1. First-Person Authorization and DCDs
Amanda Cole, RN, BSN, CCRN, MPH
Organ Procurement Coordinator
Lifesharing

2. Lifesharing Authorization Data
Eligible Authorization Rates
Registered Donors (FPA)
Data Source: National DSA Dashboard, July 2018

3. FPA All Approaches Data Source: Internal MRR Database n=39 n=41 n=59

4. Case Study - Admitted 7/18/2019 – 1541 Referral 7/20/2019 – 0142
55F, Assault with SAH/SDH
Intubated during craniotomy same day
Referral 7/20/2019 – 0142
Hospital referral to OPO - neuro insult and plan to withdrawal care
On site 7/20/2019 – within 1 hour
Patient is registered in California
History – ESLD, COPD/Asthma, past CVA
Neuro – Pupils unequal/reactive, +c/g/obv, decorticate posturing
Plan to withdrawal care that afternoon
Admitted 7/18/2019 – 1541
55F
Assault with SAH/SDH
Intubated during Craniotomy same day
Referral 7/20/2019 – 0142
Hospital notified OPO for neuro insult and plan to withdrawal care
Response to page 7/20/2019 – 0156, assistant coordinator sent on site
On site 7/20/2019 – 0240
On site assessment 7/20/2019 – 0240
Patient is registered in California
History – End stage liver disease, COPD/Asthma, past CVA
Neuro – Pupils unequal/reactive, +c/g/obv, decorticate posturing
Made Full care/DNR on 7/19/2019
Plan to withdrawal care early afternoon 7/20/2019
DCD evaluation – kidney function good, plan to have OPC on site in morning

5. 7/20/2019 – Morning
No family on site, staff states family is waiting on 1 more person to arrive and then plan to withdrawal immediately
7/20/2019 – 09:00
Huddle
7/20/2019 – 09:20
Phone approach, LNOK verbally authorized donation
7/20/2019 – 10:45
BSRN reported that LNOK has changed mind on donation…
7/20/2019 – 0845
OPC on site, staff states family is waiting on 1 more person to arrive an then plan to withdrawal immediately
7/20/2019 – 0900
Huddle with AOC, FS in office (45 min drive from hospital), plan for FS to phone approach with LNOK Daughter
7/20/2019 – 0920
FS spoke to daughter at length about the incident, her life, medical examiner, resources and then discussed donation by explaining that patient was registered and had potential to save lives. LNOK knew patient was registered and wanted to donate, process and timing (24-36 hrs) was discussed. Plan to meet at hospital after 1030.
7/20/2019 – 1045
FS on site with OPC, BSRN reported to OPC that LNOK has changed mind on donation…

6. 7/20/2019 – 11:15 OPO Team meet with family
Daughter stated that they had changed their mind about donation
Two immediate concerns:
Patient’s organs weren’t good enough
Timing
Our response:
Explained organ function for transplant, using specific recipient example
We asked “hypothetically” if they could donate today would they want to proceed
They immediately said yes, and we said outcome was not a promise, but we would make some calls and try
7/20/2019 – 1115
FS and OPC met with very pregnant LNOK Daughter and Pt’s Brother in private room on unit
Daughter told us that they had changed their mind about donation, so we asked what their concerns were
Two immediate concerns:
Viability of patient’s organs and safety of recipients
Timing. Family had their mind set on saying goodbye that day, they did not think they could handle waiting another day, or even until later that night
Our response:
We explained organ function and that even though her liver was failing her kidneys would be a life-changing gift to someone on dialysis. Also used specific recipient example
We asked “hypothetically” if they could donate today would they want to proceed
They immediately said yes, and we said it was not a promise, but we would make some calls and try.

7. Withdrawal time set for 10pm 20 family members present
Process was aided by:
Kidneys only viable organs
Morning phone authorization got process started
Medical Examiner notified after phone approach
Blood sent at noon
Ample staffing available to help
Process was hindered by:
Family timeline needed to be that day
Hospital ICU MD tried to talk family out of withdrawal
Difficulty getting hospital ABO results
Kidneys were the only organ acceptable for transplant in this patient.
Liver – ESLD
Lungs – Poor ABGs, pneumonia, Hx: Asthma/COPD
AOC agreed to do an expedited DCD, but attempt to set withdrawal time so that we would have serology resulted
OPC had sent for Medical Examiner Clearance after the verbal yes via phone
Serology/ABO drawn immediately after sit down meeting, 7/20/2019 – 1200
Withdrawal plans were temporarily de-railed by rounding MD who tried to talk the family out of withdrawal, family again decided on withdrawal, authorization paperwork/DRAI done after 1600
Original plan was to set withdrawal time for 2300 (to allow for seros), LNOK was pregnant and unsure she could wait, plan for withdrawal at 2200
ICU MD ordered basic serology to be run by hospital that morning for us
Hep B, Hep C, HIV all negative
Hospital ABO x2 ordered and printed in case ABO had not resulted
Medical Examiner Clearance at 1551
Serology/ABO results in at 2046
Kidney list run at 2130, offers sent
Patient extubated at 2232 in PACU with approximately 20 family members present
Patient did not expire within 60 minutes, family updated
Family expressed extreme gratitude for allowing possibility of donation
Patient was moved to a step-down unit to continue end of life care
Withdrawal time set for 10pm
20 family members present
Patient did not expire but family was extremely grateful

8. Lessons Learned
Reasons for family opposition to FPA can sometimes be mitigated quickly
Early conversations with family re: FPA are essential
Approaching families when they are “ready to withdraw” can be a dis-service to family and donor
OPOs should guide hospitals to allow for OPO staff to engage families earlier in end-of-life conversations

9. Applications
Talking about patient’s “decision” instead of their “wish”
Using concrete examples about recipients to explain concerns, instead of just answering with facts
Asking hypothetical questions (re: timeline, designated donation, etc..) can make family think more in depth about decision
Inform family about FPA and describe process to families after goals of care discussion, even if no decisions have been made

10. Thank you!