and providing instruction on effective coping
skills (Carter-Gentry & McCurren, 2004). The study conducted by Smith et al. (2016) also
highlighted the need to provide opportunities for professional and peer support for perioperative
nurses. Recommendations to prepare CRNAs to deal effectively with the emotional and
psychological effects of these cases include: debriefing among the perioperative team after
procurement is completed, availability and easily accessible counseling services for those who
participate in organ procurement, and fostering an environment within the perioperative setting
where CRNA staff feel comfortable voicing their concerns or feelings of stress and grief prior to
or after organ procurement procedures.
Conclusion
Organ procurement has been shown to be associated with potentially traumatic
psychological and emotional challenges for the perioperative team providing care. Research by
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 29
Gazoni et al. (2012) suggests over three-fourths of anesthesiologists felt that their ability to
provide care was compromised following an emotionally traumatic event. As CRNAs perform
the same functions in the same environment, it is likely members of this population will report
the same effects. In order to provide high quality, safe care during organ procurement anesthetic
management, as well as provide necessary emotional support for providers, anesthesia
departments are advised consider adopting the current recommendations offered in this paper. It
is of paramount importance the profession of nurse anesthesia recognizes and responds to the
potential emotional and psychological impact of stressful cases like organ procurement
procedures beyond the cognitive challenges of the physiological management of these complex
and challenging cases. Future research should be conducted to identify effective strategies to
assist CRNAs, as they encounter the emotional and psychological effects that may accompany
participation in organ procurement procedures.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 30
References
AANA. (2005). Code of Ethics for the Certified Registered Nurse Anesthetist. Retrieved from
https://www.aana.com/practice/clinical-practice-resources/code-of-ethics-for-the-CRNA
AANA. (2018). Certified Registered Nurse Anesthetist Fact Sheet. Retrieved from
https://www.aana.com/membership/become-a-crna/crna-fact-sheet
Anderson, T.A., Bekker, P., & Vagefi, P.A. (2015). Anesthetic considerations in organ
procurement surgery: a narrative review. Journal of Canadian Anesthesiology, 62(1)
529-539.
Carter-Gentry, D. & McCurren, C. (2004). Organ procurement from the perspective of
perioperative nurses. AORN Journal, 80(3), 417-431.
Columbia University. (n.d.). Cardiac transplant program: A Brief history of heart
transplantation. Retrieved from http://columbiasurgery.org/heart-transplant/
brief-history-heart-transplantation
Cooper, D. (2018). Christiaan Barnard-The surgeon who dared: The story of the first human-to-
human heart transplant. Global cardiology science & practice, 2018(2), 11.
doi:10.21542/gcsp.2018.11
Corbin, J. & Strauss, A, (2015). Basics of qualitative research. Los Angeles, CA: Sage.
Corr, C.A. & Coolican, M.B. (2010). Understanding bereavement, grief, and mourning:
implications for donation and transplant professionals. Progress in Transplantation,
20(2), 169-177.
Elkins, L.J. (2010). Inhalation anesthesia for organ procurement: potential indications for
administering inhalational anesthesia in the brain-dead organ donor. AANA Journal,
78(4), 293-299.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 31
Essman, C., & Lebovitz, D. (2005). Donation education for medical students: enhancing the
link between physicians and procurement professionals. Progress in Transplantation:
Official Publication, North American Transplant Coordinators Organization, 15(2), 124–
128.
Gao, W., Plummer, V., & Williams, A. (2017). Perioperative nurses' attitudes towards
organ procurement: a systematic review. J Clin Nurs, 26(3-4), 302-319.
doi:10.1111/jocn.13386
Gazoni, F. M., Amato, P. E., Malik, Z. M., & Durieux, M. E. (2012). The Impact of
Perioperative Catastrophes on Anesthesiologists. Survey of Anesthesiology, 56(5), 246–
247. doi: 10.1097/01.sa.0000418887.17533.cd
Hancock, J., Shemie, S., Lotherington, K., Appleby, A., & Hall, R. (2017). Development of a
Canadian deceased donation education program for health professionals: a needs
assessment survey. Canadian Journal of Anaesthesia, 64(10), 1037–1047.
Kentish-Barnes, N., Duranteau, J., Montlahuc, C., Charpentier, J., Martin-Lefevre, L., Joseph, L.,
… Azoulay, E. (2017). Clinicians’ perception and experience of organ donation from
brain- dead patients. Critical Care Medicine, 45(9), 1489–1499.
Katznelson, G., & Clarke, H. (2018). Revisiting the anaesthesiologist’s role during organ
procurement. Anaesthesiology Intensive Therapy, 50(2), 91–94.
Morse, C.Y. (2017). An overview of anesthetic management for the brain-dead donor and organ
recovery. AANA Journal, 85(5), 385-392.
Nikas, N. T., Bordlee, D. C., & Moreira, M. (2016). Determination of death and the dead donor
rule: A survey of the current law on brain death. The Journal of medicine and philosophy,
41(3), 237–256.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 32
Perrin, K., Jones, B., Winkelman, C. (2013). The co-existence of life and death for the
perioperative nurse. Death Studies, 37(9), 789-802.
Radzvin, L.C. (2011). Moral distress in certified registered nurse anesthetists: implications
for nursing practice. AANA journal. 79(1), 39-45.
http://search.proquest.com/docview/861207296/.
Regehr, C., Kjerulf, M., Popova, S., & Baker, A. (2004). Trauma and tribulation: the experiences
and attitudes of operating room nurses working with organ donors. Journal of Clinical
Nursing, 13(4), 430–437.
Sade R. M. (2011). Brain death, cardiac death, and the dead donor rule. Journal of the South
Carolina Medical Association (1975), 107(4), 146–149.
Smith, Z. (2019). Perioperative nurses’ experiences of caring for donation after cardiac death
organ donors and their family within the operating room. Journal of Perioperative
Practice, 30(3), 69–78. doi: 10.1177/1750458919850729
Smith, Z., Leslie, G., & Wynaden, D. (2015). Australian perioperative nurses’ experiences of
assisting in multi-organ procurement surgery: A grounded theory study. International
Journal of Nursing Studies 52, 705-715.
Smith, Z., Leslie, G., & Wynaden, D. (2016). Coping and caring: Support resources integral to
perioperative nurses during the process of organ procurement surgery. Journal of
Clinical Nursing 26, 3305-3317.
Smith, Z., Leslie, G., & Wynaden, D. (2015). Experiential learning not enough for organ
procurement surgery: implications for perioperative nursing education. Progress in
Transplantation: Official Publication, North American Transplant Coordinators
Organization, 25(4), 339–350
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 33
Truog, R.D. (2003). Organ donation after cardiac death: what role for
anesthesiologists?. Anesthesiology, 98(3), 599-600.
Van Norman, G.A. (2003). Another matter of life and death: What every anesthesiologist should
know about the ethical, legal, and policy implications of the non-heart-beating cadaver
organ donor. Anesthesiology, 98(3), 763-773.
Wang, J., & Lin, C. (2009). The experience of perioperative nurses involved in organ
procurement. J. Nurs Research, 17(4), 278-2850.
Wilkinson, J.M. (1988). Moral distress in nursing practice: Experience and effect. Nursing
Forum, 23(1), 16-29.
Young, P. J., & Matta, B. F. (2000). Anaesthesia for organ donation in the brainstem dead—why
bother?. Anaesthesia, 55(2), 105–106.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 34
Appendix A: Proposed Research Design
Study Title: Emotional and Psychological Responses of Certified Registered Nurses to
Participation in Organ Harvest Procedures
The authors recommend a descriptive grounded theory qualitative research design, using
the approach of Juliet Corbin and Anselm Strauss to capture participants’ beliefs and experiences
related to their participation in anesthesia care during organ procurement (Corbin & Strauss,
2015).
The interview can be conducted as a focus group using a convenience sample of CRNAs
who have previously participated as anesthesia providers in deceased donor organ procurement
procedures. Inclusion criteria for participants should include: having current certification as a
Certified Registered Nurse Anesthetist and previous participation as an anesthesia provider in
organ procurement procedures. Recruitment should occur following Institutional Review Board
(IRB) approval using an IRB-approved script, and informed consent to approach subjects who
self-identify as meeting inclusion criteria. Participants should be asked if they wish to discuss
this study. If they agree, approved study personnel can follow an IRB approved recruitment
script in describing the study and risks of participation (see Appendix B).
A comfortable, private room should be secured for the focus group. Once the doors have
been closed, subjects seated, and lack of interruption assured, subjects should sign informed
consent after all questions have been answered. The authors recommend that the subjects
provide basic demographic information by filling out a written form (Appendix C) to include
name, age, gender, ethnic background, years as a registered nurse, years as a CRNA, number of
organ procurement cases previously participated in. With the permission of participants, two
digital recorders should be turned on, and a focus group lasting 180 minutes, following the IRB-
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 35
approved semi-structured interview guide, should commence (see Appendix C). Researchers
should also collect field notes on the focus group, which are detailed descriptions of participants’
responses, attitudes, group process, and the course of the focus group conversation, yielding
further data about participant experiences.
Concepts extrapolated from the literature related to the emotional impact of organ
procurement on healthcare professionals were used to develop a semi-structured interview. In
qualitative methodology, interviews often begin with scripted questions devised by the research
team to start exploring the phenomenon under investigation (Corbin & Strauss, 2015). As the
subject responds, the interviewer will follow up with carefully constructed open-ended questions
designed to help the subject clearly elucidate what is going on. Validity of the semi-structured
interview guide was accomplished through collaboration with the literature review, Committee
Chair and other CRNA experts.
Institutional Review Board approval should be sought prior to focus group
implementation to assure that required human subject protections are in place. Suggested
protections include data collection undertaken in secure, private, comfortable location; alpha-
numerically coded subject identity with a code key kept in a secure location accessible only by
IRB-approved study personnel; any written, recorded study data should be stored in a locked
cabinet;. and all electronic study data should be kept in secure, password-protected files to
which only approved study personnel will have the password. The subjects’ identities should
never be linked in any way to published study data.
The risks of study participation are minimal, anticipated to include the possibility of
subjective personal discomfort and negative emotional responses in discussing sensitive personal
information with researchers that is associated with the participation in organ procurement
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 36
procedures. Resources for counseling services should be provided should any of the participants
experience emotions they wish to address with a counseling professional during the interview
session.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 37
Appendix B: Recruitment Script
Investigator (I): Hello, my name is ____________, and I am one of the investigators for a study
on emotional and psychological responses of CRNAs to participation in organ procurement
procedures. I understand you are a CRNA, and have participated in these procedures, is that
correct?
Potential Subject (PS): No. ---[I thanks PS and concludes interview.]
PS: Yes.
I: Would you consider participating in our study? Y – [I proceeds.] N – [I thanks PS and
conclude interview.]
PS: Yes,
I: Thank you. Let me tell you about our study. We are investigating the psychological and
emotional responses that participating as a CRNA in organ procurement procedures produces in
CRNAs. There have been no studies of this phenomenon. Based on what we have read in the
literature about how other healthcare providers have responded to these procedures, we feel it is
important to explore this to help us better understand how the perioperative team copes with
organ procurement. The study will involve a 3-hour focus group session with several other
CRNAs that have participated in organ procurement. The focus group will be held in a private
room, and the discussion will be taped, transcribed and analyzed for the feelings and responses
of the participants. Your participation is completely voluntary, and you may withdraw at any
time, and refuse to answer any question without any repercussions. The risks of participation are
minimal. There is a risk you may experience discomfort in discussing participation in organ
procurement, and we have campus psychological services referral information if desired. Your
privacy and confidentiality will be preserved, as we will assign your name an alphanumeric code,
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 38
known only to investigators, who are bound by IRB privacy rules. Your identity will not be
associated with the data produced by this study in any way. We will ask you to sign an informed
consent prior to study participation, which will explain the study and risks.
I: Do you have any questions? [Answer any questions].
I: Thank you. May I have your contact information? We will be in touch with the focus session
date, time and location. Here is my card, please do not hesitate to contact me with any questions.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 39
Appendix C: Demographic Data and Semi-structured Interview Guide
Demographic Questionnaire:
1. Age:
2. Experience: Total number of years as an RN:
3. Experience: Total number of years as a CRNA:
4. Gender:
5. Highest level of education:
6. Ethnicity:
• Native American
• Asian
• Black or African American
• Hispanic/Latino
• White
• Two or more ethnicity
• Prefer not to answer
Semi-Structured Interview Questions:
1. Please tell me about your experience with the organ procurement?
2. What is the biggest difference between participating in Organ Procurement in comparison
to other kinds of anesthetics?
3. Tell me about your experience of working with the UNOS representative in managing the
patient. How was that?
4. Recall a time before you had exposure to organ procurement. What were your thoughts
and feelings toward transplantation then? What are they now?
5. In the role of the anesthesia provider, what would you say is the best part of being
involved in organ procurement? What is the worst part of being involved?
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 40
6. What do you think of the preparation for anesthesia providers to participate in organ
procurement procedures?
7. What would you recommend as a program to prepare anesthesia providers to participate
in organ procurement?
8. What support systems are in place to aid the CRNA provider through organ procurement
procedures?
9. What advice do you have for new CRNAs who will be involved in the procurement
process?
10. Tell us about any discomfort you experienced while participating in organ procurement,
or afterward.
11. Tell us about any longer-term effects that you have experienced as a result of
participating in organ procurement procedures.
EMOTIONAL RESPONSE TO ORGAN PROCUREMENT 41
Appendix D: Literature Review Flow Chart
Identification Screening Eligibility Included
Records
identified through
database search
(n=481)
Records identified through
other sources; 23 from
snowballing, 2 fact sheets
from google
search (n=25)
Records after
duplicates removed
(n=390)
Records excluded based on
abstract or involving animal
subjects (n=179)
Records screened
(n=211)
Full text articles
assessed for eligibility
(n=83)
Full text
articles
excluded
(n=56)
Fact sheets deemed
eligible for inclusion
(n=2)
Resources included in
qualitative synthesis (n=29)
Abstract (if available)
Abstract
Certified Registered Nurse Anesthetists (CRNAs) participate in organ procurement procedures involving the harvest of organs from brain-dead donors. These cases are challenging for many reasons. Patient management, which is well documented in anesthesia literature, involves ensuring accurate determination of brain death and the irreversibility of the fatal condition, administration of multiple medications, fluid management, and temperature maintenance in an effort to maintain organ perfusion and minimize warm ischemia time. These cases differ entirely from the usual experiences of anesthesia management. CRNAs are trained to assess patients for risks of anesthesia, yet the brain-dead patient is no longer viable
Linked assets
University of Southern California Dissertations and Theses
Conceptually similar
PDF
The emotional and psychological response of healthcare providers involved in organ procurement: a literature review with practice recommendations for certified registered nurse anesthetists
PDF
The emotional and psychological response of healthcare providers involved in organ procurement: a literature review with practice recommendations for certified registered nurse anesthetists
PDF
Emergence delirium prevention in American veterans diagnosed with post-traumatic stress disorder: a critical literature review with practice recommendations
PDF
Emergence delirium prevention in American veterans diagnosed with post-traumatic stress disorder: a critical literature review with practice recommendations
PDF
Airway fire: extensive literature review and practice recommendations
PDF
Airway fire: extensive literature review and practice recommendations
PDF
The reclassification of propofol as a controlled drug: a comprehensive literature review and recommendations for practice
PDF
Wellness programs for healthcare graduate students: a literature review with recommendations for nurse anesthesia programs
PDF
Clinical competence and perceived confidence in certified registered nurse anesthetists: post thromboelastography (TEG) education
PDF
The reclassification of propofol as a controlled drug: a comprehensive literature review and recommendations for practice
PDF
Clinical competence and perceived confidence in certified registered nurse anesthetists: post thromboelastography (TEG) education
PDF
Anesthesia awareness with recall: an integrative review and best practice recommendations
PDF
The effects of mindfulness meditation on stress levels among student registered nurse anesthetists: a pilot study
PDF
Addressing financial support for nurse anesthesia residents: literature review with policy recommendations
PDF
Airway fire: extensive literature review and practice recommendations
PDF
The reclassification of propofol as a controlled drug: a comprehensive literature review and recommendations for practice
PDF
Enhanced recovery pathway for multimodal analgesia in elective cesarean surgery: literature review with practice recommendations
PDF
Addressing financial support for nurse anesthesia residents: literature review with policy recommendations
PDF
Enhanced recovery pathway for multimodal analgesia in elective cesarean surgery: literature review with practice recommendations
PDF
Evaluating perceived barriers to cognitive aid use among anesthesia providers during malignant hyperthermia, myocardial ischemia, and unanticipated difficult airway
Asset Metadata
Creator
Creef, Nicole Christine
(author)
Core Title
The emotional and psychological response of healthcare providers involved in organ procurement: a literature review with practice recommendations for certified registered nurse anesthetists
School
Keck School of Medicine
Degree
Doctor of Nurse Anesthesia Practice
Degree Program
Nurse Anesthesiology
Publication Date
06/19/2020
Defense Date
06/12/2020
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
anesthesia,anesthesiologist,OAI-PMH Harvest,OR nurse,organ procurement,organ transplantation
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Griffis, Charles (
committee chair
), Bamgbose, Elizabeth (
committee member
), Darna, Jeffery (
committee member
)
Creator Email
creef@usc.edu,ncjones528@aol.com
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c89-320331
Unique identifier
UC11663941
Identifier
etd-CreefNicol-8600.pdf (filename),usctheses-c89-320331 (legacy record id)
Legacy Identifier
etd-CreefNicol-8600.pdf
Dmrecord
320331
Document Type
Capstone project
Rights
Creef, Nicole Christine
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Tags
anesthesia
OR nurse
organ procurement
organ transplantation