1. Organ Donation Past, Present and Future Donor Identification and Referral Jeremy Brown Huw Twamley 4 th June 2013 1 LONDON

2. Organ Donation Past, Present and Future Regional Data 2 Jeremy Brown LONDON

3. Organ Donation Past, Present and Future -------- National rate 95 97 88 93 98 86 87 91 95 84 89 Referral rate (%) 0 20 40 60 80 100 Team EasternLondon Midlands North West Northern Ireland Scotland South Central South East South Wales South West Yorkshire DBD referral rate 1 April 2012 to 31 March 2013, data as at 4 April 2013 2 nd Organ Donation Past, Present and Future 3 LONDON

4. Organ Donation Past, Present and Future Referral rate (%) 0 20 40 60 80 100 Number of neurological death suspected patients 0102030405060 1 10 111213 14 151617181922021222324 2526 27 28 29 33045 6 7 8 9 HospitalNational rate95% Lower CL 95% Upper CL99.8% Lower CL99.8% Upper CL London DBD referral rate 1 April 2012 to 31 March 2013, data as at 4 April 2013 Organ Donation Past, Present and Future 4

5. -------- National rate 80 72 54 72 81 52 42 54 56 59 60 65 Referral rate (%) 0 20 40 60 80 100 Team EasternLondon Midlands North West Northern Ireland Scotland South Central South East South Wales South West Yorkshire 1 April 2012 to 31 March 2013, data as at 4 April 2013 Organ Donation Past, Present and Future 5 Tied 3 rd DCD referral rate LONDON

6. Organ Donation Past, Present and Future London DCD referral rate Organ Donation Past, Present and Future 6 Referral rate (%) 0 20 40 60 80 100 Number of imminent death anticipated patients 01020304050607080 1 10 11 12 13 14 15 16 17 18 19 2 20 21 22 23 24 25 26 27 28 29 3 30 4 5 6 7 8 9 HospitalNational rate95% Lower CL 95% Upper CL99.8% Lower CL99.8% Upper CL

7. Organ Donation Past, Present and Future Identification and Referral 7 Dr Huw Twamley North West Regional CLOD

8. Timely Identification and Referral of Potential Organ Donors Organ Donation Past, Present and Future www.odt.nhs.uk

9. LONDON Organ Donation Past, Present and Future Session Objectives 9 Organ Donation Past, Present and Future Understand difficulties with donor identification and referral Recognise benefits of improving elements of the process – Increased identification and referral – Timely referral – Responsiveness to referral Consider which of the proposed methods of identification and referral may work in your hospital

10. Organ Donation Past, Present and Future UK rates of referral Organ Donation Past, Present and Future 91% 52%

11. Organ Donation Past, Present and Future Overall timings Organ Donation Past, Present and Future

12. Potential donor 83 year old OOH PEA cardiac arrest Downtime 15-20 minutes Known hypertensive ( three anti- hypertensives) Benign Prostate Hyperplasia Organ Donation, Past, Present and Future

13. Organ Donation Past, Present and Future Best Interests Recipient Potential Donor Family Potential Donor

14. Aims of Strategy 100% Identification of potential Donors 100% Referral of Potential Donors 100% Timely Referral Implement NICE Guidance The consideration of donation should be core ICU / ED and part of all end of life care plans. Timely referral promotes this possibility Organ Donation Past, Present and Future

15. Referral rate (%) 0 20 40 60 80 100 Number of neurological death suspected patients 0102030405060 1 10 111213 14 151617181922021222324 2526 27 28 29 33045 6 7 8 9 HospitalNational rate95% Lower CL 95% Upper CL99.8% Lower CL99.8% Upper CL London DBD referral rate 1 April 2012 to 31 March 2013, data as at 4 April 2013 Organ Donation Past, Present and Future 15

16. London DCD referral rate Organ Donation Past, Present and Future 16 Referral rate (%) 0 20 40 60 80 100 Number of imminent death anticipated patients 01020304050607080 1 10 11 12 13 14 15 16 17 18 19 2 20 21 22 23 24 25 26 27 28 29 3 30 4 5 6 7 8 9 HospitalNational rate95% Lower CL 95% Upper CL99.8% Lower CL99.8% Upper CL

17. NICE Guideline 135 Organ Donation Past, Present and Future

18. British Medical Association 2012 The research data -------- showed that the use of clinical triggers and a requirement to refer according to standard criteria led to an increase in both referrals and donors. It is hoped that implementation of the NICE guideline will result in early and consistent donor referral. Organ Donation Past, Present and Future

19. General Medical Council 2010 I”f a patient is close to death and their views cannot be determined, you should be prepared to explore with those close to them whether they had expressed any views about organ or tissue donation, if donation is likely to be a possibility.” “You should follow any national procedures for identifying potential organ donors and, in appropriate cases, for notifying the local transplant coordinator.” Decisions to limit or withdraw treatments in potential DCD donors MUST be in compliance with national End of Life Care policy. Organ Donation Past, Present and Future

20. UK Donation Ethics Committee “There is no ethical dilemma if the treating clinician wishes to make contact with the SN-OD at an early stage, while the patient is seriously ill and death is likely, but before a formal decision has been made to withdraw life-sustaining treatment.” [“Benefits] include establishing whether there are contra- indications for organ donation…… Other practical and organisational factors might be relevant – if the SN-OD is based at a distant location then early contact can help to minimise distressing delays for the family.” Organ Donation Past, Present and Future

21. Objectives, benefits and outcomes All potential donors are identified and referred All donors are referred in a timely fashion SN-ODs are deployed in a way that improves responsiveness All patients are given the option of donation Access to clinical advice Prompt donor optimisation Resolution of potential legal obstacles Early assessment of marginal donors Early tissue typing / screening Planning the family approach Reduction in delays for families and units Increased donor numbers Improved consent / authorisation rates Increase in donor organs Better experience for families and staff Organ Donation Past, Present and Future

22. NHSBT Strategy Implementation not publication Key area for collaboration between hospitals and donor care teams Very clear emphasis on benefits – How not who Suite of options Clarity over implementation Organ Donation Past, Present and Future

23. Strategy proposals Every hospital should have a written policy for the identification and timely referral of all potential donors Every donating area within a given hospital adopts a consistent approach As far as possible ‘decouple’ early referral from individual clinician Donation Committees and SN-OD teams should collaborate to develop and implement a policy that ensures that all potential donors are identified and referred in a timely fashion. Organ Donation Past, Present and Future

24. 1. Daily visit by SN-OD Organ Donation Past, Present and Future

25. 2. Early daily phone call Organ Donation Past, Present and Future

26. 3. Daily ICU team safety brief Organ Donation Past, Present and Future

27. North Bristol Trust ICU Safety Brief

28. 4. Standard Operating Procedure Organ Donation Past, Present and Future

29. Midlands Standard Operating Procedure Organ Donation Past, Present and Future

30. 5. Nurse led referrals Organ Donation Past, Present and Future

31. Summary 31 Organ Donation Past, Present and Future Donation should be a element of end of life care Make identification and referral routine business of the unit. This decouples early referral from the individual clinician caring for the patient Implement or develop a solutions /policy for your individual hospitals adopt to timely referral Ensure consistency within a given hospital

32. Organ Donation Past, Present and Future 32

33. What are the barriers to implementing the NICE guidelines in your unit: any solutions? Organ Donation Past, Present and Future 33  Whichever is the earlier, either: Use trigger factors in patients with a catastrophic brain injury The absence of one or more cranial nerve reflexes AND a GCS of 4 or less that is not explained by sedation  And / or a decision is made to perform brainstem death tests. The intention to withdraw life-sustaining treatment in patients with a life-threatening or life-limiting condition which will, or is expected to, result in circulatory death.