Applying these principles requires an understanding of the healthcare system of each country. In the US, where healthcare is largely supplied and paid for by private organizations, the OPOs act as a vendor or supplier to transplant programs (Mone 2002). However in Spain where healthcare is routinely provided by governmentally funded institutions, OPOs are often a budgeted department or service of a hospital (Matesanz 2011b; Manyalich 2011). These and other culturally-determined variations will affect how these eight principles are applied, but they do not change the fact that all eight must be present to improve organ donation.

In the US, the ethical underpinnings of donation and transplant are incorporated in the Uniform Anatomical Gift Act (CAH & SC 2012) which recognizes the autonomy of the donor to make the decision to donate, independent of family or institutions. The law also recognizes the family or legal agent’s right to decide when the individual has not. The UAGA clearly dismisses the notion of state-authorized recovery of organs. Presumed Consent, which is often discussed as a solution to the organ shortage but in fact has never been shown to be applied in practice and has never resulted in increased donation (Boyarsky et al. 2011; Matesanz 2011b; Rithalia et al. 2009).

This may be one of the more controversial of the eight Principles, as many countries continue to operate their recovery programs from within transplant centers. However, the highest performing OPOs in the US, Spain and elsewhere separate these functions first and foremost to ensure adequate and consistent funding of donation, to remove incentives for the misallocation of organs to the center’s lower-ranked recipients, and to motivate the maximum utilization of organs across a broader sharing region.

Organ donation education has ranged from being weak and understated and fearful of associating with the specter of death to being factual and respectful but still private quiet, to an intentional effort to inspire people to donate by celebrating the life that is saved through transplant and the legacy of the life that was cut short but fulfilled through donation. OneLegacy and successful OPOs throughout the world have opted to engage in public and proactive donation education programs. This more public approach is grounded in the recognition that organ donation is not about death; rather organ donation is about the choices people make once death has occurred (Stadtler 2005; Cameron et al. 2013). This is a fundamental principle and practice of successful donation programs and while it is always respectful of the deceased donor, it accepts that the death has happened, is an independent event, that families ultimately must and do look forward, and recognizes the opportunity to help them do so by choosing to create a legacy of life through organ donation.

Given the reality in which the availability of organs is such that there will always be scarcity (even if everyone who could donate upon death did so, which is only 0.5 % of all deaths (Sheehy et al. 2012)), it is essential to ensure that all of those who can donate do so. To accomplish this it is essential that all who may be asked to donate believe that if they need a transplant they will have an equal opportunity to receive one. Thus the allocation of these scarce organs must be perceived as fair. Of course fair has a number of possible interpretations, so organ allocation systems are in a constant state of evolution. In the US this evolution has migrated from first-come-first served, regardless of economic factors to a more refined balance with identifying those with the most immediate need and greatest likelihood to successfully survive with a transplant (Graham 2006; Yeh 2011).

While organ donation practice began as a task of transplant center nurses, with the separation of duties to OPOs the unique needs of donor management and organ resuscitation medicine took precedence in the hiring and training of OPO personnel. As OPOs have grown, the duties and processes of organ donation have evolved to create at least seven specific skill set/specialty needs (Mone 2002). Thus, additional roles, training , and formal and informal certification of these roles and personnel have developed. Applying such specialization remains a challenge in smaller OPOs, but where the workload affords it, specialization has resulted in higher donation performance and lower costs; especially in a healthcare world in which critical care nurses and MDs are in short supply.

While Separation and Specialization bring clear benefits to donation, they create the potential for isolation and can inhibit critical cross-communication; commonly known as a “Silo Effect” (Hotaran 2009) . Thus, OPOs, Donor Hospitals, Transplant Centers, and the staff within each institution must establish formal and informal means of and reasons for regular communication . This starts with identifying common goals, sharing consequential events and problems in the search of systemic solutions, and speaking with one voice of the benefits, safety , and opportunity of donation. And, as technology advances, sharing real-time information on donors, donor management goals, and donor condition, and allocation status is essential to ensure short and long-term collaboration on the common end goal of saving lives through donation and transplant (Staes et al. 2005).

All efforts at removing the myths and misconceptions associated with donation which have been rather successful in western countries can easily become undone if rare problematic events occur and worse if they are ignored or covered up. Straightforward medical errors like inadequate brain death testing that allowed a child to be prepared for organ donation while conscious but temporarily paralyzed could have decimated donation if not corrected at the time, procedurally for the future, and honestly communicated with the public. (Associated Press 2008) However, the facts and rarity of the case were openly discussed in the media, and it was noted that if his family had not opted for donation he might have been extubated and never have recovered. Thus, a potentially horrendous mistake was shown to be an inadvertent blessing and the public discussion furthered the cause of donation rather than harmed it. Public relations specialists have long-advocated absolute transparency in such circumstance to limit the opportunity for speculation that is caused by a vacuum of information. Because donation begins upon death, the primal and visceral fears of death that we are born with rapidly rise, but can easily be quelled with clear, direct information and transparency in response to inquiry, such as when a liver mis-allocation bypassed some 50 patients in Southern California, but donation actually rose due to full public disclosure (Ornstein 2005).

This principle may end up being a catch-all for the many developments yet to come in successful organ donation, but for now it is focused on the aggressive use of latest generation donor-testing, electronic donor records, to capture, transmit and analyze donor information, the development of new organ resuscitative pumping devices, allocation algorithms to maximize the matches and life-years gained form transplantation. And of course donation and transplant innovation must include means to enhance, clone, print, genetically modify and mechanically replace organs that will one day put the donation community out of business by enabling the transplant of all who are waiting. Innovations like NAT testing have added new levels of safety (Nowicki et al. 2006), Electronic Donor Records enable Intensivist and Surgeon consults and informed decision making based on the complete medical record rather than a telephonic summary, and lung pumps are resuscitating previously untransplantable lungs and enabling them to remain viable for 5 times longer than only 3 years ago (Cypel 2011)

At OneLegacy, more than other OPOs, it is essential to communicate this message in languages, media and venues that are accessible to the 70 % of the population that is non-white/non-English speaking/immigrant (US Census QuickFacts 2010). In creating these materials the task is more complex than simply transplanting language, as individuals from other cultures inevitably arrive with spiritual, ancestral, death and healthcare beliefs and understanding that are very different than multi-generation white English-speaking American. Thus, OneLegacy employs communication strategies that cross cultural boundaries such as the annual Rose Parade that is seen by 84 million viewers (ToR 2013). This typr of event, whose audience assembles and watches for purely celebratory reasons having nothing to do with organ donation, are presented with donors and recipients from every cultural and ethnic group of the region and religious and community leaders who proclaim their religions and communities’ support for organ donation; which is often not known by their own community members.