10/7/2013
Organ Donation after
Circulatory Death
Christine Westphal NP MSN ACNS-BC ACHPN
Director/Nurse Practitioner PRISM Palliative Care
Oakwood Healthcare System
Rebecca Williams BS MA HHCC
Hospital Services Associate
Gift of Life of Michigan
1989
1905
1964
HRSA Breakthrough First Heart and World War II Ends
Collaborative Begins
Intestine Transplant
1990
1914
1966
2003
1945
1967
First Successful Trial First Pancreas of Islet Cell World War I
Transplant
Transplant
 Compare the history, criteria and process related to
organ Donation after Circulatory Death (DCD)* to
organ donation after brain death.
 Describe best practices of organ donation consent
process.
 Apply case studies to illustrate implications for
hospice and palliative care related to DCD.
* Formerly called “Donation after Cardiac Death”
Advances in Donation Benefit
Soldiers
Past, Present, Future…
Berlin Wall Comes First Cornea The Beatles Come To Down
Transplant
America
Objectives
First Full Facial First Human in Space
Gift of Life Formed
Transplant
2008
1950
1969
2010
1961
1971
Michigan First First Kidney Man Reaches the Person Consent Law
Transplant
Moon
2013>>>?
1963
1981
Uniform First Lung and Liver Determination of Transplants
Brain Death Act
Soldier receives doublearm transplant after
losing all four limbs in
roadside bomb attack
Soldier receives nerve graft
and regains use of his leg
shattered by roadside bomb
Challenging Numbers
• In the United States, almost 120, 000 people wait for a
life-saving transplant
• Who are these people?
• Every day,
day 365 days a year
year, 22 people
Co-Workers
die on the waiting list…
Grandmothers
Grandfathers
Friends.
Mothers.
Daughters
Fathers. Sons.
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Michigan Wait List
Kidney
2538
Liver
341
Lung
91
Heart
74
Kidney/Pancreas
42
Pancreas
14
Intestine
4
Kidney/Heart
4
Pancrease/liver/intestine 2
Liver/lung
1
Heart/liver
1
TOTAL
3110
Gift of Life Michigan
What Is Gift of Life?
 Gift of Life Michigan is the
federally designated organ and
tissue recovery organization
 It acts as the intermediary
between donors, hospitals and
transplant centers
How Often Does Donation Occur?
• Approximately 86,000 deaths annually in Michigan
• 40,000 calls to Gift of Life every year
• 261 organ donors
Calls to GOL
Potential organ donors
Actual organ donors
Actual tissue donors
Actual cornea donors
• 861 tissue donors
• 2061 cornea & eye donors
What does Gift of Life do?
Organ & Tissue Recovery
Education
• Obtain consent and work with
donor families
• Educate hospital
staff, physicians,
funeral homes,, and
the public
• Determines medical suitability
• Locate, match, and type tissue
for transplant
• Recover organs and tissues for
transplant
• Collaborate with Michigan Eye
Bank
Michigan Statutes
• Maintain the
Michigan Organ
Donor Registry in
cooperation with the
Secretary of State
Michigan Statutes
2008 Uniform Anatomical Gift Law
2005-PA 176 Kyle Ray Horning Law
•
•
•
•
 Medical examiners will conduct investigation within a
•
Uniformity across states and with federal regulations
Upholds individual’s autonomy in decision making
Reasonable search for documentation
Allows Gift of Life to assess medical suitability of
potential donors
Hospital must maintain care to ensure family of
medically suitable patients provided option of donation
timeframe to allow for organ donation.
 ME or designee can be present during recovery and
provided with all lab and pathology reports
reports.
 ME’s must notify Gift of Life of deaths outside hospital
Sen. Roger Kahn, appears with
the Horning family of Vassar at the
ceremonial bill signing of the Kyle
Ray Horning Law.
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10/7/2013
Uniform Determination of Death Act
The 1981 Uniform Determination of Death Act recognized
death as either:
•Determination of irreversible cessation of circulatoryy and
respiratory functions; or
•Irreversible cessation of all functions of the entire brain,
including the brain stem (“brain death”)
Adopted by the AMA and each stateDetermination of Death Act Michigan Public Health Code,
Public Act 90 of 199
What is Donation After Circulatory
Death (DCD)?
 Donation after Circulatory Death (DCD) is a
planned
l
d terminal
t
i l wean with
ith the
th possibility
ibilit off organ
donation after the patient reaches circulatory death.
 Cessation of heart beat and breathing
 Death pronounced by hospital staff per policy
Determination of Brain Death
 American Academy of Neurology Guidelines
 Irreversible neurologic condition
 Persistent coma and apnea after rule out of other
etiologies
 Absence of brain stem function by clinical testing of
cranial nerves
 Confirmatory tests are not mandatory
Who Supports DCD?
“If in the process of delivering high
quality end-of-life care, organ donation is
possible, then critical care professionals
should help enable that outcome.”
S i t for
Society
f Critical
C iti l Care
C
Medicine
M di i
Recommendations for DCD Donation, 2002
 Institute of Medicine
 Society for Critical Care Medicine
 United Network for Organ Sharing
 Association of Organ Procurement Organizations
 The Joint Commission
What can be donated in DCD?
Who are Potential DCD Donors?
 Patients with a non-survivable neurological injury
who do not meet the criteria for brain death
 Irreversible brain injury, such as those caused by
trauma,
stroke,
t
t k and
d MI
 Severe underlying illness (musculoskeletal,
pulmonary disease, high spinal cord injury),
causing ventilator dependence
 Family has decided to remove ventilator support
(terminal wean) for patient with:
 Organs: kidneys,
pancreas, liver, lungs
and intestines.
Up to 7 lives saved!
Tissues:
cornea/eye, skin,
bone, heart valves,
veins and tendons.
Up to 75 lives improved!
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10/7/2013
When is Gift of Life Called?
Overview of the DCD Process
Typical Clinical Triggers*
Irreversible
Injury
or Illness
• Every neuro injured, vented patient with a GCS ≤5
• Every vented patient being evaluated for brain death
Referral
to Gift
Of Life
Prognosis
• Every vented patient being considered for withdrawal of
vent support
• Every vented patient being considered for a change in
Organ
Recovery
Collaboration
and
Evaluation
resuscitation status
*Calls
to GOL within ONE hour required by CMS (Center
for Medicare & Medicaid Services), the Joint Commission
and HFAP (Healthcare Facilities Accreditation Program) Education
 According to research, 98% of all adults have heard about organ donation and 86% have heard of tissue donation.  90% of Americans say they support donation, but only 90% of Americans say they support donation but only 30% know the essential steps to take to be a donor.  What do YOU know about organ donation?
www.unos.org accessed February 6, 2013
Withdrawal
Of Vent
Support
Patient
and
Family Care
Consent
Process
Test yourself--yourself---True
True or False
 Consent for organ and tissue donation can only be done by next of kin.
 HIV/AIDS and cancer are contraindications to donation.
 All major religions support organ and tissue donation.
 Hospice patients cannot be considered for donation.
Initial Decision: Withdrawal
Part I
The decision to withdraw therapies :
 Must be an independent decision by the family
and the patient care team
 Is totally separate from any decision regarding
organ donation
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10/7/2013
Evaluation
 Gift of Life huddles with primary care team to
discuss current plan of care and evaluate:
Collaborative Approach
 Gift of Life representative will huddle with available
members of the healthcare team, including:

Medical
 Maintenance of therapies until family decision

Palliative care
 Does Dennis meet DCD criteria?

Spiritual support


Likely survival time after withdrawal
Wisconsin DCD Tool
 Will Dennis meet medical criteria for donation?


Age
Co-morbidities
 Gift of Life and hospital staff should approach the
family together
Why should the approach be done together?
 Increases consent rates
 Demonstrates healthcare team’s support of
donation
Discussion
Collaborative Approach
• Can anyone bring up donation?
• No one can bring up donation without special training from
Gift of Life.
• Most hospitals specify Gift of Life as the official ‘designated
requestor’ in their donation policy
• Why? To Prevent:
• Misinformation
• Family conflict
• False Hope
 The collaborative team and family discuss DCD
process.
 This includes the possibility the patient may not
expire within time frame needed for donation

If patient does not expire, he/she will return to the unit
or move to a hospice bed.

Patient will not be re-intubated and cannot become
an organ donor (may still donate tissues after death)
Coordination
When and where ventilator support will be removed?

Operating room area or ICU bed, depending on
hospital policy and family needs.

Coordination with respiratory
p
y care,, medicine and
nursing.
The Withdrawal and Organ Recovery
Will family be present?

Resources for family support and comfort
What is the plan for comfort care if death does not occur
in 60-90 minutes of extubation?

Consult for palliative and/or hospice care

Communication with receiving unit/staff
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10/7/2013
The Family
 Family may wish to be present during terminal
wean.


Majority of families remain through withdrawal
Most leave hospital after death is declared
 After death, the family may move to a private room
or go home
 Family is given updates as donation moves forward
per their wishes
 Ensure family has the support they need -- spiritual
care, social work, family support.
Palliative Care Team
 Facilitate withdrawal
 Provide for comfort care
 Spiritual support to honor the life and support family
 Support transition to hospice if patient survives
 Referrals for bereavement support
 Debrief team if needed
The Physician  Provide appropriate medical management
strategies to preserve the option of donation for the
families

Medication to maintain organ quality (e.g. Heparin
300 units/kg) should be administered five minutes
prior to extubation to minimize clots
 Direct the withdrawal process
 Provide post-withdrawal comfort care orders.
 Hospital maintains responsibility of patient until
death
Hospice and Palliative Care
 HPNA position statement “Role of Palliative Care nursing in Organ and Tissue Donation”
 Supports nurse as educator, advocate and partner with Organ Procurement Organization (OPO) to promote and obtain organs and tissues for donation
 Identifies role in care of DCD donors to ensure symptom control and support of family
 Recommends adoption of policies to support donation
www.hpna.org
The Transplant Team
 Transplant team has NO involvement with
withdraw of support process
 Transplant team is NOT allowed in patient area
Organ Recovery Process
 Hospital staff member declares cardiac death
according to hospital policy
 5 minute wait period to ensure heart does not
restart
 Transplant surgeon(s) and the recovery
team(s) begin organ recovery surgery after
this 5 minute period
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10/7/2013
Organ Recovery
 Starts with:
 Dissection down to the aorta
 Cannulation of the aorta
 Infusion of cold preservation solution
 Remaining dissection is done after the organs are
perfused with preservation solution and cooled
 Minimize cell death due to lack of O2
 Best possible outcome for recipients
Gift of Life Michigan DCD
Outcomes 2004
2004--2010 2004
140
Michigan DCD Data
2005
2006
2007
2008
2009
2010
122
120
Total
Total
Donors DCD
Donors
DCD Organs
Transplanted
DCD Organs
% of Total
Tx’d Per Donor Donors
100
95
90
80
2009
288
59
82
1.39
20.5%
2010
289
82
109
1.33
28.3%
2011
269
58
111
1.91
21.6%
2012
261
58
82
1.41
22.2%
82
78
76
Number
80
60
60
53
52
49
43
40
40
45
30
24
20
18
14
17
12
15
0
Evaluated For DCD
Benefits
 Transplant recipients are not the only ones to
benefit. Donor Families express a feeling of
comfort and hope that assists them with their
grieving process
To Organ Recovery
At Least 1 Organ TX'd
Finding Comfort
 Family focused. Some families may play special
music sing,
music,
sing or pray during the terminal wean
 Organs from DCD donors are proven to have
similar outcomes as those from donation after
brain death
 Studies demonstrate that new organ recovery
techniques have made the outcomes virtually
equal
 Provides an additional option for donation
 Often fulfills the expressed wishes of the patient
 Many donor families speak of feeling comfort
knowing that their loved one’s donation has helped
others live
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10/7/2013
What can YOU do?
 Become a registered donor
 Registered donors only represent about 30% of the total
donors (www.donatelife.net accessed Feb. 6, 2013)
 Encourage others to register
Questions?
Families give the gift of
life…
www.giftoflifemichigan.org
ift flif i hi
 Discuss organ donation as part of advance care
planning
 Recognize potential donors and inform Gift of Life
 Assist in consent process in collaboration with
“Designated Requestor”
 Become aware of opportunities for tissue donation for
hospice patients
If only we give them the
opportunity
Thank you!
Rebecca Williams BS MA HHCC
[email protected] 586-255-7827
Christine Westphal NP MSN ACNS
ACNS-- BC ACHPN
[email protected]
313--593
313
593--8614
8