Strange Harvest. Lesley A. Sharp
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The artificial ventilator now routinely enables EMTs, as well as staff based in emergency wards and trauma centers, to administer CPR to damaged patients' bodies, place them on artificial respiratory support, and then, through the assistance of drug therapies that control pain and blood pressure, for instance, maintain such patients in relatively stable states in ICUs. Many procedures are performed on patients already pronounced dead as a prelude to acquiring consent and procuring their organs. It is at these highly liminal moments in clinical care that procurement professionals become intimately involved with patients and their kin. Although such policies are not necessarily enforced, the majority of states in this country now mandate hospitals to alert their local OPO if they have a patient whom they believe may soon be brain dead. Some states even require hospitals to report all deaths to the OPO so that field staff can assess all deceased patients as potential organ and/or tissue donors. Whereas a decade or so ago many OPOs were based within hospitals that specialized in transplantation, today this is the exception rather than the norm. Typically, OPOs maintain separate offices off site, working instead with a network of hospitals that may actively assist in identifying organ donors and/or perform transplant surgeries.
Once alerted to the potential demise of a particular patient, OPO field staff enter the hospital and perform a range of tasks. Sometimes one person performs all the necessary tasks; in larger OPOs the duties may be split between two people, in part because the work at either end is exhausting, especially when a case extends over the course of several days. As one OPO staff member explained, it can be an emotionally trying experience for the same individual to tend to the clinical needs of a depersonalized body while also trying to comfort a family in the throes of grief. Here I offer perhaps the most complex version of OPO hospital work, involving a pair of employees who work side by side, as typified by the style of a large, urban OPO whose staff I observed during the mid-1990s. Following this account, I will briefly describe other arrangements.
Knowing what to call OPO staff is itself problematic: many procurement professionals employ the title “transplant coordinator,” but this is both confusing and misleading for several reasons. First, staff who work directly with recipients in transplant units also go by this title; second, the work of OPO staff in fact focuses specifically on procurement (otherwise known as “retrieval” or “harvesting”) and donation, not on transplantation. Furthermore, OPO field duties involve both clinical and counseling roles, and so in my discussion here I use labels that reflect these responsibilities. When duties are split between two staff members, their activities typically play out as follows. The first, or what I will call the clinical coordinator, works directly at the bedside of a potential donor. If brain death is thought imminent, the clinical coordinator often assumes duties previously performed by hospital nursing staff, who retreat in order to care for other, more viable patients. The clinical coordinator takes regular readings of the patient's status, and he or she may even write orders on the patient's chart, providing directives for administering medications, especially vasopressors (or “pressors” for short) that control drops in blood pressure. Clinical coordinators generally have backgrounds in critical care nursing, so that many have worked previously in hospital ICUs. It can be difficult for lay visitors to distinguish clinical coordinators from in-house nurses because they frequently dress in hospital scrubs, wear no badge that identifies their employer, and may make little effort to clarify to family members for whom they actually work.
The clinical coordinator may be paired, in turn, with a family counselor, someone who arrives dressed in a suit or somewhat formal street clothes. The primary duty of family counselors is to provide emotional support to family members; typically they explain that they specialize in helping families cope with end-of-life issues. They also respond to a range of pragmatic concerns. For instance, when overtaxed nursing staff are too busy to help family members find meals or coffee, or a private room in which to talk or rest, the family counselor will respond to these needs. As with their clinically trained partners, their purpose (and employer) may be left unstated at least at the onset. Family counselors generally wear no identification badge (save that required by hospital security), allowing them the option of passing as hospital employees rather than proclaiming outright that they are from an OPO. Such practices are justified by OPO employees who stress the importance of establishing social bonds with kin before raising the topic of donation. A badge that declares that one works in organ retrieval would subvert their ability to breach the topic gradually with kin, and only once they have gained their trust as compassionate health workers. The fact that many OPOs have altered their names in recent years also facilitates this process. Whereas ten years ago most agencies bore composite names consisting of their state or region plus “OPO” (for instance, NWOPO or Northwest Organ Procurement Organization), many have assumed new titles that emphasize organ donation as an act that saves lives (thus, NWOPO is now LifeCenter Northwest).10 Today only a few OPOs are based within hospitals, but ten to fifteen years ago such relationships were common, only further complicating the duties of procurement work. I can only hypothesize at this point, but drawing from my data culled from fourteen OPOs of a range of sizes, it appears that employees from smaller offices are less likely to attempt to pass as hospital staff. The question of how OPO field staff should introduce themselves to the kin of prospective donors is currently a topic of heated debate. As my descriptions reveal here, procurement strategies in the United States are, oddly, both compassionate and covert.
Successful procurement rests heavily on the shoulders of family counselors. Particularly important is their skill in engendering trust among family members, for without this their attempts at procurement will fail. In those cases where family members experience callous treatment from overextended hospital staff, the OPO family counselor provides a sympathetic ear and shoulder, allowing kin to express their sadness and rage openly and free of judgment. An important strategy employed by many OPOs today is referred to as “decoupling,” where successful procurement is understood as relying on the sequential acceptance of two messages by a patient's surviving kin (DeJong et al. 1998). The first message concerns brain death criteria, and OPOs generally rely on hospital physicians—preferably neurologists—to explain this initially to patients. OPOs thus expend much time and energy running in-house educational seminars for hospital staff on the dos and don'ts of talking about brain death with patients' families. The OPO family counselor then follows up with another discussion or series of conversations about brain death, sometimes supported with visual aids but, more frequently, by employing vernacular language devoid of mystifying clinical jargon. As I will explain in greater detail later, metaphorical analogies abound. Only once kin begin to show signs of accepting brain death criteria (they start to talk about funeral arrangements, for instance) does the family counselor shift to the second message: that is, the great social value of organ and tissue donation.
Within one East Coast OPO in particular, I found that family counselors defined a well-developed area of in-house expertise. This OPO is based in a large and ethnically diverse city, and in the mid-1990s the director hired a team of counselors who represented an eclectic range of professions, religions, and ethnicities. This hiring practice was based on the premise that it would facilitate the rapid establishment of rapport with families whose backgrounds overlapped with those of individual counselors. Such an approach was nevertheless highly controversial within this OPO and beyond because of a dominant assumption in the realm of organ transfer that all patients or bodies are equal beneath the surgeon's knife (Sharp 2002b). Nevertheless, in this particular OPO, if it was known in advance that a potential donor was, say, Latina, the team's director would make every effort to assign a family counselor fluent in Spanish and, preferably, also of Latin American descent. Similarly, an Orthodox rabbi, who often agreed to be on call, would respond to requests to meet with Jewish families of a range of levels of observance; and an African American woman, who had worked previously as a Pentecostal minister within a storefront church, was regularly matched with inner-city African American and Caribbean families.
These elaborate pairings generally characterize only the nation's largest OPOs and were more typical in the 1990s than they are at present. Financial pressures (linked in large part to false hopes that donations would grow substantially each year) have forced some OPOs to scale back, rendering specialized hiring practices an unaffordable luxury today, except where linguistic barriers may prevent successful donation outcomes. Similarly, clinical coordinators and family counselors may have reverted to