Organs

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How to Basics in Initiating a DCD Policy in Your
Hospital HRSA DoT Telephone Conference October
4, 2006 Wednesday 1100 am 12 Noon Pacific
Time / 200 pm 300 pm Eastern Time
1.888.455.7918 Pass-code DCD
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Agenda

• Welcome Framing our Conference Call  Glenn M.
  Matsuki,
• Hospital Services Coordinator
• Onelegacy
• What is Donation after Cardiac Death
  (DCD)? Wanda Jones, RN, BSN, CPTC, MJ,
  Clinical Manager
• 
  
  Onelegacy
•                        
• How we did it Mission Hospital,
  Margie Whittaker, RN,
  MSN,
• St Joseph Medical System CCRN, CNRN,
  Nurse Manager
• Surgical-Neuro-Trauma ICU
• Mission Hospital, St. Joseph
  Medical System
• Orange, CA
• Physicians providing a leadership role in DCD
  Policy Bradley J. Roth, MD
• Development and Implementation Assistant
  Professor of Clinical Trauma Surgery and
  Critical Care
• LA County and USC MedicalCenter
• Los Angeles, CA

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Agenda (Continued)

• Physicians providing a leadership role in
  Pediatric DCD Thomas A. Nakagawa, MD,
• Policy Engaging the Physician
  Leadership Associate Professor,
• Director of Pediatric Intensive Care Unit
• Wake Forest University Baptist Medical
  Center
• Brenner
  Childrens Hospital
• Winston-Salem, NC
•                        
• HRSA Collaborative Management Team Margaret
  Riggs Allee, RN, M.S., J.D
• Resources Available Consultant,
• 
  
  HRSA Collaborative Management Team
  
• Questions and Answers
• Follow instructions by call operator to
  pose a question, or you may email Andra Kai Shaw
  at
• akshaw_at_onelegacy.org during teleconference.
•                        
• Closing / Evaluation Jade Perdue, MPA
• HRSA Dept. of Transplantation

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Faculty
Thomas A. Nakagawa, MD, Associate Professor,
Director of Pediatric Intensive Care Unit Wake
Forest University Baptist Medical Center Brenner
Childrens Hospital Winston-Salem, NC
Bradley J. Roth, MD Assistant Professor of
Clinical Surgery Division of Trauma / Critical
Care University of Southern California LAC-USC
Trauma Center Holy Cross Trauma
Center Huntington Trauma Center
Margie Whittaker, RN, MSN, CCRN, CNRN Nurse
Manager, Surgical-Neuro-Trauma IC Mission
Hospital, St. Joseph Medical System Orange, CA
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Faculty (continued)
Wanda Jones, RN, BSN, CPTC, MJ Clinical
Manager Onelegacy
Margaret Riggs Allee, R.N., M.S.,
J.D. Consultant, HRSA Collaborative Mgmt Team
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Donation After Cardiac Death(DCD) Back to the
FutureWanda H. Jones, RN, BSN, MJ,
CPTCClinical ManagerOneLegacy
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History and Facts

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

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Fundamentally

• The family should make the decision to withdraw
  life support independent of, and prior to, any
  discussion regarding organ donation.
• This decision is made with the primary health
  care team, based on their advice and
  recommendations, and is always the case in these
  situations.

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Criteria

• The patient has a non-recoverable illness or
  injury and has suffered neurologic devastation.
• The family, in conjunction with the medical
  staff, has decided to withdraw life support.
• Death will likely occur within one hour of
  withdrawal of life support.

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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 de-escalate care or withdraw
  support (DNRs)

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Withdrawal of Support

• A DCD consent form will be signed by the
  next-of-kin. The original copy will remain in the
  patients chart.
• Removal of life support usually takes place in
  the O.R., but may take place in the ICU,
  depending on its location relative to the O.R.
• Per hospital protocol, comfort measures are
  administered, and the family may be present if
  that is their wish.
• Organ recovery occurs 5 minutes after asystole/
  pronouncement of death

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Pronouncement of Death

• The adult patient will be pronounced dead when
  mechanical silence occurs as measured by arterial
  pulse monitoring. Organ recovery can begin after
  a five minute pause and cardiac inactivity has
  been confirmed.
• Death will be pronounced by a physician or
  designated nursing staff.
• The physician certifying death may not be
  involved in the recovery or transplantation of
  the organs.
• The physician will record the date and time of
  death in the medical record and, if applicable,
  complete the death certificate.

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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.
• The Institute of Medicines evaluation of the
  ethics of DCD stated that the procedure should
  be considered a reasonable source of organ
  donors.

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References

• California Health and Safety Code, sections
  7150-7156.5, 7180-7184.5 and 7188-7195.
• Medical and Ethical Issues in Procurement
  Division of Health Care Services, 1997 (IOM).
• Conditions of Participation for Hospitals, Part
  482, Federal Register, 1998.
• Gift of Life Sample Hospital Policy and
  Procedure Non Heart-Beating Organ Donation
• University of Pittsburgh Medical Center
  Presbyterian Hospital Policy and Procedure Manual
  Non-Heart Beating Organ Donation

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Donation After Cardiac Death

• Margie Whittaker
• RN, MSN, CCRN, CNRN
• Nurse Manager SICU
• Mission Hospital, St. Joseph Medical System

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Beginnings..

• Why?
• Annes Story
• Did we have other choices?
• Donation after Cardiac Death

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How?

• Collaboration with OneLegacy
• Researched, presented at committee
• Critical care
• Ethics
• Surgery
• Hospital / System administrative committees
• 6 8 month process initially with revisions
  every couple of years

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Ethical Considerations

• Catholic Teaching-
• Mission policy became a template
• Dead Donor rule
• 5 minutes of non-perfusing rhythm
• DCD - allowing people to die to gain organs?
• Families have made decision to withdraw care
  prior to approach

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Challenges and Solutions

• Education and acceptance by all disciplines re
• DCD vs. DBD
• Underestimated surgical services involvement and
  response, including anesthesiologist

• Education at for all departments
• ICU, OR, SW, RT, etc.
• Debrief all involved staff, including OR
• Anesthesia is not required

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Challenges and Solutions

• Lack of clarity around who would pronounce
  patient death

• Initially - ED physician or attending to
  pronounce death
• Now - progressed to nurse pronouncement
• PS. Utilize RNs who has not had any contact with
  patient

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FINAL THOUGHT

• Background as ethics nurse consultant was well
  received which led to minimal questions and
  opposition to process
• Policy has been in place since 2001
• 6 donations since that date (about 1-2 year)
• Potential DCD donors increased every year
• _at_ 14 lives saved
• Research all facets of process, anticipate
  questions,
• BE PREPARED!!!

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Donation After Cardiac Death
Physicians providing a Leadership Role

• Bradley J Roth, MD, FAC
• Assistant Professor of Clinical Surgery
• Division of Trauma / Critical Care
• University of Southern California
• LAC-USC Trauma Center
• Holy Cross Trauma Center
• Huntington Trauma Center

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Continuity of Resuscitation
ER Resuscitation ABCs
Brain Resuscitation
Organ Resuscitation
Death
X
Deceleration of Care
Clin Tran 2003Suppl. 9, p-78
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15 yr old Male S/P Self Inflicted GSW to the Head

• Presented Hypoxic and Hypotensive
• Rapid Resuscitation to.CT
• Pt arrested X 2 in ED
• To ICU on Epinephrine Drip
• Norepinephrine Dobutamine added
• Abdomen Decompressed in the ICU
• 36 units of blood products later..to OR
• Two Kidneys, one Liver

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Continuity of Resuscitation
ER Resuscitation ABCs
Brain Resuscitation
Organ Resuscitation
Death
X
Deceleration of Care
Clin Tran 2003Suppl. 9, p-78
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Discussion to End Life Support
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Continuity of Resuscitation
Death
ER Resuscitation ABCs
Brain Resuscitation
Organ Resuscitation
Termination of life support care
requested Donation request made
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Where to start?

• Identify a Physician Champion
• Discuss DCD in detail to all involved hospital
  departments (possibly multiple times)
• Expect resistance and give people a way out.
• Protocol?

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Donation after Cardiac Death

• Terminal patient is identified in the ICU
• Discuss patient with Physician Champion
• OPO is notified
• OPO approaches the family
• The patient is re-evaluated by the Wisconsin
  Criteria or similar criteria.
• Transplant team is notified, OR is ready
• Death occurs ICU/OR?

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• Thomas A. Nakagawa, MD,
• Associate Professor, Anesthesiology and
  Pediatrics
• Director of Pediatric Intensive Care Unit
• Wake Forest University Baptist Medical Center
• Brenner Childrens Hospital
• Winston-Salem, NC

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Implementing a DCD policy in the PICU

• Changing the culture
• Identify champions within the institution
• Physician
• Nurses
• Administrators
• Improving/strengthening relationships with the
  OPO
• Anticipating resistance

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How does a physician leader initiate the
development and implementation of a DCD policy in
a PICU?

• Involving colleagues
• Provides ownership
• Provides responsibility and accountability
• Reaching consensus
• Education
• Emphasize end of life care
• Emphasize donation is a family decision

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Implementing a DCD policy

• Involve other services who will be directly
  involved with the DCD process
• Nursing staff
• Ancillary staff
• Chaplain
• Anesthesiologist and the OR staff
• Transplant surgeons
• Palliative care team
• Other colleagues who will be involved with the
  DCD process
• Ethics committee

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Developing the DCD policy

• Clearly outline criteria for declaration of death
  
• Provide flexibility allowing latitude to practice
  within accepted and evolving medical standards
• Stress patient and family comfort
• Utilize resources
• Work closely with the OPO
• Identify centers that already have a DCD policy
  in place

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The role of the intensivist in DCD

• First and foremost the intensivist must care for
  the dying patient and their family
• Ensure patient comfort
• Encourage family participation
• Coordinate care of the potential donor and family
• Chaplain
• Social work
• Translators
• Transplant specialists
• Child life specialists
• Pronounce death when death occurs

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Future directions and closing thoughts
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HRSA-Collaborative Management Team

• Available Resources

Margaret Riggs Allee, R.N., M.S.,
J.D. Consultant, HRSA Collaborative Mgmt Team
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HRSA-Collaborative Management Team

• DCD A Reference Guide
• - Sponsored by UNOS and HRSA
• - This is a 200 page reference guide/manual
• - Contains valuable resource materials
• - IOM Recommendations
• - Society for Critical Care Medicine Position
  Statement
• - Listing of Mentors willing to help
• - Sample protocols
• - Both a written manual and CD for reference
• - Data Chapter is updated every 6 months
  available through UNOS
• - Manual is free, but there is a 10 shipping
  fee
• - Ordered from the OPTN/UNOS Website
• http//www.unos.org/resources/productCatalog.asp?d
  isplayprofessionalResources

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HRSA-Collaborative Management Team

• OPTN/UNOS DCD Statement
• - Available on the KMS for downloading
• www.organdonationnow.org
• - Developed by the OPTN/UNOS Ethics Committee
• - Approved by the OPTN/UNOS Board of Directors
  September 20, 2006
• - Being sent to Hospital Ethics Committees

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HRSA-Collaborative Management Team

• DCD Table Top Drill Tool
• - Available on the KMS for downloading
• www.organdonationnow.org
• - Developed from a model used for disaster
  preparedness planning
• - Breaks down the DCD process in to
  sub-components for protocol development

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HRSA-Collaborative Management Team

• HRSA Organ Donation and Transplant Breakthrough
  Collaborative
• - National Learning Congress October 18th and
  19th
• - Collaborative and List Serve Involvement
• To subscribe
• http//mailman.listserve.com/listmanager/listinfo/
  organdonation
• - Opportunities for Networking with other
  facilities that have demonstrated best
  practices
• - HRSA individual consulting availability

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On-Line Resources
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Acknowledgements
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Committee Members

• Wanda Jones, RN, BSN, MJ, CPTC, MJ , Clinical
  Manager
• OneLegacy, Long Beach, CA
• Glenn M. Matsuki, Chair , Hospital Services
  Coordinator
• OneLegacy, Long Beach, CA
  
  gmatsuki_at_onelegacy.org
• 562.608.4124
• Melissa Forest, RN, Hospital Services Liaison
• Onelegacy, Sherman Oaks, CA
  mforest_at_onelegacy.or
  g
• Hedi Aguiar, RN, Hospital Services Coordinator
• Onelegacy , Long Beach, CA
  
  haguiar_at_onelegacy.org
• Seung Lee, CTBS, SEBT, Hospital Services
  Coordinator
• Onelegacy, Long Beach, CA
  
  slee_at_onelegacy.org
• Andra Kai Shaw, Hospital Services Coordinator
• Onelegacy, Sherman Oaks, CA
  akshaw_at_onelegacy.org

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Special Thanks

• For Making the Bold Request
• Jade Perdue, MPA,
• HRSA-Department of Transplantation Management
  Team
• For bringing us expected natural resources
• Dennis Wagner, MPA
• HRSA-Department of Transplantation Management
  Team
• For asking us to always be in action and for
  your unwavering support
• Esther-Marie Carmichael, Hospital Services
  Director
• Onelegacy
• Our Collaborative Jedi Master who helps us
  empower our hospitals
• Carla Hentz, Collaborative Specialist
• Onelegacy