Standards › Standard 43 › Policies
Policy · TXP-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 43.1
At a glance
- Donor or family consent is obtained by a person independent of the transplant team that needs the organ (TXP-FRM-001).
- The consent conversation is recorded with the donor’s known wishes.
- No member of the requesting team takes consent.
- The consent process is the same for every donation.
- Stop and get help straight away if: consent is taken by a member of the transplant team that will receive the organ.
1. Purpose
To make sure donation decisions are free and not influenced by the team that benefits from them (43.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Donation must be a free choice, made by the donor or their family, and not pressured by the team that will use the organ. A consent process separate from the treatment team protects that choice.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Donation lead | Owns the independent consent process | Clinical director |
| Independent consent clinician | Takes consent and records the wishes | Donation lead |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Assign.
- Assign a consent clinician who is not on the transplant team for the donation.
Key point: Assigned.
Step 2. Consent.
- Take consent and record the donor’s known wishes or the family’s decision (TXP-FRM-001).
Key point: Consented.
Step 3. Confirm.
- Confirm the consent is recorded before any organ is retrieved.
Key point: Confirmed.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Donations with independent consent recorded | 100% | Quarterly | Donation lead | Escalate to the clinical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| TXP-FRM-001 | Donor consent record | Record |
| CON-SOP-001 | Informed consent before significant care (existing) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation (2010), including the principles on donation without commercial gain, and the ASF Hospital standard for consent. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)