Donation After Cardiac Death

1. Donation After Cardiac Death May 26, 2010 Margie Whittaker, RN MSN

2. Anne’s Story • RN colleague collapsed while at work • SAH with extensive bleeding • Poor prognosis • Family wishes to donate organs to honor Anne • Did not progress to brain death • After 48 hours of waiting, withdrawal of life support occurred and Anne died within about 30 minutes

3. Fundamentally… The family / patient should make the decision to withdraw life support • independent of and • prior to ANY discussion regarding organ donation.

4. History and Facts • History of DCD: • Prior to Brain Death Laws – common practice: Kidney 1951 Liver 1961 Pancreas 1966 Heart 1967

5. DCD over the years

6. Why DCD? • > 100,000 people on the waiting list • 17-20 people die every day • DCD Organ recovery can positively impact the shortage of transplantable organs

7. Introduction • Organ donation can occur after brain death or after cardiac death DCD – potentials: • The patient has a non-recoverable illness or injury and has suffered neurological devastation. • Family / Patient is considering withdrawing life-sustaining treatment

8. Process • Family and medical staff begin discussions of withdrawal of life sustaining treatment. • Refer the patient to OneLegacy. • OneLegacy will evaluate pt for medical suitability – at this time NO APPROACH will be made.

11. Assessment • OneLegacy and health care team determine cardio-respiratory death likely to occur within one hour of withdrawal of life support • Huddle – to Care - Plan

13. Decision • Decision is made by the family to withdraw life-sustaining treatment • OneLegacy will consult coroner or medical examiner for release

14. Consent Process • Effective requestor approaches • Family declines donation – continue with end-of-life care process • Family consents to donation – continued medical management of patient

16. Pre-OR • Continued supportive care for patient • Attending MD/critical care nursing continues to manage the pt • OneLegacy provides recommended parameters for donor management and lab studies

17. Pre-OR (cont.) • OneLegacy will utilize usual process for the organ allocation. • OneLegacy will collaborate/coordinate with the OR and transplant team for a timing of recovery. • OneLegacy will huddle with hospital staff to care-plan for the OR

19. Intra-OR Process • After transfer to the OR • Withdrawal of life-sustaining treatment is performed in the OR • Driven and directed by the hospital under their policy

20. Pronouncement of Death • The patient will be pronounced dead after 5 minutes of no blood pressure and: • asystole or • ventricular fibrillation or • pulseless electrical activity • The practitioner certifying death may not be involved in the recovery or transplantation of the organs

21. Pronouncement of Death • The practitioner will record the date and time of death in the medical record and, if applicable, complete the death certificate.

23. Alternative Outcome • Patient does not arrest within organ-viability time-frame – donation is no longer an option • Continue with end-of-life care in a nursing unit • OneLegacy responsible for the costs: • From time of consent – until – organ donation completed or donation process aborted

26. Ethical Principles • Ethical principles around organ donation continue to be discussed and studied • Primary discussion is around “dead donor rule” • Allowing patients to die for organ gains • Use of ECMO after cardiac/respiratory cessation • Honoring wishes and rights of first person consent for SCI or ALS patients • Analgesia at time of withdrawal

27. Outcome of Process Policy has been in place since 2001 • 10 DCD donations since that date (about 1-2 year) • Potential DCD donors increased every year • 15 lives saved!! • Family able to honor patient’s wishes

28. Conclusions Donation after Cardiac Death is a viable option to honor patient’s wishes. It should be considered in excellent end of life care for any patient who has sustained a catastrophic neuro event. Margie.whittaker@stjoe.org