Dr Alison Ingham (ITU Consultant and CLOD Bangor)
Dr Liz Williams (Associate Specialist Palliative Care)
Usual not UnusualUsual not UnusualUsual not UnusualUsual not UnusualUsual not UnusualUsual not UnusualUsual not UnusualUsual not Unusual
All parts of the NHS must
embrace organ donation as a
usual, not an unusual event.
Local policies, constructed
around national guidelines,
should be put in place.
Discussions about donation
should part of all end-of-life
care when appropriate.
Recommendation 4a
� To facilitate good end of life care for patients and their families on ICU following withdrawal of treatment
� To make organ and tissue donation a usual part of end of life care
� To facilitate good documentation of end of life care
� Audit of current practice
� Initial pathway development
� Consultation
� Final draft
� Trial / pilot phase
� Audit
� Final pathway and all Wales use
Withdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatment
� 73% deaths on ITU in Glan Clwyd occurred after withdrawal of active treatment.
� 72% deaths on ITU in Bangor occurred after withdrawal of active treatment.
Time from treatment withdrawal to
death
Was DNAR form completed? Yes No
Was end of life conversation with family
well documented?
Yes No
Clear documentation of what treatments
are to be withdrawn?
Yes No
Were inappropriate medications
discontinued?
Yes No
Were IV fluids discontinued? Yes No
Were PRN
medications
prescribed?
Analgesic Yes No
Anxiolytic Yes No
Secretions Yes No
Nausea / vomiting Yes No
Is there documentation that family were
given bereavement leaflet / information?
Yes No
Were the family asked about tissue
donation?
Yes No
Is it obvious from the notes exactly who
was present at the time of death (family
and staff)?
Yes No
Time from withdrawal to deathTime from withdrawal to deathTime from withdrawal to deathTime from withdrawal to deathTime from withdrawal to deathTime from withdrawal to deathTime from withdrawal to deathTime from withdrawal to death
35%53%56%% died within 2 hours
6 min to 77 hours
10 min to 12 hours
5 min to 17 hours
Range
180 min55 min110 minMedian
203823No. patients (total 81)
WrexhamGlan ClwydBangor
RangeRangeRangeRangeRangeRangeRangeRange
T im e fro m w ith d ra w a l o f c a re to tim e o f d e a th (W re xh am )
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
0 2 4 6 8 10 12 14 16 18 20
P a tie n t n u m b e r
Ho
urs
Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death -------- BangorBangorBangorBangorBangorBangorBangorBangor
� 25% patients die within 1 hour
� 56% patients die within 2 hours
AuditAuditAuditAuditAuditAuditAuditAudit
75%?89%IV fluids discontinued
50%?16%55%Inappropriate medications
stopped
45%55%61%Clear documentation of which treatments to be
withdrawn
50%97%100%End of life conversation
with family well documented
45%53%61%DNAR completed
WrexhamGlanClwyd
Bangor
0
10
20
30
40
50
60
70
80
90
100
pe
rce
nta
ge
an a lg esia an xio lytic secretio n s an tiem etic
B an g o r
G lan C lw yd
W rexh am
AuditAuditAuditAuditAuditAuditAuditAudit
10%73%18%
Obvious who was present at time of
death
0%5%0%Family asked about tissue donation
0%15%0%Documented that family were given bereavement leaflet
WrexhamGlan ClwydBangor
� We do well but there is room for improvement
� Short and easy to use
� Replace all other documentation – less work
� Make organ and tissue donation usual
� Help to complete cremation forms
� Developed from the Liverpool Care Pathway
� Welsh collaborative Pathway Project 1999
� Multidisciplinary practice based on guidelines and evidence.
� Now used across Wales in a variety of settings
Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last
hours/days of life.hours/days of life.hours/days of life.hours/days of life.hours/days of life.hours/days of life.hours/days of life.hours/days of life.
For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to
withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.
� A guideguideguideguide to provide care for family and patient
� Multi disciplinary document replacing all medical, nursing and paramedical notes
� Each professional encouraged to exercise own judgement within guidelines
� Series of suggested goals of treatment
� Variances to the care suggested are recorded
FlowchartFlowchartFlowchartFlowchartFlowchartFlowchartFlowchartFlowchart
� Instructions
� Criteria
� Goal 1 Donation after Cardiac Death
� Carried out by ITU physician
� Discontinuing non essential medication
� PRN medication for common end of life symptoms
� Discontinuing inappropriate interventions
� Carried out by ITU nurse
� Communication
� Religious issues
� Family care
� Completed by ITU nurse
� Hourly observations
� In accordance with Academy of Medical colleges code of practice (2008)
� Cause of death
� Family needs
� Special need of deceased
� Tissue donation
� Communication with other Medical agencies
� Monitor and audit
Drug ChartDrug ChartDrug ChartDrug ChartDrug ChartDrug ChartDrug ChartDrug Chart
Trial PhaseTrial PhaseTrial PhaseTrial PhaseTrial PhaseTrial PhaseTrial PhaseTrial Phase
� Plan to re-audit after first 20 uses
� Please tell us what you think
� Make changes as necessary
Any Questions?Any Questions?Any Questions?Any Questions?Any Questions?Any Questions?Any Questions?Any Questions?