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Donation Preference


Thank you! Your decision to give the Gift of Life has the opportunity to save up to 8 individuals and enhance up to 50 lives.

I only give consent for the following organs to be donated (check all that apply):

I only give consent for the following tissues to be donated (check all that apply):

Other Restrictions (check all that apply):


* Every possible effort will be made to help save the lives of individual recipients through your gift of organ and tissue donation. If in the event that your organ(s) and tissue(s) are unable to be used for transplantation, they may be donated for education and research purposes.

Click here for more detail on organs and tissues.

Organs

Heart

A heart transplant is a life-saving surgical procedure in which a malfunctioning heart is replaced with a healthy donor heart. The heart is responsible for circulation of blood throughout the body. Heart transplant recipients are generally people who suffer from long-term heart failure, heart muscle disease, severe birth defects or other irreversible heart injury from damage to the vessels of the heart that cannot be treated by any other medical or surgical means.

Kidneys

A kidney transplant is a life-saving surgical procedure performed to restore function to a recipient whose kidneys aren’t working as the result of disease. Kidneys are responsible for removing wastes from the body, regulating electrolyte balance and blood pressure and the stimulation of red blood cell production. A recipient may need a transplant because of primary kidney disease, congenital disease, urinary tract obstruction, high blood pressure, diabetic nephropathy or toxic reactions. Even though most people have two kidneys, one healthy kidney is able to function as if it were two, allowing for a normal, healthy and active life. Therefore, one donor’s kidneys are usually separated and transplanted into two recipients, saving two lives.

Small Intestine

Small intestine transplantation is the life-saving replacement of a unhealthy or surgically removed section of the small intestine. Key to the digestion process, the small intestine is responsible for the absorption of water, vitamins and nutrients. Small intestine recipients require a transplant as the result of diseases such as Crohn’s disease, diverticulitis or short bowel syndrome. Without a transplant, the patients have difficulty maintaining adequate nutrition and sometimes require intravenous feeding. Successful transplantation results in the recipient’s ability to eat normally and maintain nutritional health without intravenous feeding. The small intestine also can be transplanted in combination with other organs such as the pancreas, stomach and liver.

Lungs

A lung transplant is a life-saving surgical procedure performed to replace one or both diseased lungs with a healthy lung. The lungs are responsible for oxygenating the blood supply within the body. A person who needs a lung transplant may be suffering from lung disease such as emphysema, sarcoidosis, pulmonary hypertension or cystic fibrosis. Even though most people have two lungs, one healthy lung is usually able to function in place of two, allowing for a normal, healthy and active life. Therefore, a pair of lungs can be transplanted into two different recipients, saving two lives. A double-lung transplant, as well as a combination heart-lung transplant, can also be done for some patients.

Liver

A liver transplant is a life-saving surgical procedure performed to replace a diseased liver with a healthy one. The liver is the largest and one of the most complex internal organs in the body, with more than 400 functions. Damage to the liver can limit the absorption of vitamins and nutrients, prevent waste elimination and reduce the production of proteins needed to clot the blood. A person who needs a liver transplant may suffer from liver disease such as hepatitis, Wilson’s disease, blood clots, cirrhosis or autoimmune disease. In some cases, one donor liver can be separated into two separate lobes and transplanted into two recipients, saving two lives.

Pancreas

A pancreas transplant is a life-saving surgical procedure performed when a recipient’s own pancreas is diseased. The pancreas produces the hormones glucagon and insulin that help regulate levels of blood sugar (glucose) in your body. Pancreas recipients suffer from a form of diabetes sometimes called insulin-dependent or juvenile onset diabetes, which is the result of an attack on the insulin producing cells of the pancreas. The resulting lack of insulin leads to high blood sugar levels that must be treated with self-administered insulin injections. Despite this treatment, complications of diabetes often include visual disturbances, heart disease, nerve disorders and kidney disease. A pancreas transplant is the only cure for diabetes. Some patients require a kidney-pancreas transplant to treat both the pancreatic and kidney disease suffered as a result of diabetes. In this case, the same donor donates both the pancreas and the kidney.

Tissues

Bones

Bones can be transplanted in order to prevent amputation, promote healing, maintain mobility, and provide structure.

Bone grafts are transplanted during reconstructive orthopedic surgery, which results from injury or medical disorders that have limited the recipient’s activities of daily living. In some cases, a bone transplant prevents the loss of a limb for a recipient whose only alternative is amputation.

Eyes/Cornea

The parts of the eye which may be transplanted are corneas and the sclera, which is the white of the eye. The cornea is the most commonly and successfully transplanted portion of the eye. Corneal transplants are performed in an effort to restore sight to an individual whose vision has been compromised by a genetic defect, degenerative disease or traumatic injury. One donor can restore sight for two recipients.

Heart Valves

Heart valve transplantation is a lifesaving surgical procedure in which a recipient’s damaged valve is replaced with a functioning donor valve. The valves aid the heart’s ability to pump blood through the body. Heart valves are often transplanted into children born with congenital heart valve defects. One of the benefits of this type of procedure is children grow into a donated valve, which is superior to a synthetic alternative. In order to facilitate this gift, the heart is recovered and valves are removed from the heart for transplantation. One heart valve donor can save or heal the lives of several recipients. Heart valves are only donated when the heart cannot be donated as a functioning organ for medical reasons.

Pericardium

Pericardium transplants benefit recipients through orthopedic surgery and neurosurgery. Pericardium is the protective lining surrounding the heart in the chest. The lining is a membrane that can be successfully transplanted to replace the lining of the brain during neurosurgery, or in conjunction with surgery to repair sports-related injuries.

Skin

Skin can be used to aid the healing process for severe burn victims, hernia repairs, mastectomy repairs, or for those who suffer from a disfiguring injury or disease. Donated skin protects recipients from infection while promoting regeneration of their own skin.

Veins

Many people lose circulation in their legs, or even in their heart, due to disease or trauma. Donated veins can restore circulation in heart bypass surgeries and help prevent leg amputation for people suffering poor circulation.

Soft Tissue Tendons

Tendons can be used in a number of orthopedic surgeries. Recovered tendons are often used to repair ruptured ligaments (ACL repair). These surgeries allow the patients to return from an injury and regain full function.

Nerve

Nerve transplants are used to repair damages to the patient’s nerve. This can allow the patient to return feeling and motor control after a serious injury.

Transplant Only

Every effort will be made to transplant your organ, eye and tissue donation to a recipient in need. However, there are some instances when a suitable recipient cannot be identified. If you choose this option, and your donated gifts cannot be transplanted, they will be medically disposed.

Transplant and Research

Every effort will be made to transplant your organ, eye and tissue donation to a recipient in need. However, there are some instances when a suitable recipient cannot be identified. If you choose this option, and your donated gifts cannot be transplanted, every attempt will be made to place your gifts with a qualified facility that can use your donation to learn more about disease processes and treatments.

Donors Under 18

If you are between 13 and 17 years old AND have a state ID card or Driver's License/Learner's Permit, you can join the Donate Life Tennessee organ and tissue donor registry. However, please be aware that your parents will make the final decision about organ and tissue donation at the appropriate time.

Authentication

The following information is intended to provide you with information on the process of donation. If you have any questions or would like further explanation on this section, please call Donate Life Tennessee at 877-552-5050.

I understand and authorize the following as indicated by my signature for authorization at the end of this document:

Donation requires both a physician’s legal declaration of death and the decision to help others. There is no cost to you, your family or estate nor compensation for anything related to the donation. All unrelated hospital charges as well as funeral expenses remain the responsibility of the family or estate.

The privacy and confidentiality of the donor and the decision for donation will be respected. Information will be shared, accessed and obtained from those individuals and organizations involved in the donation process; may include hospital and transplantation staff, the funeral provider, medical examiner’s office, coroner and pathologists. Copies of the medical records, death certificate and autopsy report, if there is one, will be obtained and reviewed.

Part of the donor evaluation process requires transmissible disease testing. These tests are performed to ensure the safety of transplant recipients. Tennessee state law requires that positive confirmed tests be reported to the Tennessee Department of Health Services. In addition, blood, tissues, such as spleen, lymph nodes or blood vessels, or any other medically relevant specimen may be recovered for the purpose of determining suitability and/or compatibility with the potential recipient(s); including archiving of donor samples.

The placement of organs and tissues is directed by local, state and federal guidelines and transplantation standards. At times, tissue may be sent to help people in other countries. Through medical breakthroughs, recovered tissue can be reshaped and reformed to accommodate a variety of transplant needs. Also, in order to benefit the greatest number of recipients, both nonprofit and for-profit organizations may be involved in the process.

The recovery in the donation process is performed with care and does not normally interfere with funeral arrangements. Donation includes careful restoration of the donor. Bruising and swelling may occur. For tissue donation, the donor may be transported to a donation facility for recovery procedures. The medical examiner’s office will determine if an evaluation or autopsy is necessary and if any restrictions regarding the donation process are required. Following the recovery of anatomical gifts and the medical examiner’s evaluation (if applicable), funeral plans and/or other arrangements may proceed.


By submitting this registration, I affirm that I am the applicant described on this application and that the information entered herein is true and correct to the best of my knowledge. This registration will serve as a document of gift as outlined in the Tennessee Uniform Anatomical Gift Act. A document of gift, not revoked by the donor before death, is irreversible and does not require the consent of any other person. It also authorizes any examination necessary to ensure the medical acceptability of the anatomical gift.