Professional Development Programme for Organ Donation1
Paul MurphyGurch RandhawaElla Poppitt
September 2010
Identification and Referral
“Improving organ donation within your hospital”
Professional Development Programme for Organ Donation2
The progression of your learning journey
On
line T
oo
l: Self-A
ssessment T
ool, Docum
ent Sharing, P
odcasts, Discussion
Forum
, PD
P A
tlas, Program
me P
rogress Tracker
National Kick-Off Event(inc Law & Donation after Cardiac Death Master Class)
Change Management & Leadership Fundamentals
Master Class 1 (Diagnosis of Brain Stem Death and Regional Peer Consulting
Group Launch)
Master Class 2(Donor Management & Physiology and Emergency Medicine)
Making Change Happen(Development of action plan to implement changes in Trust)
Master Class 3(Referral / consent / authorisation / Media
Paediatrics(
Regional Collaboratives
National Review Event(Review of Programme and Ethics and Media Skills Master
Class)
National Kick-Off Event(inc Law & Donation after Cardiac Death Master Class)
Change Management & Leadership Fundamentals
Regional Peer Consulting Group(Introduction and coaching in action learning sets)
Making Change Happen(Development of action plan to implement changes in Trust)
Regional Collaboratives
National Review Event(Review of Programme and Ethics and Media Skills Master
Class)
Podcasts: Eye & Tissue D
onation, Epidemiology of D
onation & Transplantation, Audit &
Statistics and PD
A: interpretation & Action
Online Tool Self Assessm
ent Tool, Docum
ent Sharing, Podcasts, Discussion Forum
, Programm
e Atlas, Program
me Progress Tracker
All Clinical Leads Chairs of Donation Committees
Professional Development Programme for Organ Donation3
Agenda
1Identification, referral and consent / authorisation: an overview
40mins
2 Approaches to consent / authorisation 40mins
Break 15 mins
3 Cultural and religious influences 45mins
Break 15 mins
6 Close 5mins
Identification, referral and consent/ authorisation
An overview
Dr Paul Murphy
4
Professional Development Programme for Organ Donation
Introduction
Achieving the strategic big wins for Organ Donation requires breaking down the barriers to success to reveal the underlying issues and plan the most effective interventions
5
There are two important elements to referral
1.That it happens
2.That it occurs soon enough to maximise the opportunity for that person to be a donor
Consent / authorisation is the biggest single obstacle to donation
Considerable evidence for modifiable factors within the family approach.
Professional Development Programme for Organ Donation
Introduction
Achieving the strategic big wins for Organ Donation requires breaking down the barriers to success to reveal the underlying issues and plan the most effective interventions
6
International evidence suggests that timely identification and
referral may improve all facets of the donation pathway, and
thereby increases the possibility of an individual’s desire to
donate being identified and fulfilled.
Professional Development Programme for Organ Donation7
Pathway for a potential DBD donor
Audited Patients Was patient ever ventilated?
Was BSD a likely diagnosis?
Were BSD tests performed?
Was BSD diagnosed?
Were there any absolute contraindications?
Was subject of solid organ donation considered?
Were Next of Kin offered donation?
Was consent/authorisation obtained?
Did organ donation occur?
Referral to Co-ordinator staff
Professional Development Programme for Organ Donation
Understanding the bigger picture
8
• NICE short clinical guideline
– Donor identification and referral
– Family consent
– Consultation begins in spring 2011
• Never events consultation
– Inadvertent ABO mismatch
– Failure to refer patient on Organ Donor Register
• Quality Outcome Framework for Primary Care
– % patients registered on ODR
– www.nice.org.uk/aboutnice/gof/suggestions.jsp
Identification and referral of potential donors
9
Professional Development Programme for Organ Donation10
Professional Development Programme for Organ Donation11
Donation not considered
Brainstem dead, donation not considered (approx 140 cases / year)
1.4
37.2
13.3
1.4
5.3
41.4
0.0 10.0 20.0 30.0 40.0 50.0
cardiac instability
not known
family
no NOK
coroner
contra-indication to donation (incl. age)
% total
Professional Development Programme for Organ Donation12
Donation considered, family not approached
Brainstem dead, family not approached (approx. 70 cases / year)
1.1
9.5
24.3
4.2
24.3
36.6
0 10 20 30 40 50
cardiac instability
not known
family
no NOK
coroner
contra-indication to donation (incl. age)
% total
Professional Development Programme for Organ Donation13
Why do we not consider / refer everyone?
• delays in co-ordination and retrieval – arrival of SN-OD
– very limited absolute contra-indications
– protracted decision-making and offering algorithm
– inconsistency between theory and practice
• lack of confidence with process
• family – cultural and language barriers
– fear of violence
– tragic circumstances
• difficulties with Coroner / Procurator Fiscal / police
• resources
Drilling down to the root causes of failure to refer
potential donors in a timely fashion
Professional Development Programme for Organ Donation14
Age distribution of deceased donors since January 1st 2000
0
500
1000
1500
2000
2500
0-10 11-20 21-30 31-40 51-60 61-70 71-80 81-90
Age group
Nu
mb
er
DBD DCD
Ages of deceased donors in the UK
Professional Development Programme for Organ Donation15
Contra-indications to Donation
• absolute
– variant CJD
– HIV disease (not HIV infection)
• near absolute
– disseminated malignancy
– melanoma (except local melanoma treated > 5 years before donation)
– treated malignancy within 3 years (except non-melanoma skin cancer)
– age > 90 years
– known active tuberculosis untreated bacterial sepsis
Near absolute contra-indications may be overridden when the recipient’s condition is grave (e.g. fulminant hepatic encephalopathy)
Oldest deceased donors in UK (yrs)
DCD DBD
Kidney 80 85
Liver 70 85
Heart - 62
Lung 56 65
Pancreas 59 63
Professional Development Programme for Organ Donation16
Minimum Notification Criteria from Organ Donation Taskforce
Donation after Brain-stem Death
When no further treatment options are available or appropriate, and
there is a plan to confirm death by neurological criteria, the DTC should
be notified as soon as sedation/analgesia is discontinued, or immediately
if the patient has never received sedation/analgesia. This notification
should take place even if the attending clinical staff believe that donation
(after death has been confirmed by neurological criteria) might be
contra-indicated or inappropriate.
All patients should be have the possibility for donation considered as part of their end of life care, and early referral
promotes this possibility
Professional Development Programme for Organ Donation17
Minimum Notification Criteria from Organ Donation Taskforce
Donation after Cardiac Death
In the context of a catastrophic neurological injury, when no further
treatment options are available or appropriate and there is no intention to
confirm death by neurological criteria, the DTC should be notified when a
decision has been made by a consultant to withdraw active treatment and
this has been recorded in a dated, timed and signed entry in the case
notes. This notification should take place even if the attending clinical staff
believe that death cannot be diagnosed by neurological criteria, or that
donation after cardiac death might be contra-indicated or inappropriate.
These proposals are an acceptable but minimum description of what is necessary. They should be implemented in all acute Trusts.
ODTF Report
Professional Development Programme for Organ Donation18
Expanded Notification Criteria from Organ Donation Taskforce
Clinical Triggers
The Taskforce considers that there is an urgent need for a pilot study
looking at the impact of introducing clinical indicators as a trigger for
notification. The Taskforce believes that it should assess not only the role
of triggers in increasing donation, but also the impact upon staff and
patients and their families of introducing what the Taskforce accepts is a
radical change of practice. The Taskforce believes that having the
evidence from such a study would be critical in gaining the necessary
support to be able to move the agenda forward on this important issue.
These clinical notification proposals should be seen not in isolation, but as part of the overall strategy
ODTF Report
Professional Development Programme for Organ Donation19
US Breakthrough Collaborative
Clinical Triggers
• Likelihood of death
– GCS < 5
– Absence of one of more brain stem reflexes
• Declared intention to perform brain death tests
• Declared intention to withdraw cardiorespiratory support
Overarching strategies
• focus on change, improvement
and results
• rapid and early referral and
linkage
• integrated donation process
• ‘aggressive pursuit of every
donation
‘In short, early referral leads to increased time with potential donor’s family and results in higher donation rates’
Shafer, T (2006)
Professional Development Programme for Organ Donation20
US Breakthrough Collaborative
400
450
500
550
600
650
700
750
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Org
an D
onors
1999 2000 2001 2002 2003 2004 2005 2006
Collaborative Starts Here
Professional Development Programme for Organ Donation21
400
450
500
550
600
650
700
750
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Org
an D
onors
1999 2000 2001 2002 2003 2004 2005 2006 2007
Collaborative Starts Here
US Breakthrough Collaborative
Professional Development Programme for Organ Donation22
All patients with severe brain injury requiring mechanical ventilation
Call if:
• brain stem death testing planned
• GCS ≤ 4
• absence of 1 or more cranial nerve reflex
– pupils fixed
– no corneal reflex
– no cough or gag reflex
– unresponsive to painful stimuli
A decision to withdraw active treatment has been made in a ventilated patient of any age
or
Clinical triggers for referral………in Birmingham
Professional Development Programme for Organ Donation23
Advantages of Clinical Triggered Referral
Professional Development Programme for Organ Donation24
Advantages of Clinical Triggered Referral
All patients should be have the possibility for donation considered as part of their end of life care, and early referral promotes this possibility
• all potential donors are referred
• early access to coordination and retrieval advice
– advice on confirmation of brain-stem death
– allows donation potential to be identified and end of life care plans to be defined
– reduces likelihood of delays in arrival of SN-OD or retrieval team(s)
– facilitates ‘long contact’ model of family support for consent / authorisation
• improves accuracy of PDA data
Professional Development Programme for Organ Donation25
‘Never Events’
‘Never events’ are defined as serious, largely preventable patient safety incidents that should not occur if the available preventable measures have been implemented by healthcare providers.
Criteria:
• clear potential for or has caused severe harm / death
• evidence of occurrence in the past (i.e. it is a known risk)
• existing national guidance on prevention
• event is largely preventable if guidance is implemented
• occurrence can be easily defined, identified and continuously measured
The occurrence of a never event is a clear indicator of an organisation that which has not put in place the right system and processes to
prevent the incidents from happening.
Professional Development Programme for Organ Donation26
Current ‘Never Events’
• wrong site surgery
• retained surgical instrumentation
• wrong route administration of chemotherapy
• failure to detect misplacement of orogastric or nasogastric tubes prior to use
• in-hospital maternal death from post-partum haemorrhage following elective Caesarean section
• iv administration of mis-selected concentrated potassium chloride
In July 2010 the Government committed to proceed with work to impose fines for an extended list of never events.
Professional Development Programme for Organ Donation27
Proposed ‘Never Events’
• inadvertent transplant of an ABO / HLA incompatible organ
• A person who is on the Organ Donor Register and who does not have an absolute contra-indication for organ donation and who dies without having been referred for consideration of organ donation.
• consultation in October
‘..serious failure will not be tolerated, especially where there are clear guidelines and procedures in place to prevent serious incidents. Where serious failings still occur, organisations will be subject to serious sanctions…’