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Taking the time to complete an advance directive involves careful consideration and discussion of your wishes about end-of-life care. These discussions often raise a variety of related issues, one of which is organ donation. Choice in Dying receives numerous calls from people who are in the midst of completing an advance directive and want to learn how they can become a donor. Many callers are concerned about how a decision to become a donor will affect their advance directive. In the following Q & A article, we answer some of these questions about organ donation.

Why should I consider becoming an organ donor?

The idea of organ donation appears to have widespread public support. According to a recent Gallop Poll, more than 95% of Americans are aware of organs. Despite this enthusiasm, thousands of lives are lost each year due to a lack of donor organs. Recent statistics from the United Network for Organ Sharing estimate that approximately 40,000 people in the United States presently are awaiting organ transplantation and approximately one-third of patients with heart or liver failure die while awaiting a suitable donor.

A recent study published in the Annals of Internal Medicine suggests that lack of family consent is one of the major obstacles to organ donation. Of all deaths studied, less than 50% of potential donor's families agreed to donating organs. This finding is important because most physicians will not override a family's refusal to donate even when a patient's wishes are known.

Under what conditions can organs be donated?

Due to advances in medical technology and pharmacology, it is now possible to transplant organs and tissue such as the heart, lungs, liver, pancreas, kidneys, bone, skin, veins, eyes and corneas. The ability to donate particular organs or tissue depends upon the underlying cause of death. The vital organs, such as the heart, lungs, liver and kidneys, are taken from individuals who suffer brain death, an irreversible loss of brain function. Brain death is most often caused by direct trauma to the head from a car accident or gunshot wounds, massive bleeding into the brain from ruptured aneurysms or lack of oxygen to the brain. In these situations, the vital organs must be protected from the damage until they are removed. This is done by providing oxygen, fluids and chemical support to the donor's body through a respirator and other artificial means. These procedures are commonly called life-support. Although the individual is legally dead, the goal of life support is to preserve the vital organs until they are removed, at which time these treatments are discontinued.

A person's death also might be due to the irreversible loss of heart beat. Once the heart stops, blood flow to the organs stops. Although tissues such as corneas, bone and skin can be removed after a loss of circulation has occurred, the donation of vital organs is no longer possible.

Which laws govern organ donation?

In response to the increasing shortage of organ donors, the National Conference of Commissioners on Uniform State Laws developed the Uniform Anatomical Gift Act (UAGA) in 1969 (amended in 1987). The UAGA has been adopted in some form by every state and the District of Columbia. The act allows people to donate all their organs, specific organs or their entire body for medical research. The goal of the UAGA is to make it easier for individuals to donate their organs and to organize the medical procedures for procuring organs from potential donors. Today, a properly signed and witnessed donor card is recognized throughout the country.

But because the UAGA did little to alleviate the shortage, 26 states and the District of Columbia have enacted Required Request Laws. These laws mandate hospitals to inform families of potential donors of the option to donate organs and tissues. Despite these efforts, a shortage of organs remains.

How do I let others know of my decision to be an organ donor?

Every state recognizes the use of a properly completed organ donor card. Some states print the card on the back of driver's licenses. The most effective method of communicating a decision to donate organs is to discuss decisions to donate organs or wishes with family members. Remember that family refusal to donate is one of the largest obstacles to organ donation.

Can I use my advance directive to donate organs?

Yes. An advance directive is one way to document the desire to donate organs. Several states specifically include organ donation within their advance directive statutes (AZ, CA, CT, ID, IL, KS, MD, MN, ND, RI). Even if your state's form does not have a specific section for organ donation, you can always indicate your wishes under "other instructions."

Regardless of the method used to document wishes, you should always discuss your decisions with your health care agent and loved ones. Although the law does not require permission from family members of a patient who already has consented to donate organs, it is unlikely that a physician will override your family's refusal to donate your organs or tissue.

Will a conflict exist between my advance directives and my will to donate organs?

It is important to remember that the conditions under which an advance directive becomes effective, such as terminal illness or a persistent vegetative state, drastically reduce the chance you will be considered as a donor of vital organs. Although patients in these conditions still may be eligible to donate tissues such as corneas, bone and skin, the procedure for doing so does not require a patient to be maintained on mechanical life support. For this reason, it is extremely unlikely that a conflict will arise between your advance directive refusing life-support and your wish to donate organs. If you are diagnosed as being brain dead, life support would be needed until the vital organs are removed. Again, this is for a short period of time and treatment is stopped once the organs are removed.

The best way to ensure your decisions about organ donation are honored is to inform your family of your wishes. Be sure they understand your desire to donate organs and make it clear that certain procedures would be acceptable for this limited purpose. Making your wishes known through an advance directive and your organ donation card is an important first step, but remember that your family will be called upon to make the final decision about organ donation.