Donation After Cardiac Death DCD: What Should I Expect

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Donation After Cardiac Death (DCD) What Should
I Expect?

• Janet Hewson, RN, Director Trauma Services
  Sherri Lamon, RN, BSN, Director Critical Care
  Services Antonio Chavez, Surgical Recovery
  Coordinator

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Questions to Run On

• What role does the hospital staff take in the OR
  during a DCD case?
  
• What role does the OPO staff take in the OR
  during a DCD case?

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Case Scenario

• 30 year old male Caucasian
• Status post hanging - Anoxic Brain Injury
• PMH depression, bouts of extreme fitness and
  health vs. extreme depression (self-destructive)
  
• Family initiated donation - weekend

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Preparation for DCD

• DCD tool and Health Care Team discussion
• Evaluation of DCD unlikely to expire within 1
  hour
  
• Family wished donation attempt
• HONOR familys wishes when possible!

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Preparation for DCD cont.

• Prepared family for process in OR and in the
  event pt doesnt expire.
  
• Held a bed med/surg per availability
• Physician orders comfort meds for OR and for
  med/surg care if needed
  

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Preparation for DCD cont.

• RN, physician and OR staff receive prep by OL on
  process
  
• Ethics Committee informed
• Due to weekend and complex case Trauma Director
  came for support

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OR Preparation for DCD

• Arrival 3 hours prior to OR time to
• huddled with PTC and ICU staff
• review sequence of events
• Identify everyone's roles and responsibilities
• Proceed to OR to huddle with staff and to confirm
  OR time.
  

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OR Preparation for DCD

• 1.5 hours prior to OR time huddle with assigned
  OR staff to inform them of
  
• circumstances surrounding DCD case
• their option to step out during withdrawal of
  life-sustaining treatment.
  
• On this case staff opted not to step out.

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OR Preparation for DCD

• Next steps of preparation
• Open supplies
• Make slush
• huddle with OR staff again to review sequence of
  events step by step.
  
• Extremely important to stick to the plan we
  have discussed and agreed upon.

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Process in the OR

• Prior to OR, huddle with ICU RN, RT and
  pronouncing MD
  
• COMMUNICATION is important for smooth donor
  process
  
• ICU RN brings comfort medications from ICU to OR

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Process in the OR

• In OR suite, pt transferred to OR table, bed
  warmer utilized on DCDs
  
• Pt prepped and draped, warm solutions used to
  prep incision area
  
• Lights are dimmed and curtain formed above pts
  shoulders, to prevent family from seeing
  instrumentation and slush

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Process in the OR

• Once everyone is ready, we let family in OR
  suite
  
• MD orders comfort measures and heparin to be
  given
  
• Withdraw of support initiated per MD
• In this case pts vital signs stable

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Events in the OR

• Challenges Solutions
• Physician availability for OR time
• Preparation find hospital physician and
  back-up
  
• Physician comfort level with EOL care
• Preparation not to treat pt differently
• Mother very distressed, begging for more meds to
  hasten death
  
• Knowing limitations and standard practice

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Events in the OR

• Appearance of suffering distressing
• Preparation of family
• Family aware of time frame required for donation
• Visible clock for family can be helpful
• Distressed OR staff
• Preparation of OR staff in how to deal with
  family presence during death process

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Events in the OR

• Waited 1 hour, vital signs strong throughout
• Stopped donation process and reversed heparin
• Informed everyone that we would be returning pt
  to prearranged room.
  

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Outcomes of the OR

• Pt did not expire within 1 hour
• Family very disappointed
• Pt moved to predetermined med-surg bed
• OL discussion with med/surg RN
• Pt expired 2 hours after extubation

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Lessons Learned

• Families and staff require preparation on the
  dying process not just the donation process,
  i.e. what to expect gurgling, bucking, etc.
  
• Helpful for family, if same nurse can follow pt
  and stay until expires FCC and Trauma Director
  stayed

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Lessons Learned

• Same physician to follow through and pronounce
  in this case same physician
  
• Knowing when to give more comfort meds and what
  the limit is possibly institute standard
  orders
  
• Frank discussions with Ethics Committee

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Lessons Learned

• More education on EOL care vs Euthanasia
• Particularly for physicians and OR staff
• Education for Med/Surg staff by OL
• Trauma Director drove the family to their hotel
  ongoing care
  
• Family sent a gift basket grateful their wishes
  were honored
  
• EXPECT THE UNEXPECTED!

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Questions to Run On

• What role does the hospital staff take in the OR
  during a DCD case?
  
• What role does the OPO staff take in the OR
  during a DCD case?

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Thank you for your attention.
Questions?