1. Donation After Cardiac Death May 26, 2010 Margie Whittaker, RN MSN

2. Anne’s Story RN colleague collapsed while at work RN colleague collapsed while at work SAH with extensive bleeding SAH with extensive bleeding Poor prognosis Poor prognosis Family wishes to donate organs to honor Anne Family wishes to donate organs to honor Anne Did not progress to brain death Did not progress to brain death After 48 hours of waiting, withdrawal of life support occurred and Anne died within about 30 minutes After 48 hours of waiting, withdrawal of life support occurred and Anne died within about 30 minutes

3. Fundamentally… The family / patient should make the decision to withdraw life support –independent of and –prior to ANY discussion regarding organ donation.

4. History of DCD: History of DCD: –Prior to Brain Death Laws – common practice: Kidney1951 Liver1961 Pancreas1966 Heart1967 History and Facts

5. DCD over the years

6. 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 impact the shortage of transplantable organs DCD Organ recovery can positively impact the shortage of transplantable organs

7. Introduction Organ donation can occur after brain death or after cardiac death Organ donation can occur after brain death or after cardiac death DCD – potentials: The patient has a non-recoverable illness or injury and has suffered neurological devastation. The patient has a non-recoverable illness or injury and has suffered neurological devastation. Family / Patient is considering withdrawing life-sustaining treatment Family / Patient is considering withdrawing life-sustaining treatment

8. Process Family and medical staff begin discussions of withdrawal of life sustaining treatment. Family and medical staff begin discussions of withdrawal of life sustaining treatment. Refer the patient to OneLegacy. Refer the patient to OneLegacy. OneLegacy will evaluate pt for medical suitability – at this time NO APPROACH will be made. OneLegacy will evaluate pt for medical suitability – at this time NO APPROACH will be made.

11. Assessment OneLegacy and health care team determine cardio-respiratory death likely to occur within one hour of withdrawal of life support OneLegacy and health care team determine cardio-respiratory death likely to occur within one hour of withdrawal of life support Huddle – to Care - Plan Huddle – to Care - Plan

13. Decision Decision is made by the family to withdraw life-sustaining treatment Decision is made by the family to withdraw life-sustaining treatment OneLegacy will consult coroner or medical examiner for release OneLegacy will consult coroner or medical examiner for release

14. Consent Process Effective requestor approaches Effective requestor approaches –Family declines donation – continue with end-of-life care process –Family consents to donation – continued medical management of patient

16. Pre-OR Continued supportive care for patient Continued supportive care for patient Attending MD/critical care nursing continues to manage the pt Attending MD/critical care nursing continues to manage the pt OneLegacy provides recommended parameters for donor management and lab studies OneLegacy provides recommended parameters for donor management and lab studies

17. OneLegacy will utilize usual process for the organ allocation. OneLegacy will utilize usual process for the organ allocation. OneLegacy will collaborate/coordinate with the OR and transplant team for a timing of recovery. OneLegacy will collaborate/coordinate with the OR and transplant team for a timing of recovery. OneLegacy will huddle with hospital staff to care-plan for the OR OneLegacy will huddle with hospital staff to care-plan for the OR Pre-OR (cont.)

19. Intra-OR Process After transfer to the OR After transfer to the OR Withdrawal of life-sustaining treatment is performed in the OR Withdrawal of life-sustaining treatment is performed in the OR Driven and directed by the hospital under their policy Driven and directed by the hospital under their policy

20. Pronouncement of Death The patient will be pronounced dead after 5 minutes of no blood pressure and: The patient will be pronounced dead after 5 minutes of no blood pressure and: –asystole or –ventricular fibrillation or –pulseless electrical activity The practitioner certifying death may not be involved in the recovery or transplantation of the organs The practitioner certifying death may not be involved in the recovery or transplantation of the organs

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

23. Alternative Outcome Patient does not arrest within organ- viability time-frame – donation is no longer an option Patient does not arrest within organ- viability time-frame – donation is no longer an option Continue with end-of-life care in a nursing unit Continue with end-of-life care in a nursing unit OneLegacy responsible for the costs: OneLegacy responsible for the costs: –From time of consent – until – organ donation completed or donation process aborted

26. Ethical Principles Ethical principles around organ donation continue to be discussed and studied Ethical principles around organ donation continue to be discussed and studied Primary discussion is around “dead donor rule” Primary discussion is around “dead donor rule” Allowing patients to die for organ gains Allowing patients to die for organ gains Use of ECMO after cardiac/respiratory cessation Use of ECMO after cardiac/respiratory cessation Honoring wishes and rights of first person consent for SCI or ALS patients Honoring wishes and rights of first person consent for SCI or ALS patients Analgesia at time of withdrawal Analgesia at time of withdrawal

27. Outcome of Process Policy has been in place since 2001 –10 DCD donations since that date (about 1-2 year) –Potential DCD donors increased every year –15 lives saved!! –Family able to honor patient’s wishes

28. Conclusions Donation after Cardiac Death is a viable option to honor patient’s wishes. It should be considered in excellent end of life care for any patient who has sustained a catastrophic neuro event. Margie.whittaker@stjoe.org