Brain Death and Organ Donation: Do You Know What To Do and Say

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Brain Death and Organ Donation Do You Know What
To Do and Say?
Suzanne Owens-Pike, MDIV Lead Chaplain HCMC
Carol Ann Smith, RN, CNRN Program
Coordinator Traumatic Brain Injury Center HCMC
Ann Lovdahl, MA/CCC Hospital Coordinator LifeSourc
e
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Our Focus Today

• Organ Donation basics
• What happens at the hospital
• Communicating with families
• What does this mean to you?

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We believe that lifeis a gift to share
We pledge to provide the bridge between the loss
of life and the gift of life through organ
tissue donation transplantation.
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A federally designated OPO (Organ Procurement
Organization) serving
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LifeSource Our Hospital Partners

• HIPAA
• CMS
• The Joint Commission
• Organ Breakthrough Collaborative
• Organ Transplant Breakthrough Collaborative
• Spreading Best Practices

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The Growing Needfor Transplantable OrgansORGAN
DONORS VS. WAIT LISTED PATIENTS

Based on OPTN data through March 31, 2008
www.OPTN.org
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How Often Does Organ Donation Happen?

• Not every death qualifies to donate
• Must be in the hospital and on a ventilator
• Must meet specific medical legal criteria to be
  declared brain dead
• Designated donor or have family consent
• Donation after cardiac death requires family
  consent
• In 2008 there were 430 deaths at HCMC and of
  those only 20 people went on to become organ
  donors
• Those 20 people donated 76 organs which saved the
  lives of 68 people
• Every hospital death is reviewed by OPO staff

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1999-2003 The Old National System
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Holding the Gains..But More Improvement is
Needed
Collaborative Starts Here
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What happens at the hospital

• When to refer a patient to LifeSource
• Brain death definition
• Process of declaring brain death
• Communicating with the family
• Role of LifeSource

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Referring Patients to LifeSource

• When patient meets the clinical triggers,
  LifeSource should be called within one hour
• Timely referral allows for assessment of donor
  suitability and donor designation
• Clinical Triggers are
• Neurological injury
• Patient on a ventilator
• Loss of two brain stem reflexes or a GCS of lt 5
• Call is mandated, staff does not need permission
  to make the call

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Brain Death Definition

• MN State Statute 145.135 Subd. 2. Determination
  of death
• An individual is dead if the individual sustains
  irreversible cessation of
• Circulatory and respiratory functions or
• all functions of the entire brain, including the
  brain stem
• A determination of death must be made in
  accordance with generally accepted medical
  standards

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Clinical Criteria for Brain Death

• Known etiology of brain death and/or evidence of
  irreversibility
• No brainstem function on physical exam
• No respiratory effort on apnea test
• No cerebral blood flow noted on blood flow study
  (optional)

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The Brain Death Exam

• Physician obtains history and physical including
  neurological examination to determine etiology of
  brain death and/or evidence of irreversibility
• Patient must not be under the influence of
  sedatives, paralytics, anesthesia, ETOH or street
  drugs
• Patient must be normothermic with a temperature
  of gt 32 degrees Celsius

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The Brain Death Exam

• Voluntary motor control absent
• May have spinal cord reflex arcs
• All cranial nerve reflexes absent, for example
• Pupils cannot react
• Absent corneal reflex
• Absent cough and gag reflexes

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The Brain Death Exam

• Document clinical exam and order apnea test by
  Respiratory Care
• Strict protocol followed by Respiratory Care to
  see if patient able to breathe off of ventilator
• Mammalian diving reflex
• Some facilities require a confirmatory study as
  well as a clinical exam, such as
• Cerebral angiogram
• Radioisotope study
• EEG

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Brain Death Declaration

• While the state statute defines brain death, the
  process of declaring brain death will vary with
  each hospital. Know your hospitals policy.
• A patient is declared brain dead if there is no
  brainstem function AND there is no respiratory
  effort during the apnea study.
• Most hospitals require two exams or one exam and
  a confirmatory study.
• Time of death is the first exam consistent with
  brain death

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Donation after Cardiac Death

• If patient does not meet legal Brain Death
  criteria, donation may still be an option
• If family decides to withdraw medical support and
  allow patient to proceed to a peaceful cardiac
  death, the option of donation after cardiac death
  may be offered to the family under specific
  circumstances

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Donation after Cardiac Death

• If patient is age lt 60, LifeSource will offer an
  assessment for donation after cardiac death
• Patient is assessed to determine if cardiac death
  can be achieved within 90 minutes of removing the
  mechanical ventilation and intubation tube
• Chaplain stays with family for education and
  support through this process

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Supporting the Family Under Stress

• Challenges in Family Communication
• Best Practices
• Role of the Chaplain
• What to say and what not to say

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Is a Person Diagnosed as Brain Dead in a Comatose
State or Dead?
n102
(plt.08)
n62
Percent of respondents
Franz, et.al. 1997.
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True or False People Cannot Recover When They
are Brain Dead
n102
(plt.0002)
n62
Percent of respondents
Franz, et.al. 1997.
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• Poor Understanding of brain death is associated
  with significantly lower rates of consent to
  donate organs of the deceased.
• Journal of Transplant Coordination
• Vol. 7, Number 1, March 1997

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Family Communication Protocol for Explaining
Brain Death
Do not mention organ donation
Develop a family communication plan

• GRAVE PROGNOSIS
• Explain/reinforce grave prognosis and care plan
  with family
• Support family/assess understanding
• Review/adjust communication plan
• DOES FAMILY UNDERSTAND GRAVE PROGNOSIS?

YES
NO

• BRAIN DEATH IMMINENT
• Explain/reinforce brain death imminent and care
  plan with family
• Support family/assess understanding
• Review/adjust communication plan
• DOES FAMILY UNDERSTAND BRAIN DEATH IS IMMINENT?

YES
NO

• BRAIN DEATH CONFIRMATION
• Explain/reinforce brain death confirmation and
  care plan with family
• Support family/assess understanding
• Review/adjust communication plan
• DOES FAMILY UNDERSTAND BRAIN DEATH CONFIRMATION?

YES
NO
Franz, et.al. 1997.
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What Do You Say

• if the family raises the topic of donation?
• Prior to Brain Death
• Donation may be possible. We work closely with
  the donation agency and Ill arrange to have them
  speak with you
• After Brain Death
• We work very closely with the donation agency
  and they are available to answer your questions
  about donation

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What Do You Say

• after Brain Death declaration?
• First, please meet with the LifeSource
  Coordinator (team huddle) to ensure everyone
  understands the next steps in communicating with
  the family
• Family Discussion
• Use the word death and tell the family the time
  of death
• Refer to the ventilator and I.V. medications as
  artificial support
• I have arranged for you to speak with someone
  who will give you information about next steps

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Who Approaches the Family About Donation?

• The individual designated by the hospital to
  request to the family must be an organ
  procurement representative or a designated
  requestor.
• CMS Conditions of Participation 482.45(a)(3)
• Donor Designation / Advance Directives

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The Process of Donation

• Overview of donation
• The role of LifeSource
• Donation opportunities
• What does this mean to you?
• Donor benefits
• Donor designation

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Overview of the Donation Process

• Identification of potential donor
• Referral to OPO (LifeSource)
• Declaration of brain death
• Family Approach
• Assessment and Donor Management
• Allocation UNOS
• Recovery
• Family Follow-Up

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Donation Opportunities
Corneas (1905)
Heart/Heart Valves (first fresh valve 1955)

(first heart 1967)
Lungs (1963)
Liver (1963)
Kidneys (1954)
Pancreas (1969)
Intestines (1987)
Skin (1822)
Bone/Connective Tissues (1668)
Blood Vessels (1955)
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Organ Matching (allocation)
DonorInformation
RecipientInformation
United Network for Organ Sharing (UNOS)

• Blood type
• Size
• Severity of illness
• Wait time

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Family Follow-up

• Letter to family
• Bereavement and aftercare program
• Donor Family Gathering
• Hope for the Holidays
• Recipient information
• Donor family and recipient correspondence

We are struggling each day with the loss of our
sonbut knowing he was able to help others gives
us comfort. -Donor Family
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Donation Benefits

• Benefits for donor families
• Aids in re-establishing control
• empowerment
• Helps the grief process
• Provides something positive
• Add meaning to a tragedy
• Honor a loved ones wishes
• Memorialize a loved one

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Donation Benefits

• Donation is not just what you give. You receive
  too. What you receive is the blessing of being
  able to give to others a gift, a gift of life.
• Margarita Cepeda Aguilar
• Donor Mother

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Donor Designation

• Donor designation is the practice of ensuring
  that an individuals documented wishes about
  donation are fulfilled
• giving the donor a voice
• What does it mean to be a designated donor?
• Drivers license
• Advanced directive
• What if Im under age 18?

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How Can You Impact Donation?

• Support Organ, Tissue, and Eye Donation by
  remembering to refer all patients who meet the
  clinical triggers within one hour
• Register to be a designated donor and talk with
  your loved ones about your wishes
• Dont forget 18 People die each day waiting for
  an organ transplant.But rememberYou can help
  save those lives!

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In 2008, 68 grateful people received the Gift of
Life from 20 organ donors at HCMC (76 organs).
Intestine
Lung
Heart
Pancreas
Kidney
Liver