2.5 ANCC rganIssues in contact hours OProcurement, Allocation, and Transplantation By Deborah Nierste

ABSTRACT: Organ transplanta- tion extends lives and improves health but presents complex ethical dilemmas for nurses caring for donors, recipients, and their families. This article overviews organ procure- ment and allocation, discusses ethical dilemmas in transplantation, and offers strategies from professional and biblical perspectives for coping with moral distress and maintaining compassionate care.

KEY WORDS: moral distress, nursing, organ transplantation, ­workplace coping

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Copyright © 2013 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited. xpanding knowledge and deal with moral turmoil and continue advancements opened the door technology in organ and providing excellent patient care? for present-day successful organ tissue transplantation are transplantation. providing hope for the Brief History of Today, transplantation of the heart, treatment of chronic ­Transplantation lung, heart/lung together, liver, kidney, diseasesE and new life for those who Ancient literature suggests human pancreas, pancreatic islets, kidney/ otherwise would experience incapacity organ transplantation may have been a pancreas, intestines, hematopoietic stem or premature death. Although organ treatment for diseased tissue as early as cells, bone, cornea, skin, and face transplantation extends lives and 450 BC as the Sushruta manuscripts (composite tissue allotransplantation) is improves health, it presents complex contain a description of the first skin performed (Klein et al., 2011). Organs ethical dilemmas and questions that do transplant (Klein, Lewis, & Madsen, and tissues from one donor can not have easy answers. Who should be 2011). Schlich (2011) credits the “first potentially save up to eight lives, eligible to receive transplants? Should organ transplant in the modern sense” whereas tissues from the same donor illegal aliens, foreigners, people with a (p. 1372) to Swiss surgeon Theodor can benefit 50 lives (Donate Life, history of addiction or noncompliance, or convicted criminals be eligible? Who should have first priority to receive transplants: patients in the Organs and tissues from one greatest need or those most likely to benefit with the best donor can potentially save up long-term outcome? How is end-of-life determined to eight lives, while tissues for deceased donors? Nurses working in from the same donor can various settings can find ­benefit 50 lives. their personal values in conflict with the law, the values and decisions of colleagues, and/or the values of the patients and families who donate or Kocher. In 1883, Kocher transplanted 2010). Recipient complications of receive transplants. For example, the healthy thyroid tissue into patients transplantation include rejection, United States Constitution guarantees who had undergone a thyroidectomy infection, and cancer from long-term healthcare for prisoners (Fung, 2011). A to observe whether or not this would immunosuppressive therapy (Klein et nurse may feel it unfair for a criminal reverse symptoms now known as al., 2011). However, the success of to receive an organ ahead of a law- hypothyroidism. His technique transplantation is demonstrated by abiding citizen. Yet nursing actions are established a model for future organ 5-year survival rates for organ recipi- directed by the patient’s right to auton- transplantations. ents (Table 1), supporting the value of omy, the law, or decisions made by Despite obstacles and setbacks, the transplantation programs. colleagues—whether or not they agree process of transplantation progressed. with the process and outcomes. These German scientist Karl Landsteiner How Are Organs conflicts can initiate inner turmoil that, contributed with his discovery of the ­Procured? if left unchecked, can lead to moral blood group system and its relationship Although some organs (kidney, distress. What help is there for nurses to to organ rejection. Alexis Carrel and partial liver, partial lung) are procured Mathieu Jaboulay furthered the from live donors, most organs come Deborah Nierste, BSN, RN, serves as an Adjunct Faculty at Indiana Wesleyan development of organ transplantation from deceased donors. Approximately University, Marion, Indiana, and is with successful vascular suturing three of every four organs transplanted pursuing a Master of Science in Nursing techniques. Joseph Edward Murray’s are recovered from deceased donors Education. use of immunosuppressive drugs (Steinbrook, 2007). Typically organ Accepted by peer review 12/13/12. allowed the first successful kidney donation only is possible when a The author declares no conflict of interest. transplant from an unrelated donor in person dies as a result of irreversible DOI:10.1097/CNJ.0b013e3182839b47 1962 (Klein et al., 2011). These cessation of all brain function, known journalofchristiannursing.com JCN/April-June 2013 81

Copyright © 2013 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited. as Donation after Brain Death or DBD, TABLE 1: Five-Year Survival Rates for Select U.S. while their heart and lung function is a artificially maintained (National Health Organ Transplants Performed 1997–2004 and Medical Research Council, 2007). Organ: Males Females Few people die in ways that allow Number % Survival Number % Survival them to become donors. Persons who Alive Rate Alive Rate are HIV, hepatitis B or D seropositive; Heart 4,522 73.2 1497 69 have current neoplastic conditions (with some exceptions); systemic Lung 802 46.6 815 47.3 infection from agents for which treatment is not feasible (i.e., methicillin- Heart/lung 29 35.8 45 41.4 resistant Staphylococcus aureus); a prion disease (i.e., Creutzfeldt–Jakobs); or for Kidney 19,430 84.2 13,667 85.8 whom risk assessment is not possible cannot donate organs. Pancreas 339 84.6 280 79 The Uniform Determination of Death Act (UDDA) states “an individu- Kidney/pancreas 1537 86 1036 84.4 al, who has sustained either irreversible cessation of circulatory and respiratory Liver 6496 71.8 4460 73 function, or irreversible cessation of all Intestine 62 49 49 45.5 functions of the entire brain, including the brain stem, is dead” (U.S. President’s aLatest available data as of January 25, 2013. Commission for the Study of Ethical Source: Organ Procurement and Transplantation Network. (2013). Data: Data reports: National. Retrieved from Problems in Medicine and Biomedical http://www.unos.org/donation/index.php?topic=data and Behavioral Research, 1981, p. 2). Current practice allows organs to be removed from patients who are declared brain dead then he or she is If solid organ retrieval (heart, kidneys, ­considered brain dead and from those clinically and legally dead and may be etc.) cannot occur quickly, other who expire as a result of cardiac death. considered a candidate for organ tissues not as dependent on blood In every case certain criteria must be donation. The brain-based definition of perfusion can still be harvested (i.e., met before organs can be procured. death became acceptable as criteria for skin, cornea, bone). The key term in determining cardiac transplantation since the brain-dead Many controversies surround both death is irreversible, meaning the heart patient is no longer considered living DBD and DCD. Marquis (2010, p. 25) has permanently stopped beating and (based on neurological criteria), but asserts that “...the permanence of the cannot be restarted through interven- maintains viable organs that have been cessation of circulatory function in tion. Obtaining organs from donors continually perfused by a fully func- DCD donors does not entail its after cardiac death was the approach tioning heart (Steinbrook, 2007). irreversibility.” He contends that when used prior to 1970 (Steinbrook, 2007). Today, a rising demand for organs a person presents in the emergency With the formulation of the UDDA in and decreasing number of brain-death department (ED) with no heartbeat, 1981, cardiac death criteria continued donors has stimulated a renewed but is successfully resuscitated, they to be used, but more attention was interest in cardiac-death donors were in the same physiological state as given to brain death. Brain death (Zamperetti, Bellomo, & Ronco, 2009). a patient declared dead by the DCD typically denotes that the brain ceases Donation after Cardiac Death (DCD), protocol, hence a potential conflict. to function before the heart stops formerly known as non-heart-beating Furthermore, declaring either brain or beating; breathing and heartbeat are organ donation (NHBOD), is now cardiac death, is fraught with emotional assisted mechanically but will likely recognized when defining death. In complexity and turmoil for providers cease once mechanical intervention is DCD, solid organs are procured after and patients’ families and friends. removed. To determine brain death, a the heart stops beating (usually within Once a patient has met criteria for series of tests are performed to deter- 5 minutes of cardiac arrest) following becoming a potential donor, a health- mine if there is absence of brainstem withdrawal of life-sustaining treatment care professional contacts the local reflexes, motor responses, and absence (WLST) (Rady, Verheijde, & McGregor, organ procurement organization of respiration when removed from 2007). Organ retrieval in this case affiliated with the hospital. A profes- artificial ventilation. Other tests can occurs only after “irreversible cessation sional trained in the donation process verify absence of brain activity and of respiration and circulation has been makes an onsite visit to assess and intracranial blood flow. If a person is declared” (Rabinstein et al., 2012, p. 414). evaluate the potential donor’s medical

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Copyright © 2013 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited. condition and history. Once a physi- the most ­regulated areas of healthcare citizens who are not U.S. residents cian performs the required tests and today” (n.d., para. 1). State laws (OPTN, 2012c). Once the person’s declares the patient to be brain dead, a generally address the process of pertinent information is entered into transplant coordinator from the organ donation. The National Conference of the OPTN database, the computer procurement organization also makes Commissioners on Uniform State generates a prioritized list of persons an onsite visit to review the patient’s Laws formulated the Uniform Ana- suitable to receive organs, matching information and meet with the medical tomical Gift Act (UAGA) of 1968. The these candidates to donors (Trans- team and family. When consent from UAGA regulates state laws on the plant Living, 2012). The rules for the family is obtained, a search for donation of organs and tissues from allocation vary by organ but these potential recipients begins. cadavers (Clemmons, 2009). This law general principles guide the alloca- It should be noted that “Nearly all also lists the hierarchy for next of kin tion process: (1) patient’s medical religious groups support organ and notification. urgency, (2) blood, tissue, and size match tissue donation and transplantation as Federal laws focus on the procure- with the donor, (3) time on the waiting long as it does not impede the life or ment, allocation, and transplantation list, and (4) proximity to the donor hasten the death of the donor” (United of donated organs. The National (Brezina, 2010). Network for Organ Sharing [UNOS], Organ Transplant Act, enacted in 1984, 2012, para 2). Summary statements from established the Organ Procurement Who Should Receive a large number of faith traditions about and Transplantation Network (OPTN). ­Organs? organ donation and transplantation can This federal organization maintains a According to UNOS, in February be found on the UNOS website under “list of patients waiting for transplants,” 2013 117,086 people were waiting for “Fact Sheets: Theological Perspectives.” operates “a system for matching organ transplants in the United States; As soon as recipients are located, the donated organs with individuals on 23,360 transplants occurred January to donor is taken to the operating room the list,” establishes “medical criteria October 2012 from 11,663 donors where the organs are removed from the for allocating organs,” collects and (OPTN, 2012a). In 2010, a total of body. The retrieved organs are flushed analyzes “data on organs donated and 6,521 patients died while waiting for with a cool solution to remove all transplanted,” and conducts “work to organ transplants (Donate Life, 2010). blood. The organ is measured, evaluated, increase the supply of donated organs” Clearly the need for organs is far and packaged in a sterile environment (OPTN, 2012b, para. 2). The OPTN is greater than the quantity available and

Nearly all religious groups support organ and tissue donation and transplantation as long as it does not impede the life or hasten the death of the donor.

with ice for transportation. Tissue and managed by the UNOS that develops complex decisions must be made as to blood samples are taken from the donor and monitors policies for OPTN, who receives available organs. Consider for further testing (Gift of Life, n.d.). facilitates procurement and allocation the following true scenarios: of organs, and collects and analyzes data Potential Recipients: A 16-year-old The Current regarding transplantations (Crowe & female collapses at a family dinner and is ­Allocation System Cohen, 2006). transported to the ED and admitted with A system governed by state laws, Currently in the United States, to a massive myocardial infarction due to federal laws, federal regulations, and be added to the UNOS waiting list a thrombosis of a major coronary artery. UNOS policies attempts to guarantee person must be in end-stage organ Her condition deteriorates to the point fairness in the distribution of donated failure and seen by a physician at a that a ventricular assist device (VAD) is organs. The U.S. Department of Health U.S. hospital where transplants are inserted until heart transplantation can & Human Services (DHHS) asserts ­performed (Clemmons, 2009). This occur. The family is paying for her care that “the field of organ and tissue includes U.S. citizens, non-U.S. citizens with the assistance of medical insurance donation and transplantation is one of who are U.S. residents, and non-U.S. (Hollar, 2012; Trachtenberg, 2010). journalofchristiannursing.com JCN/April-June 2013 83

Copyright © 2013 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited. A 27-year-old male is admitted TABLE 2: General Recipient Contraindications to with a previous history of congestive a heart failure treated with a pacemaker Transplant defibrillator and medication. The patient’s condition has worsened and • Incurable or serious active infection greater intervention is needed. A • Active malignancy VAD is implanted while the patient • Any condition with a death prognosis < 5 years awaits a heart transplant. Armed • Untreatable severe psychiatric or psychological condition guards accompany him since he is a • Severe neurological deficits prisoner serving an 11-year sentence • Severely limited functional status (i.e., severe mental retardation) for drug convictions. The cost of his care is covered by the government • Substance abuse within last 6 months (Associated Press, 2009; Green, • Complete absence of reliable/consistent social support system 2011). • Convincing evidence of non-compliance Second Time Around: A 16-year- • Obesity (body mass index [BMI] range > 30–45 kg/m2) old male with juvenile diabetes is • Severe cachexia (BMI < 17–18 kg/m2) admitted to a dialysis center in need • Inadequate financial resources of peritoneal dialysis due to kidney • Multiple intercurrent conditions failure. He has been noncompliant with his diabetic regimen. He is placed aCollected from a variety of transplant programs in the United States and England; specific organ transplants may on the transplant list and eventually have additional contraindications. receives a kidney. Posttransplantation he does better with his diabetic care, but eventually stops taking his antire- These situations are challenging and jection medications. He also begins controversial, bringing dilemmas nurses Web Resources smoking cigarettes and using marijuana. face as they provide care. The dilem- Several years later, the transplanted mas, both discernible and obscure, United Network for Organ Sharing— kidney begins to fail, creating the need include allocation and distribution of http://www.unos.org for another donor kidney (E. Martin, organs, shortage of organs, and pro- Organ Procurement and personal communication, February 15, curement of organs from dying donors. Transplantation Network— http://optn.transplant.hrsa.gov 2012). International Transplant Nurses A Tragic Donor: A 23-year-old is ­Society—http://www.itns.org rushed to the ED after sustaining ETHICAL DILEMMAS IN Donate Life America— massive head trauma in an automobile ­TRANSPLANTATION http://donatelife.net accident. She is resuscitated, intubated, Transplantation is an expensive Gift of Life— and placed on a ventilator. She is given procedure involving the cost of the http://www.donors1.org intravenous medications and blood surgical process along with rehabilita- transfusions, but remains unresponsive. tion and lifetime immunosuppressive Over the next few days physicians maintenance. Because of the expense, to be smoke-free and substance perform a series of rigorous tests to the scarcity of organs, and the risk of abuse-free for at least 6 months to be determine brain activity and blood rejection or failure of newly transplanted on the waiting list, and it is expected flow through the brain. Testing reveals organs, it is necessary to consider only they remain smoke and drug-free. Little absence of brainstem reflexes and medically suitable recipients. Recipient research is available that addresses the motor responses in addition to contraindications from a number of relapse rate in transplantation cases; absence of respiration when removed transplant programs are given in Table 2. however, one study reported one in from the ventilator; other tests verify However, even these contraindications four heart transplant recipients resume absence of brain activity and intracra- can be imprecise. Questions arise such smoking (Macrae, & Hagan, 2008). The nial blood flow. The patient is declared as: Where do you draw the line when relapse rate for alcohol use after trans- brain dead by two physicians, each determining which patients are plantation falls within a range of 2 to 10 having conducted his own indepen- medically suitable? What is fair selec- for every 100 people (McGowan dent testing. The family has agreed to tion? Does this include choosing those Institute of Regenerative Medicine, donate this patient’s organs (BestofBay. in need as a result of addictive, abusive, 2012). In addition, one cannot indi- com, 2012). or poor health behaviors over those vidually predict which patients will All of these scenarios, as well as without history of addictions? Most relapse; this issue raises moral distress many others, occur in the real world. transplant organizations require patients and questions of fairness.

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Copyright © 2013 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited. Likewise, is it fair to include those transplant ahead of another patient sion, frustration, feelings of reduced who are incarcerated for heinous who also is in need of a transplant and self-worth, and withdrawal from family crimes, often with a history of addic- has been compliant with the medical and friends (Gallagher, 2010; Schluter, tive behaviors? The law protects regimen. Is it ethical to give organs to Winch, Holzhauser, & Henderson, prisoner rights to healthcare by virtue patients who have caused or precipi- 2008; Wiegand, & Funk, 2012). Moral of the Eighth Amendment to the tated their organ failures when others distress affects the health of nurses and Constitution (Fung, 2011). Law-­ may die as a result? their provision of care, job satisfaction, abiding citizens must pay for their own Given the three scenarios and assum- retention, and personal relationships. transplants while prisoner transplants ing that all criteria are met, it is possible The distress can become so great that are provided for by taxpayers (Hill & that the 23-year-old victim rendered nurses do not want to care for their Mooney, 2012; Leung, 2009; Loew, brain dead could become the donor of patients or their families and begin to 2012). Is it fair for a criminal to receive the heart for the criminal whose heart work fewer hours, eventually leaving an organ before a law-abiding citizen? may have been damaged as a result of the nursing unit or the profession UNOS states that convicted criminals drug use. At the same time the 18-year- altogether (Gallagher, 2010; Schluter are “sentenced by the judicial system old teenager with a VAD dies while et al., 2008; Wiegand, & Funk, 2012). only to a specific punishment, i.e., waiting for a heart, through no fault of How can nurses respond to moral incarceration, fines, or probation, not to her own. This same donor could conflicts to manage distress? additional punishment such as inability become the donor of a kidney for the to be considered for medical services” patient who is need of a second kidney COPING WITH (OPTN, 2012c). transplant due to noncompliance and ­MORAl CONFLICT Similarly, where should the line be illegal drug use. These outcomes can Many years ago a wise nursing drawn when a patient is medically create emotional conflict and lead to instructor told me it’s necessary to first suitable but cannot afford transplanta- moral distress for nurses caring for these take care of the nurse, so the nurse can tion? Patient financial status and patients. Furthermore, in most cases take care of the patient. Individual insurance coverage can be consider- despite whether or not they agree, final management of daily stressors is key to ations when placing a person on the decisions are out of the nurses’ hands. nurses’ well-being and job performance waiting list. Research shows the poor Nurses experience moral distress when dealing with difficult dilemmas. and the uninsured are less likely to when personal values conflict with Thankfully, God provides biblical receive a transplant since their inability ethical obligations on a regular basis principles to deal with stress and moral to pay for the immunosuppressive while caring for patients and their conflict. medication will result in failure of the families. It is not uncommon for moral When Jesus was under stress he donated organ (Laurentine & distress to result when dealing with applied Scripture. Knowing God’s Word ­Bramstedt, 2010). Salahi (2011) reports that “transplant centers have the right to turn patients away, but physicians are required The field of organ and tissue to care for every patient they see” (Sydney D. donation and transplantation is Caplan as cited in one of the most regulated areas Salahi, para. 9). In the first scenario above, of healthcare today. if the two young patients are deter- mined to have equal medical urgency with the same blood, tissue end-of-life situations, including those helped him bout Satan (Matthew 4:1-11), and size match, and proximity to the that involve fair allocation of resourc- when criticized (Matthew 9:10-13; donor, but the 27-year-old male es and protecting patients’ rights Mark 2:23-28), and at his Crucifixion patient was placed on the list first, then ­(Lazzarin, Biondi, & Di Mauro, 2012; (Luke 23:35-43, 46). Studying God’s he could be awarded the organ despite Radzvin, 2011; Repenshek, 2009). Word provides a way to know God his involvement in illegal drugs and Nurses who experience moral distress intimately and reveals his wisdom and incarceration. Likewise, should the have reported physical symptoms such direction for difficult situations. noncompliant diabetic patient in as headaches, neck pain, and stomach Throughout his life, Jesus got alone the second scenario test drug-free for problems. Psychological and emotional and prayed to seek God’s presence 6 months, he could receive a kidney symptoms include anger, guilt, depres- (Matthew 14:23; Luke 22:39-46). In journalofchristiannursing.com JCN/April-June 2013 85

Copyright © 2013 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited. addition to quiet times with God It is important to develop personal Because of his faith and trust, ­Abraham’s outside of work, nurses can use break relationships to build a support system life was changed forever (Genesis time for a brief walk outside or rest for challenging times. Lack of social 12-22). Being faced with dilemmas in a quiet room for a few minutes. support has a “direct effect on emo- enables nurses to reach out to and Distance from difficult circumstances tional exhaustion and burnout” (Prins reflect on God’s faithfulness, knowing enables us to not only release emotions, et al. as cited in Pardoe, 2011, p. 28). God will take care of them and their but reflect on the situation and analyze In Scripture, Martha’s sister Mary patients, somehow meeting their needs thoughts, feelings, and emotions (Lim, demonstrated building relationships. during difficult times (Proverbs 3:5-6), Bogossian, & Ahern, 2010). A time of Mary chose to abandon her duties and working with them to bring about prayer and reflection strengthens the temporarily and do nothing but sit at good (Romans 8:28). spirit and helps us focus on God and Jesus’ feet (Luke 10:38-42). Nurses can gain his perspective (Philippians 4:8). set priorities to spend time with God PROFESSIONAL CARING This clearing of the mind and strength- and others to help them through Despite difficult circumstances, ening of the spirit provides the clarity stressful events. “Knowing that support nurses have the responsibility to act as necessary to continue care and work is readily available can greatly enhance an advocate for the patient and to through dilemmas. This is an important coping strategies and help ease the practice compassionately within legal, concept for a nurse caring for a tension or perception of stressors” ethical, and professional standards. The

Professional and spiritual sources help nurses compassionately care in difficult transplant situations.

potential donor. Removing oneself (Gurung, 2006 as cited in Pardoe, American Nurses Association (ANA) from the situation permits the nurse 2011, p. 29). Seeking help from Code of Ethics for Nurses with Interpretive to mentally transition the focus from in-house ­support groups for those Statements (2001) states, “the nurse caring for the living to maintaining working with transplant patients or respects the worth, dignity, and rights organs that will give others a second palliative care can be beneficial. of all human beings irrespective of the chance at life. Research has shown that these groups nature of the health problem. The Renewing the mind alleviates help staff members identify the effect worth of a person is not affected by troublesome thoughts, which, in turn, of traumatic experiences and losses, disease, disability, functional status, or enables the body to sleep better. Rest, while validating their experiences proximity to death” (p. 3). Shelly and along with proper nutrition and exercise, (Hanna, & Romana, 2007). Miller explain that Christian caring is can restore the body and give strength. The Bible encourages God’s “hands-on, patient-centered, physical, While feeding the 5,000 the disciples followers to persevere to grow spiritually. psychosocial and spiritual intervention were so busy they did not have time to Perseverance through difficulty makes a to meet the needs of a patient regardless eat. At one point Jesus pulled them person stronger (2 Corinthians 4:16-18; of how the nurse feels” (2006, p. 250). aside and accompanied them to a place James 1:2-4; 1 Peter 1:6-7). Jesus was a Puchalski adds that “Compassion is an where they could rest (Mark 6:31). great example of perseverance through- attitude, a way of approaching the Rest need not always involve sleep but out his life and especially through his needs of helping others with their can entail leisure activities such as Crucifixion (Hebrews 12:1-3). suffering, but it is also a way of being, a relaxation practices (walks, massages), The final principle encompasses way of service to others, a spiritual prac- vacations, hobbies, and entertainment. putting trust in God and his faithfulness tice, and an act of love” (2009, p. 188). Healthy eating and exercise help with during difficult times. Because of the Christ calls us to care for everyone, endurance and strength. It is important relationship Abraham had previously even the least deserving, as we would to keep the body healthy and rested so built with God, Abraham was able to care for him (Matthew 25:31-46), nurses are better prepared for wearing trust God when he had no heir and reminding us that God values all life responsibilities. later, to sacrifice his only son Isaac. and in every detail, stage, and condition

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Copyright © 2013 InterVarsity Christian Fellowship. Unauthorized reproduction of this article is prohibited. (Luke 12:6-7). These professional and Hill, J., & Mooney, T. (2012, August 7). R.I. prison Rabinstein, A. A., Yee, A. H., Mandrekar, J., Fugate, J. E., spiritual sources help nurses compas- inmate gets liver transplant at state, federal expense. de Groot, Y. J., Kompanje, E. J. O., ..., Wijdicks, E. F. M. Providence Journal. Retrieved from http://news. (2012). Prediction of potential for organ donation after sionately care in difficult transplant providencejournal.com/breaking-news/2012/08/ cardiac death in patients in neurocritical state: A situations. ri-prison-inmat-1.html prospective observational study. The Lancet Neurology, Nurses working in areas that relate Hollar, C. (2012). J.R. Martinez and Jessica Melore heroes at 11(5), 414–419. to organ donation and transplanta- Rose Parade. Retrieved from http://suite101.com/ Rady, M. Y., Verheijde, J. L., & McGregor, J. (2007). tion—EDs, ICUs, Transplant Units, article/jr-martinez-and-jessica-malore-heroes-at-rose- “Non-heart-beating,” or “cardiac death,” organ donation: parade-a403919 Why we should care.” Journal of Hospital Medicine, 2(5), can be empowered to fulfill the Klein, A. A., Lewis, C. J., & Madsen, J. C. (2011). Organ 324–334. Retrieved from http://www.medscape.com/ ministry to which God has called transplantation: A clinical guide. New York, NY: viewarticle/563803_2 them. A key to persevering through Cambridge. Radzvin C. L. (2011). Moral distress in certified difficult times is to remain focused Laurentine, K. A. & Bramstedt, K. A. (2010). Too poor registered nurse anesthetists: Implications for nursing practice. AANA Journal, 79(1), 39–45. on the purpose; providing care that is for transplant: Finance and insurance issues in transplant ethics. Progress in Transplantation, 20(2), 178–185. Repenshek, M. (2009). Moral distress: Inability to act or legal, ethical, professional, and Christ- Retrieved from http://www.natco1.org/members/ discomfort with moral subjectivity? Nursing Ethics, 16(6), like. Centering on the purpose documents/TooPoorforTransplant.pdf 734–742. doi: http://dx.doi.org/10.1177/0969733009342138 provides motivation, keeps priorities Lazzarin, M., Biondi, A., & Di Mauro, S. (2012). Moral Salahi, L. (2011, April 26). Convicted rapist Kenneth straight, develops potential, and offers distress in nurses in oncology and haematology units. Pike turns down heart transplant. ABC News. Retrieved Nursing Ethics, 19(2), 183–195. from http://abcnews.go.com/Health/HeartHealth/ strength and energy. God has given Leung, R. (2009, March 5). Change of heart. 60 convicted-rapist-kenneth-pike-turns-organ-transplant/ nurses a special ministry, and he minutes. Retrieved from http://www.cbsnews. story?id=13458512#.UGntLFF1goN provides what we need to look com/2100-18560_162-572974.html Schlich, T. (2011). The art of medicine: The origins beyond difficulties and care compas- Lim, J., Bogossian, F., & Ahern, K. (2010). Stress and of organ transplantation. The Lancet, 378(9800), 1372–1373. sionately in morally complex coping in Australian nurses: a systematic review. International Nursing Review, 57(1), 22–31. Schluter, J., Winch, S., Holzhauser, K., & Henderson, A. ­situations such as organ donation doi:10.1111/j.1466-7657.2009.00765.x (2008). Nurses’ moral sensitivity and hospital ethical and transplantation. Loew, M. (2012, May 15). AZ inmates receive health care climate: A literature review. Nursing Ethics, 15(3), some law-abiding citizens can’t. CBS5. Retrieved from 304–321. doi: http://dx.doi.org/10.1177/0969733007088357 http://www.kpho.com/story/18411127/az-inmates- Shelly, J. A., & Miller, A. B. (2006). Called to care: A American Nurses Association. (2001). Code of ethics for receive-health-care-some-law-abiding-citizens-cant Christian worldview for nursing. 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