Michael Haley, MD

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Maintaining the Option to Donate Pre-Donor
Management and Brain Death Declaration

• Michael Haley, MD
• Medical Director - LifeShare of the Carolinas

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• Disclosure Statement
• No Financial or Commercial Interest to Declare
• Serve as Medical Director for LifeShare of the
  Carolinas

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Objectives

• Brief Overview of Donation
• Recipient, Donor, and Regulatory Compliance
• Pathophysiology Associated with Brain Injury
• Declaration of Death by Neurologic Criteria
• Review the Pathway to Organ Donation and Identify
  Potential Areas in Which the Option to Donate may
  be Loss

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Making the Case forPreserving the Option to
Donate

• Recipients Need
• Donors Desire
• Regulatory-Compliance

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The Growing Organ Gap
Recipient Needs 18 people die each day due to
the lack of a suitable organs for transplant
(6500 lives/yr)
Organ Procedure and Transplant Network and the
Scientific Registry of Transplant Recipients from
1989-2009
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This circle represents the United States 310
million people
.
This dot represents the 8,126 deceased donor in
2011
Over 100 million registered donors in the USA
USA Deaths 2011 - 2,515,458 8,126 represents
0.3 of all deaths
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Psychological Effects of Donation on Families

• 98 Would choose donation again
• 92 Identified positive aspects to the
• donation process/experience
• Donation was comforting
• Associated with less depression

Clinical Transplantation. Vol 22 (3) 341347,
2008
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Hospital Compliance

• Hospital Requirements
• (Centers for Medicare/Medicaid Services)
• OPO- Organ Procurement Organization
• Functions within their designated service area
• increasing the number of registered donors
• coordinating the donation process
• Notification process
• Declaration of brain death
• Patient/family opportunity to donate
• Performance Improvement (PI) program

LifeShare of the Carolinas
Federally designated OPO for 40 hospitals in a 22
county area
ASPE.hhs.gov
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The Pathway to Organ Donation
Vulnerable Period
Irrecoverable loss of brain function
Severe Brain Injury
Hours to Days in Length Physiological Changes
Associated with Brain Injury
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Physiology Associated with Severe Brain Injury

• Peripheral vasoconstriction
• Tachycardia - Arrhythmias
• Central redistribution of blood
• Pulmonary edema
• Myocardial dysfunction
• Endothelial dysfunction
• Platelet activation-micro thrombi-DIC
• Cytokine Inflammatory activation
• (SIRS)

Brain Injury
Elevated ICP
Compensatory HTN
Catecholamine Surge
Experimental studies demonstrate circulating
epinephrine concentrations increase on the order
of 200 to 1000-fold in association with increase
in ICP
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Pre-Donor Management

• Just Good Critical Care
• Catastrophic Brain Injury Guidelines
• Maintain MAPgt 65 (IVF resuscitation vasopressor
  support)
• Maintain oxygenation (Satgt90)
• Monitor and correct electrolyte abnormalities
• What is good for the patient is good for the
  donor

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The Pathway to Organ Donation
Vulnerable Period
Irrecoverable loss of brain function
Severe Brain Injury
Healthcare providers often recognize poor outcome
early on. Healthcare providers can feel
conflicted Ongoing Support vs. DNR-DNI
or Limitation of Care
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The Pathway to Organ Donation
Vulnerable Period
Irrecoverable loss of brain function
Severe Brain Injury
Death by Neurologic Criteria
Vulnerable Period
Withdraw of Care
Physiologic Changes with Brain Death
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Decline in Organ Function after Brain Death

• Physiologic Changes
• Hemodynamic Instability
• Inflammatory response
• Capillary leak
• Coagulopathy
• Volume depletion
• Hypothermia
• Hormonal Abnormalities

Pre-existing Co-morbidities Associated Injury
(trauma)
Organ Dysfunction (Loss of Opportunity to Donate)

• Treatments
• Mannitol
• Steroids
• Volume Resuscitation

Outcomes are better with organs obtained from
live donors compared to organs from brain-dead
donors as these physiologic insults are avoided
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The Pathway to Organ Donation
Vulnerable Period
Irrecoverable loss of brain function
Severe Brain Injury
Death by Neurologic Criteria
Withdraw of Care
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Death by Neurologic Criteria

• lt1 of all deaths in the US per year
• Estimated 15k/yr 2.5million deaths in US/yr
• Historically---Death- permanent cessation of
  heart breathing
• 1950s Invention of artificial respirator
• Breathing supported even when people were in a
  deep coma.
• Invention forced doctors to rethink their
  definition of death
• 1968 Ad Hoc Committee of the Harvard Med School
• A Definition of Irreversible Coma (JAMA
  1968205337340)
• 1981 The Uniform Death Determination Act
• An individual who has sustained either (1)
  irreversible cessation of circulatory and
  respiratory functions, or (2) irreversible
  cessation of all functions of the entire brain,
  including the brain stem, is dead.

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Process of Brain Death Declaration

• Clinical Prerequisites
• Must evaluate for these confounding variables
  prior to consideration of brain death
• Neurological exam

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Clinical PrerequisitesPrior to Brain Death
Consideration

• 1st - Irreversible Cause -
• Must have a proximate cause for the brain death
• TBI, ICH, SAH, CVA with associated edema,
  hypoxic-ischemic, etc.
• Often demonstrated by neuro-imaging
• 2nd - Exclude Potentially Reversible Conditions
• Drug intoxication/poisons electrolyte/acid-base
  disturbance endocrine disturbance
• 3rd - Exclude Hypothermia (gt32C)

Normal
SAH
TBI
ICH
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Brain Death Neurological Exam

• Coma---Absent Brain Stem Reflexes---Apnea
• Coma
• No spontaneous movements, posturing, or
  localization-withdraw to stimulus
• Assess brainstem
• Midbrain- CN 3- pupil response
• Pons- CN 4,5,6- corneal, occulocephalic, cold
  caloric testing
• Medulla- CN 9,10- gag/cough and spontaneous
  respirations
• Atropine test
• Apnea Test

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• Sound Easy..
• So Why Can Problems Arise With Brain Death
  Declarations?

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Brain Dead Patients Move

• Movements present in 40 of heart-beating
  cadavers
• Interpreting motor responses can be challenging-
  some demonstrate abnormal motor activity when
  stimulated due to spinal reflexes
• Movements occur when a sensory stimulus arises
  from receptors in the muscle, joints, and skin,
  resulting in a motor response that is entirely
  contained within the spinal cord.
• Spinal reflexes include
• Finger jerks/oscillations
• Plantar flexion in one or both lower extremities
• Head turning with stimulation
• Triple flexion response to plantar stimulation
• Stereotypic flexion of one or more limbs
• Facial myokymia
• Lazarus sign

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Video of Movements
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Confounding Variables May be Present

• Drug intoxication/poison electrolyte/acid-base
  disturbance endocrine disturbance
• Sedative Metabolism
• Varies amongst individuals
• Hypothermia slow drug metabolism
• Confirmatory Testing

Brain Perfusion Scan Technetium 99 Isotope
Cerebral Angiogram
EEG
TCDs
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Why is the Formal Declaration of Brain Death
Important

• Provides family with a diagnosis of finality
  (no decision about stopping necessary)
• Allows de-coupling period from death and
  donation
• Simultaneous approach at the time of brain
  death notification is associated with a decreased
  donation rate by 30 (Niles Mattice, 1996)

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The Pathway to Organ Donation
Vulnerable Period
Irrecoverable loss of brain function
Severe Brain Injury
Death by Neurologic Criteria
Withdraw of Care
Donation after Brain Death
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LifeShare of the Carolinas
2011 2012 2013
Referrals 10080 9984 9490
Donors 83 87 84
Donor Mtg Time (hr) 19 25 21

Organs Recovered 322 340 338

Transplanted 274 271 259
Research 11 9 46
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CaroMont Regional Medical Center
2011 2012 2013
Referrals 1051 968 836
Donors 7 4 6
Donor Mtg Time (hr) 17 30 25

Heart 2 0 2
Lung 6 0 1
Kidney 10 7 6
Liver 5 3 6
Pancreas 0 0 1
Intestine 0 0 1
Organs Recovered 23 10 17

Transplanted 22 10 11
Research 1 0 6
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The Pathway to Organ Donation
Vulnerable Period
Irrecoverable loss of brain function
Severe Brain Injury
Death by Neurologic Criteria
Withdraw of Care
Donation after Brain Death
Donation after Cardiac Death (DCD)
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Donation After Cardiac Death

• Prior to brain death laws, DCD was the way in
  which all organs were recovered for transplant
  from deceased donors (standard practice prior to
  the 1980s)
• 3 Separate reviews by the Institute of Medicine
  (IOM)
• ethically acceptable practice of end-of-life
  care, capable of increasing the number of
  deceased-donor organs available for
  transplantation

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DCD Process

• Withdraw of Care is decided upon prior to any
  discussions about donation (DNR order entered)
• DCD is a patient/family driven process
• Life Support removal- typically in operating room
• Cardiac Death
• Time from the onset of insufficient cardiac
  activity to generate a pulse or blood flow (not
  necessarily the absence of all EKG activity) to
  the declaration of death is 5 minutes
• Data suggest that circulation does not
  spontaneously return after it has stopped for 2
  minutes (auto-resuscitation)
• If death does not occur (typically within 60min)
  then recovery of organs does not occur,
  end-of-life care continues (up to 20 of cases)

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National Trends in DCD
LifeShare of Carolinas 2011-13 DCD- n-36
(14)
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Changing Paradigm in Critical Care
Hope for Recovery
Hope through Donation
Aggressive Care
Life Saving Donation
End of Life Discussions
Deteriorating Condition
Donor Management
Preparing Family- Grave Prognosis
Preserving the option to donate
Declaration of Death Family Support
DNR-DNI Limitation of Care Donation after Cardiac
Death (DCD)
Goals of Care Discussions are being addressed
earlier if the patient has the ability to
donate and is thought to be dead by neurological
criteria then brain death testing should be
pursued
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Conclusions

• Need for organs continues to outpace the
  availability
• Medical management of potential donors can be
  time consuming and requiring advanced critical
  care
• Brain death declaration can be complex but is an
  essential component to donation
• National donor data shows an increase trend in
  DCD donations
• All healthcare providers need to be aware of the
  potential vulnerable periods during the path to
  donation