CMS SOM App. Y, Tag Z188

the time of consent to donation and the withdrawal of support;

Interpretive Guidelines §486.344(f)(2)

Once informed donation consent is obtained, or in the case of first person consent, the

OPO should work in collaboration with the donor hospital staff to prepare the family or

the legally authorized representative for withdrawal of support and honor the family’s or

the legally authorized representative’s desire to be included as much as possible

consistent with hospital policies and protocols.

The OPO must have written protocols for its collaboration with the donor hospital staff

regarding withdrawal of life support including clear directives as to the responsibilities of

the donor hospital staff and the OPO staff in the period of time between extubation and

declaration of death. The protocol should state that recovery personnel (surgeons and

other recovery practitioners) may enter the operating room to prep and drape the donor,

but then must leave the operating room until declaration of death. OPO personnel may be

in the operating room prior to the actual recovery pursuant to OPTN policy 2.1 and 2.3

which requires that they maintain complete information on any and all organs recovered.