Donation After Donation After Cardiac DeathCardiac Death

May 26, 2010May 26, 2010

Margie Whittaker, RN MSNMargie Whittaker, RN MSN

Anne’s StoryAnne’s Story

RN colleague collapsed while at work RN colleague collapsed while at work SAH with extensive bleedingSAH with extensive bleeding Poor prognosisPoor prognosis Family wishes to donate organs to Family wishes to donate organs to

honor Annehonor Anne Did not progress to brain deathDid not progress to brain death After 48 hours of waiting, withdrawal After 48 hours of waiting, withdrawal

of life support occurred and Anne died of life support occurred and Anne died within about 30 minuteswithin about 30 minutes

Fundamentally…Fundamentally…

The family / patient should make the The family / patient should make the decision to withdraw life support decision to withdraw life support

– independentindependent of of and and

– prior toprior to

ANY discussion regarding organ ANY discussion regarding organ donation.donation.

History of DCD:History of DCD:– Prior to Brain Death Laws – common Prior to Brain Death Laws – common

practice: practice: KidneyKidney 19511951LiverLiver 19611961

PancreasPancreas 19661966

HeartHeart 19671967

History and FactsHistory and Facts

0

100

200

300

400

500

600

700

800

900

10001994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

DCD over the yearsDCD over the years

Why DCD?Why DCD?

> 100,000 people on the waiting list > 100,000 people on the waiting list

17-20 people die every day 17-20 people die every day

DCD Organ recovery can positively DCD Organ recovery can positively impact the shortage of impact the shortage of transplantable organstransplantable organs

IntroductionIntroduction

Organ donation can occur after brain death Organ donation can occur after brain death or after cardiac death or after cardiac death

DCD – potentials:DCD – potentials: The patient has a non-recoverable illness or The patient has a non-recoverable illness or

injury and has suffered neurological injury and has suffered neurological devastation.devastation.

Family / Patient is considering withdrawing Family / Patient is considering withdrawing life-sustaining treatmentlife-sustaining treatment

ProcessProcess

Family and medical staff Family and medical staff beginbegin discussions of withdrawal of life discussions of withdrawal of life sustaining treatment.sustaining treatment.

Refer the patient to OneLegacy.Refer the patient to OneLegacy. OneLegacy will evaluate pt for OneLegacy will evaluate pt for

medical suitability – at this time NO medical suitability – at this time NO APPROACH will be made.APPROACH will be made.

AssessmentAssessment

OneLegacy and health care team OneLegacy and health care team determine cardio-respiratory death determine cardio-respiratory death likely to occur within one hour of likely to occur within one hour of withdrawal of life supportwithdrawal of life support

Huddle – to Care - PlanHuddle – to Care - Plan

DecisionDecision

Decision is made by the family to Decision is made by the family to withdraw life-sustaining withdraw life-sustaining treatmenttreatment

OneLegacy will consult coroner or OneLegacy will consult coroner or medical examiner for releasemedical examiner for release

Consent ProcessConsent Process

Effective requestor approaches Effective requestor approaches

– Family declines donation – continue Family declines donation – continue with end-of-life care processwith end-of-life care process

– Family consents to donation – Family consents to donation – continued medical management of continued medical management of patient patient

Pre-OR Pre-OR

Continued supportive care for patientContinued supportive care for patient

Attending MD/critical care nursing Attending MD/critical care nursing continues to manage the ptcontinues to manage the pt

OneLegacy provides recommended OneLegacy provides recommended parameters for donor management parameters for donor management and lab studiesand lab studies

OneLegacy will utilize usual process for OneLegacy will utilize usual process for the organ allocation. the organ allocation.

OneLegacy will collaborate/coordinate OneLegacy will collaborate/coordinate with the OR and transplant team for a with the OR and transplant team for a timing of recovery.timing of recovery.

OneLegacy will huddle with hospital OneLegacy will huddle with hospital staff to care-plan for the OR staff to care-plan for the OR

Pre-OR (cont.)Pre-OR (cont.)

Intra-OR ProcessIntra-OR Process

After transfer to the ORAfter transfer to the OR

Withdrawal of life-sustaining Withdrawal of life-sustaining treatment is performed in the ORtreatment is performed in the OR

Driven and directed by the hospital Driven and directed by the hospital under their policyunder their policy

Pronouncement of Pronouncement of DeathDeath

The patient will be pronounced dead The patient will be pronounced dead after 5 minutes of no blood pressure and:after 5 minutes of no blood pressure and:– asystole or asystole or – ventricular fibrillation or ventricular fibrillation or – pulseless electrical activity pulseless electrical activity

The practitioner certifying death The practitioner certifying death may may notnot be involved in the recovery or be involved in the recovery or transplantation of the organstransplantation of the organs

The practitioner will record the The practitioner will record the date and time of death in the date and time of death in the medical record and, if applicable, medical record and, if applicable, complete the death certificate.complete the death certificate.

Pronouncement of Pronouncement of DeathDeath

Alternative OutcomeAlternative Outcome

Patient does not arrest within organ-Patient does not arrest within organ-viability time-frame – donation is no viability time-frame – donation is no longer an optionlonger an option

Continue with end-of-life care in a Continue with end-of-life care in a nursing unitnursing unit

OneLegacy responsible for the costs: OneLegacy responsible for the costs: – From time of consent – until – organ From time of consent – until – organ

donation completed or donation process donation completed or donation process abortedaborted

Ethical PrinciplesEthical Principles

Ethical principles around organ Ethical principles around organ donation continue to be discussed and donation continue to be discussed and studiedstudied

Primary discussion is around “dead Primary discussion is around “dead donor rule”donor rule”

Allowing patients to die for organ gainsAllowing patients to die for organ gains Use of ECMO after cardiac/respiratory Use of ECMO after cardiac/respiratory

cessationcessation Honoring wishes and rights of first Honoring wishes and rights of first

person consent for SCI or ALS patientsperson consent for SCI or ALS patients Analgesia at time of withdrawalAnalgesia at time of withdrawal

Outcome of ProcessOutcome of Process

Policy has been in place since 2001Policy has been in place since 2001– 10 DCD donations since that date 10 DCD donations since that date

(about 1-2 year)(about 1-2 year)– Potential DCD donors increased Potential DCD donors increased

every yearevery year– 15 lives saved!!15 lives saved!!– Family able to honor patient’s Family able to honor patient’s

wisheswishes

ConclusionsConclusions

Donation after Cardiac Death is a Donation after Cardiac Death is a viable option to honor patient’s viable option to honor patient’s wishes. It should be considered wishes. It should be considered in excellent end of life care for in excellent end of life care for

any patient who has sustained a any patient who has sustained a catastrophic neuro event.catastrophic neuro event.

Margie.whittaker@stjoe.orgMargie.whittaker@stjoe.org