Saving Lives Through Donation After Cardiac Death DCD

1
Saving Lives Through Donation After Cardiac
Death(DCD)
Wanda H. Jones, RN, BSN, MJ, CPTCClinical
ManagerOneLegacy
2
Supply vs. Demand
Donors and Waiting Patients, 1995-2006
Source UNOS1/22/06
3
The Waiting List

• As of 0400 am (EST) there are 96,657 people
  waiting for a life-saving transplant
• Jan- March 2007 6,789 organ transplants
• Jan-March 2007 3,474 organ donors!

4
Californians Waiting

• Kidney 14,609
• Liver 3,738
• Pancreas 151
• Kidney / Pancreas 482
• Heart 386
• Lung 325
• Heart / Lung 17
• Intestine 20
• 19,289
• UNOS 2004

21 of national waiting list resides in CA
5
Sources of Organs

• Living Related Organ Donors
• Living Unrelated Organ Donors
• Deceased Organ Donors
• Donation after Brain Death
• Donation after Cardiac Death
• Xenografts

6
Two Ways for Deceased Donors to Donate
Donation After Cardiac Death(DCD)
Donation After Brain Death(DBD)
Lungs Liver Kidneys Pancreas Tissue
All Organs Tissues suitable for transplant
7
History of DCD

• FACT Prior to the acceptance of the brain
  death criteria in the mid-1970s, all organ
  donations were performed after cessation of
  cardiopulmonary function (DCD).

Kidney 1951
Liver 1961
Pancreas 1966
Heart 1967
8
Dead Donor Rule
All I can say is well do everything we can to
find a donor.

• Organ donation should not cause or hasten
  death.

9
Potential DCD Donor

• Patients with severe neurological injury
• Intracranial hemorrhage, stroke, anoxia, trauma
• Patients without neurological injury
• Degenerative neuromuscular diseases
• End-stage cardiopulmonary diseases
• Do not meet the criteria for brain death
• No chance for survival off the ventilator
• Family elects to deescalate care or withdraw
  support (DNRs)

10
OneLegacy Clinical Triggers

• Meets one of the following
• Irreversible Brain injury
• End stage musculoskeletal disease
• High spinal cord injury
• Ventilator dependent
• Family has made patient DNR or plans to withdraw
  all life support
• Family inquired or initiated discussion about
  organ donation

11
Process

• Refer the patient to OneLegacy.
• A coordinator will come on site and evaluate the
  patient to determine suitability.
• In conjunction with the health care team, the
  family will be informed of the patients
  suitability.
• If suitable, the family will be fully informed
  about all procedures relating to the
  pronouncement of death and the organ recovery
  process by OneLegacy.

12
When do we offer DCD?

• The Institute of Medicine (IOM) recommends that
  the decision to withdraw life-sustaining
  treatment should be made independently of and
  prior to any staff-initiated discussion of organ
  and tissue donation.
• Would this patient be removed from
  life- sustaining treatment whether OneLegacy was
  there or not?

13
Consent for DCD

• Collaborative effort between hospital staff and
  OPO
• A OneLegacy DCD consent form will be signed by
  the next-of-kin. The copy of consent will remain
  in the patients chart.
• OneLegacy will obtain consent/ permission from
  the medical examiner/coroner

14
Medical Management

• Care of the DCD patient is maintained by the
  attending MD (or designee), until death occurs.
• Management suggestions are offered, however
  because this is a live patient Onelegacy cannot
  write orders.

15
National DCD ConferenceApril 2005

• 6 working groups that addressed specific DCD
  issues
• Determining death by a cardiopulmonary criterion,
  
• Assessing medical criteria to predict DCD
  candidacy following the withdrawal of life
  support,
• Protocols for successful DCD organ recovery and
  subsequent transplantation ,
• Initiating DCD in Donor Service Areas (DSA),
• Allocation of DCD organs for transplantation,
• Media, public perceptions, and DCD .

16
AIM of Conference

• Aim of this national conference to expand the
  practice of DCD in the continuum of quality
  end-of-life care

17
Message

• The message was to convey a societal
  responsibility that regularly enables organ
  transplantation from deceased donors, determined
  to be dead by either circulatory or brain
  criteria.

18
Organ Transplant Breakthrough Collaborative
Goals

• Organs Transplanted per Donor

Standard Criteria Donors 4.3 DCD
Donors 2.75 ECD Donors 2.5
Total
3.75 At Least 10 of all Donors Are DCD
19
Initiating and Increasing DCD

• The Joint Commission Recommendations
• Revise accreditation standards to require
  hospitals to implement DCD protocols
• Treat lack of a DCD protocol as a requirement
  for improvement

20
Impediments to DCD

• Hospitals
• No protocols, no interest, staff resistance
• OPOs
• Limited resources (staffing, finances, expertise)
• Organs
• Organ quality
• Ethics
• Medical intervention, withdraw of support,
  determination of death

21
Important Facts to remember

• The family should make the decision to withdraw
  life support independent of the decision to
  donate organs.
• This procedure should not be viewed as a way to
  circumvent brain death criteria but as a means to
  provide families with an additional option of
  donation that complies with the patient or
  authorized family directives.
• Like all care at the end of life, donation after
  cardiac death (DCD) should focus on the patient
  and family

22
Support for DCD

• The Institute of Medicine (IOM), the SCCM, and
  the Joint Commission have concluded that DCD is
  an ethically proper approach of recovering organs
  from a deceased patient for the purpose of
  transplantation

23
IOM Study Conclusions

• The recovery of organs from DCD donors is an
  important, medically effective and ethically
  acceptable approach to reducing the gapbetween
  the demand for and the available supply of organs
  for transplantation.

24
(No Transcript)
25
Saving Lives Through Donation After Cardiac
Death(DCD)CASE STUDIES
26
Case Study 1

• 30/F/ H
• Diagnosis ALS 1 year prior
• Vent-dependent for 5 months
• Decision made by patient to be removed from vent
• Pt family expressed interest in donation

27
Referral

• 2/17/05 initial referral by Extended Care
  Facility
• OL PTC on-site evaluated and determined patient
  to be a suitable candidate
• Patient had made decision to have life support
  withdrawn
• Patient wanted to be an organ donor

28
Huddle

• Multi-disciplinary conference scheduled for 2/22
  with Patient, Family members, M.D., Social
  Worker, Psychiatrist, and Administration
• 2/21 OneLegacy asked Director of Critical Care at
  Western Medical Center (Santa Ana) if they would
  be willing to accept her as a transfer patient

29
Approach

• OneLegacy NOT part of the multi-disciplinary
  conference in discussion of withdrawal of support
• Patient and Family made decision to withdraw life
  support
• OneLegacy Regional Director calls PTC and FCC to
  go to the facility to meet with patient and family

30
Consent

• Patient gave verbal consent to becoming an organ
  donor after support was withdrawn
• OneLegacys 1st First-person consent for organ
  donation

31
Considerations

• Ethics Committee members consulted
• Huddled with Critical Care and OR staff regarding
  to review the withdrawal of care process and
  organ recovery process

32
Transfer

• 2/22 follow-up call made to Western Medical
  Center regarding patient
• Pulmonary M.D. accepts patient. Patient
  transferred at 1500
• Trauma M.D. agrees to pronounce in the OR

33
Operating Room

• Scheduled at 1600, went at 1640
• Disconnected by Director of Trauma/ER
• Patient expired in 22 minutes
• L, K, K, successfully recovered and transplanted

34
Case Study 2

• 57 M/C
• PMH Quadriplegic for 17 years
• Admitted for recurrent pneumonia
• Pt on Bipap
• Verbalized interest in becoming an organ donor

35
Referral/ Approach

• Initial referral by RN at hospital
• PTC on-site evaluated and determined patient to
  be a suitable candidate
• PTC spoke with patient and brother regarding
  organ donation
• Patient wanted to be an organ donor and gave
  verbal consent, brother signed form as witness

36
Medical Management

• Attending MD remained involved with care
• Worsening respiratory status required patient to
  become intubated
• Pulmonary MD approached patient and family
  regarding intubation
• Pt and family agreed to intubation

37
Transfer

• DCD policy not finalized
• Pt transferred to Western Medical Center (Santa
  Ana) for withdrawal of hemodynamic and
  ventilatory support
• Accepting MD agrees to pronounce pt in the OR

38
Operating Room

• Taken to OR at 1830
• Pt extubated at 1900 by Attending MD
• Brother in OR with pt until he expired
• Expired within 22 minutes
• Kidneys recovered
• Corneas, skin, and bone recovered