1. Breakout Session A: “Wait
Breakout Session A: “Wait!! This patient is NOT brain dead… How can they be a donor?” Donation After Cardiac Death Case Studies
Moderator:
Margie Whittaker, RN, Mission Hospital
Presenters:
Julie Vaupel-Phillips, RN, CHOC Children’s
John Brady, RN, St. Mary Medical Center
Esther Montoya, RN, OneLegacy

2. Wait!! This patient is NOT brain dead…How can they be an organ donor?
Moderator:
Margie Whittaker, RN
Manager SICU
Mission Hospital
BIO:

3. Transplant Time Line 1954 First Successful Kidney Transplant
1962 First Successful Cadaveric
Kidney Transplant
1963 First Successful Lung
1967 First Successful Heart and
Liver Transplant
1954 First Successful Kidney Transplant
Herrick Twins - Live donation
Dr. Joseph Murray, Dr. David Hume
Brigham Hospital, Boston
1962 First Successful Cadaveric Kidney Transplant
Dr. Joseph Murray, Dr. David Hume,
1963 First Successful Lung Transplant
Dr. James Hardy
University of Mississippi Medical Center, Jackson
1967 First Successful Liver Transplant
Dr. Thomas Starzl
University of Colorado, Denver
First Successful Heart Transplant
Dr. Christiaan Barnard
Groote Schuur Hospital, South Africa
Dr. Joseph Murray successfully planted the first kidney from a live donor into his identical twin brother.
Eight years later he performed the first transplant from a cadaveric donor.
The first transplants were kidneys from patients who had suffered a traditional circulatory death , where the heart and lungs ceased to functioning. Survival rates were poor due to problems with rejection and poor organ quality caused by warm ischemic time., the period where organs begin to die due to lack of oxygen supply.

4. “How to be…” Being in action! The answers are in the room
“Report out” on Questions to Run-on:
Scribe
Spokesperson
All Teach / All Learn
Moderator

5. Questions to Run on…
How will you apply what you learned today during future end of life care plans? How will you remember to include donation?

6. Objectives
By the end of this presentation, the attendee will be able to:
Identify best practices in DCD
Recognize the importance of collaboration and communication in donation
Describe strategies to improve the DCD process

7. Corporate Presentation Speaker Notes
Wednesday, April 19, 2017
Pediatric Donation After Cardiac Death (DCD)
Julie Vaupel-Phillips, MHA, RN, CCRN
Director of PICU and ETS Services
CHOC Children’s Hospital
Juliet A. Vaupel-Phillips, MHA, BA, RN, CCRN
Julie is currently the Director of the Pediatric Intensive Care Unit and Emergency Transport Services Inpatient Nurse Practitioners at CHOC. She has over 24 years experience in Pediatric Nursing and in Administration.
238 bed not-for-profit children's hospital
Orange County, California
Shared services with adjacent adult hospital
30 bed PICU and 12 bed CVICU
PICU Received the Beacon Award
Magnet Facility
© 2008 CHOC Children's. All Rights Reserved.

8. Corporate Presentation Speaker Notes
Donation Facts
Wednesday, April 19, 2017
In the USA 1% all deaths are considered brain death.
One organ donor has the potential to save up to 8 people by donating organs and may provide 50 people with tissue and cornea transplants.
There are more people on the organ wait lists than organs available. 18 people die each day waiting for an organ transplant
Literature shows that parents want to be asked about organ donation, including donation after cardiac death.
Families of children are more likely to agree to organ donation than families of adult patients.
© 2008 CHOC Children's. All Rights Reserved.

9. Donation after Cardiac Death (DCD)
Corporate Presentation Speaker Notes
Donation after Cardiac Death (DCD)
Wednesday, April 19, 2017
DCD offers an option to patients and families who may wish donation to occur after life sustaining equipment is withdrawn, and death is determined by cardiopulmonary criteria.
For DCD to occur, patient death is determined by cessation of cardiac & respiratory function, rather than by the absence of cerebral and brain stem function.
DCD is generally practiced in the USA
Sensitivity and respect for the families wishes allows the health care providers the opportunity to help them through the end of life process and offer them the satisfaction and comfort that can come from the donation process. There generous gift allows families to find hope during their time of grief.
© 2008 CHOC Children's. All Rights Reserved.

10. Donation after Cardiac Death
Things to think about:
Some children die despite all our efforts
Death is not a failure
Death is a natural part of life.
Donation is a family driven process.
The family has already made the decision to allow the patient to die.
The families decision to donate must be separate from their decision to withdrawal of support.
Family participation is essential
The patient must always be provided comfort measures
Slide courtesy of Dr. Thomas Nakagawa, MD, FAAP, FCCM

11. Donation after Cardiac Death at CHOC Children’s Hospital
2005, Q3           1 DCD
2006, Q1, Q3     2 DCDs
2007, Q3           1 DCD
2008, Q3           1 DCD
2009                0 DCD
2010                0 DCD
2011, Q1, Q2
At CHOC Children’s we have had a total of 5 patients whose families have chosen to donate their child’s organs using Donation After Cardiac Death as an option.

12. Things to Consider with PEDS DCD
The parents may change their mind at any time.
Expect that the parents will want to be present in the OR and hold their child at the time of death.
Expect that the OR will not be comfortable with the parents coming into the OR.
Try to time the OR for evening, night or early am when there are fewer cases in the department.
Request an OR room that has an easy egress but is private so that the family can be as comfortable as possible.
Huddle frequently and often.

13. Case Study 3 month old female Twin A Found unresponsive in crib
Asystolic when arrived in ED
Metabolic workup positive for fatty acid oxidative defect
Parents informed of poor prognosis
Family requested withdrawal of support and asked about organ donation
OneLegacy contacted
Consent obtained for Organ Donation

14. Case Study Patient prepared for transport to OR.
Patient 4.2 kg, no local recipients.
Stanford University accepts liver and kidneys.
OR Booked for 16:00
Flight plans set for transplant team to fly from Palo Alto.
Parents request to be close to the OR but will not be present in the OR. Family in secluded area of the OR.
Family Care Coordinator and Priest support the family.
20 minutes from OR time, the transplant team experiences an in-flight emergency
Flight is diverted to Sacramento

15. Case Study
Family is informed but are willing to wait the 3-4 hours it may take to get the team down to Orange County.
Transplant team arrives (8 pm) and patient brought back to the OR.
Parents placed in secluded OR room.
Withdrawal of LST performed by the PICU Intensivist.
Patient was pronounced dead 11 minutes after withdrawal of life support.
Parents immediately informed, baby blanket and toy returned to them.
Surgery starts after 5 minutes of observation period.
Liver and Kidneys successfully recovered.

16. Words of Advice… Support internal staff and each other
Expect the unexpected
Develop a plan
For family-demographics, communicate and explain what will occur, what they will see and hear, and all the what if’s
For patient-palliative care, terminal extubation person,
For staff-roles and responsibilities
Post case debrief (OPO & hospital) for staff involved
Learn something from every case
DCD is patient/family centered care

17. Their lives depend on it!

18. Thank you.

19. St Mary Medical Center Apple Valley
Donation After Cardiac Death
Case Review
St Mary Medical Center Apple Valley
John Brady, RN, CCRN, CNRN
ICU Nurse Manager
John Brady, RN, CCRN, CNRN
John is currently the ICCU Manager at St. Mary Medical Center in Apple Valley. He has been RN for 20+ years, mainly in ICU leadership. He is certified in critical care and in neuroscience nursing. He is currently completing his BSN in nursing.
St. Mary Medical Center is part of the St. Joseph Health system. SMRM offers a range of services from wellness and prevention programs to an emergency department and heart care services including the only open heart surgery program in the High Desert.
For over 50 years, SMRM has grown and continues to plan for the future progressing from a small hospital in 1956 to the comprehensive, 194-bed medical center it is today.

20. Donation at St. Mary Medical Center
Organ donors
7 Organ Donors
5 brain dead
2 DCD (2006 and 2011)
17 organs recovered
14 organs transplanted
3 organs for placed for research

21. Day 1: Admission 45/M Status post cardio-pulmonary arrest Areflexic
Medical history methamphetamine use, high cholesterol, & diabetes
Down time 45 minutes
Transfer in from local hospital for higher level of care

22. Day 2 Consult to OneLegacy Patient made a DNR
Family wanted to extubate soon
Family initiated donation discussion with physician

23. Day 2: OneLegacy Consult
Family wanted to extubate that evening
Awaiting OneLegacy’s arrival to discuss donation
Patient’s mother initiated donation topic stating…
It was a difficult decision but she wanted her son to save lives through donation.
OneLegacy discussed donation options with the family. The family consented for both brain death and DCD donation, said their final goodbyes, left the hospital, and requested post OR follow-up.
Plan: EEG ordered for next day

24. Day 2: OneLegacy Consult
OneLegacy discussed donation options with the family.
The family consented for both brain death and DCD donation, said their final goodbyes, left the hospital and requested post OR follow-up
Hospital planned for EEG on Day 3

25. Day 3 EEG showed activity, Patient NOT BRAIN DEAD DCD Policy reviewed
Huddle with all Champions: Attending Physician, Nurse Manager, Charge Nurse, Bedside Nurse, Respiratory Therapist, Palliative Care, Risk Manager and House Supervisor

26. Day 3
Patient placed on CPAP and shallow breaths were observed; attending physician determined that there was a high probability that the patient would not survive longer than 60 minutes
Palliative Care informed the family that EEG showed activity
Family confirmed that they wanted to proceed with donation 26

27. The Next Steps
Attending physician aware that he will be pronouncing the patient
OR scheduled for 18:30pm
16:00pm patient’s sister called the unit hysterical; the bedside nurse referred caller to speak with the patient’s mother 27

28. The Next Steps
Attending physician became concerned with recent phone call from patient’s sister and requested a second teleconference with the family to confirm donation choice
Patient’s mother contacted Palliative care and verified consent for donation

29. OR Delayed
Attending physician left hospital at 19:00pm and delegates pronouncement to Hospitalists or ED physician; no new OR time set
Risk Manager contacted the Medical Director who instructed the Attending to return to SMRM to pronounce the patient in OR 29

30. The Gift of Life
OR: Pt extubated 20:35pm; pronounced by Attending Physician at 20:59pm (24 minutes) Outcomes: Right Kidney placed locally 61 Female on waiting list 2, 899 days Left Kidney placed locally 60 Male on waiting list 2, 833 days Liver and pancreas placed for research

31. What We Learned
Planning
Communication
Teamwork

32. DCD Data & The Story it Tells
Presented by:
Esther Montoya RN, MSN ED
Donation Development Coordinator
OneLegacy
As these hospitals shared, there is a learning curve that occurs on many levels when a DCD case presents itself at a facility. OneLegacy is no different and I am going to share some of the data related to our learning curve and to the possibilities for the future.

33. Dr. D”Allessandro coined this term “Back to the Future” and it still captures the reality of DCD donation. As many of you know, DCD was the way donation was done before BD pronouncement was an accepted method of determining death. You can see that nationally, the number of DCD cases grew, but here on the West Coast, this type of donation was no longer pursued

34. DCD vs. Brain Dead Donors (United States)
When you compare BD to DCD donation nationally, you can see that BD donation has been pretty much consistent throughout the years. DCD donation on the other hand, shows an increase. The difference in BD donors from 2003 to today is a little over 800, not much growth. DCD donation on the contrary has shown significant growth.

35. OneLegacy DCD History 3rd Qtr
OneLegacy or SCOPC as it was previously known began, performing DCD cases again in We began by learning from our Eastern OPO’s and from each individual case as well. We are projected to perform 30 DCD cases this year.

36. OneLegacy Brain Dead vs. DCD Donors4%
3rd Qtr 7% 6% 5%
When you compare BD with DCD donors in our service area, you can see DCD is a small percentage of the overall donors. In 2003 DCD cases were less than 2% of our total donors and this year they are projected to be 7% of OneLegacy’s total donors. As mentioned before, the number of brain dead donors has been relatively stable throughout the years despite all the education and efforts of the OPO’s and government over these years.

37. OPO DCD Comparison
OneLegacy (CAOP) compared to high performing OPO’s (DCD) in the US:
MIOP= Michigan-Gift of Life
MAOB= New England Organ Bank-MA
PADV= Gift of Life Donor Program-PA 76 60 72 23
When OneLegacy is compared to high performing OPO’s ( ) we see most of them are on the eastern part of the country where they never stopped pursuing DCD cases in addition to BD donors. Their numbers of DCD cases are much higher and we have a bit of catching up to do. The difference in averages is 46.

38. DCD & Organs Transplanted
Average=1.84
Average=1.66
Average=1.80
Average=1.48
Potentially 84 More Lives Saved
When you look at a different perspective such as the average number of organs transplanted from those cases. You can see that OneLegacy has performed slightly better than those same OPO’s. The 25 DCD cases last year resulted in approximately 46 transplants. If we could mimic the high performing OPO’s and reach their average of 69 DCD donors a year, that would equate to 84 more lives saved than last year.

39. California Donor Registry
Designated Donors Among Recovered Donors

40. Trends in Donation
Registered Donors= % in our service area, 27.3% Nationally
DCD donors occurred at 52 out of 220 hospitals since ( )
AA= 33 23% A= %
B= % C= %
Hospitals with DCD P&P’s:
2003 = <2% = >90%
2010 Research/study
Clinical trigger cards introduced to selected hospitals to capture DCD potentials.
In reviewing the data, the trends we see and the areas with the greatest potential for growth are registered donors and DCD donors.
The donor registry began in 2003 and now constitutes about 21% of our total donor cases (of all types) which includes BD and DCD cases. In our area, through June 2011, 41 of our donors were on the registry. This is a national trend we believe will continue to grow.
DCD cases are 7% of our donor cases. We also expect our number to DCD cases to increase.In 2003 less than 2% of hospitals had a DCD policy in place compared to today when greater than 90% of hospitals have policies in place. Only 52 hospitals of the 220 we serve, have had a DCD case at their facility.We (OneLegacy) categorize the hospitals by level of activity. An AA is a very large hospital, an A is a large hospital, a B is a medium sized hospital, and a C is a smaller hospital. As you can see DCD donor cases have occurred at all sizes of hospitals. So do not think one could not occur at yours too.
Another factor is that most hospitals did not have a DCD policy back in 2003 and today most do. Having a policy in place and staff knowledgeable about the process is vital to identification of that potential donor in your hospital.
Last year OneLegacy introduced an adapted clinical trigger card. You all know what that is, a card posted within the units that helps staff identify a potential donor by listing the patient criteria for referral and lists our phone number. This adapted card either removed the GCS and/or added verbiage to refer on those patients, where terminal extubation was being discussed or planned and they were not expected to survive.

41. Clinical Trigger Research
2009
2010
2011
3rd Qtr
Projection
Referrals
4398
5144
3597
5383
Eligibles
549
487
362
541
Donors
382
349
270
406
DCD 24
(6%) 25
(6.9%) 21
(7.4%) 30
(7.3%)
Here are the results of that study. The referrals since the project continue to grow despite decreases during the same time period, in the number of traumas and eligible donors within our hospitals. As a result many of our hospitals have either eliminated the GCS on the clinical trigger or included new verbiage that captures the ventilator patient case where EOL decisions are being made. 41

42. What Story does the Data Tell?
Highlights areas of potential growth by trends
DMV and Registered donors
DCD donation
In summary, the data supports the belief that the registry will continue to grow and we will see many donor cases because of it.
DCD donation is also expected to grow. I think we can do better by working as partners on performance improvement activities like those clinical trigger changes and identification of those potential donors. I hope you can take something away from all our presentations that will help you grow your donation program at your facility and help us all serve our families better on both sides of donation, the donor family and the recipient family. Thank you!
TOGETHER WE CAN DO BETTER
-PARTNERS FOR LIFE!

43. What we learned? Practices for Success:
Communication and collaboration is key
All inclusive clinical trigger card & early referral
Implementation of supportive P&P’s
Pt. and family centered care philosophy

44. Questions to Run on…
How will you apply what you learned today during future end of life care plans? How will you remember to include donation?

45. What we learned? Practices for Success:
Communication & collaboration is key
All inclusive clinical trigger card
& early referral
Implementation of supportive P&P’s
Pt & family centered care philosophy
Moderator