A Clinical Balancing Act: Honoring the DNR Decision While Preserving the Option of Donation Brian J. Kimbrell, MD, FACS Trauma / Surgical Critical Care

A Clinical Balancing Act:Honoring the DNR Decision While Preserving the Option of Donation

Brian J. Kimbrell, MD, FACSTrauma / Surgical Critical Care Director

St. John’s Regional Medical CenterOxnard, CA

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Question to Run-On

What ideas would most help you in your work with patients and families

facing end-of-life decisions?

A Clinical Balancing Act:Honoring the DNR Decision While Preserving the Option of Donation

Brian J. Kimbrell, MD, FACSTrauma / Surgical Critical Care Director

St. John’s Regional Medical CenterOxnard, CA

DNR Decision

What does the DNR decision mean to the family?

• No Chest Compressions?• No Shock?• No Medications?• No Labs?• No Fluids?

“Do not harm?” or “Do not treat?”

DNR Decision

What does the DNR decision mean to the healthcare team?

• Routine decision in the Critical Care Unit

• Interpreting DNR decision varies by hospital, unit, physician, nurse

Donation Decision

Understanding the donation option clinically:• Maintaining blood pressure• Normalizing electrolytes• Managing oxygenation and organ perfusion• Balancing Intake and Output• Assessing brain death accurately

How can a family give the gift of life when the organs are not preserved for transplantation?

Balancing DNR and Donation

Devastating Traumatic Brain Injury (TBI)+ Overall Clinical Deterioration+ DNR Decision by Next-of-Kin + Fatal Diagnosis (Brain Death?)

“Step Down” in clinical management?- or -

Maintain clinical management and prevent Maintain clinical management and prevent secondary injury to organs?secondary injury to organs?

Case Study

Patient: 41 y/o Male s/p MVC with blunt head trauma (ICH) Admitting GCS = 8

Data: post-craniectomy, GCS=6, BP=140/80, H/H=14/38, UO=200mL/hr, pH=7.4, Na=135, Cr=0.8/BUN=10, ICP=15

Management: IV fluids, Mannitol, no pressors, sedation, Neurosurgery on case

Case Study

2 days post-admission: Data: GCS=5, BP=100/60, H/H=10/30, UO=200mL/hr,

pH=7.35, Na=155, Cr=1.1/BUN=20, ICP=45 Family conference with PhysicianPhysician Progress Note: “Discussed DNR with family. No Heroic Measures.”

Management: IV fluids, Mannitol, no pressors, sedation, RN calls OneLegacy

Case Study

4 days post-admission:

Data: GCS=3, BP=90/50, H/H=8/25, UO=200mL/hr, pH=7.30, Na=170, Cr=1.3/BUN=22, ICP=60

Physician Progress Note: “Pt. appears brain dead. Discussed grave prognosis with family. Neurosurgery to evaluate.”

Management: IV fluids, sedation Family Conference with Physician

Case Study

5 days post-admission:


Brain Death Note #1Neurosurgery Progress Note: “Attempted apnea test. Pt

did not breathe for 2 minutes but became unstable. Apnea test aborted. PT is brain dead, based on clinical exam.

Discussed with family. Will require brain death confirmatory test. Second brain death note to follow.”

Management: IV fluids, sedation, high dose Levophed and Neosynephrine

Assessing the Balancing Act

Admission:

Data: post-craniectomy, GCS=6, BP=140/80, H/H=14/38, UO=200mL/hr, pH=7.4, Na=135, Cr=0.8/BUN=10, ICP=15

5 Days Post-Admission:


Does our patient data reflect preservation of the family’s donation option?

Assessing the Balancing Act

Devastating TBI+ Overall Clinical Deterioration+ DNR Decision + Fatal Diagnosis (Brain Death)

Maintain clinical management and Maintain clinical management and prevent secondary injury to organs.prevent secondary injury to organs.

Pathophysiology of Traumatic Brain Injury

Physiologic collapse frequently accompanies TBI:

Hypotension

Endocrine Dysfunction

Pulmonary Dysfunction

Hematologic Dysfunction

Hypotension:• “Autonomic storms”

• Systemic and pulmonary vasoconstriction• Associated with herniation• Can recur unpredictably

• Smooth muscle ATP depleted = vasomotor hypotension• Diuretics


Hypotension:

• Closely monitor Intake and Output – DI?• Anticipate BP spike followed by BP drop• Consider Fluid Resuscitation• Titrate Vasopressors• Consider Hormone replacement – T4


Endocrine Dysfunction:

• Hypothalamic injury -> pituitary dysfunction

• Thyroid dysfunction– T4 Infusion

• Glycemic control disrupted– Insulin infusion


Endocrine Dysfunction:

• Relative deficiency of corticosteroids– Solumedrol Infusion

• Reduction of Antidiuretic Hormone / Diabetes Insipidous– ADH, Vasopressin Infusion


Pulmonary Dysfunction:

• Neurogenic pulmonary edema– Multifactorial– Systemic hypertension + LV dysfunction

• Primary pneumatocyte dysfunction


Pulmonary Dysfunction:

• Iatrogenic injury due to aggressive resuscitation

• Exacerbated by intubation, aspiration, atelectasis

• Concurrent blunt lung injury common– Parenchymal injury problematic in immunosuppressed

recipients


Hematologic Dysfunction:

• Thrombocytopenia– Platelets as needed

• Coagulopathy/DIC– FFP / Cryo as needed

• Hypothermia– Keep them warm!


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What Are Traumatic Brain Injury Guidelines?

Hospital approved guidelines for treating patients with

Traumatic Brain Injury

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Prevent secondary injury, even with grave prognosis• Secondary injury includes other organs, as well as the

brain

Maintain Organ Perfusion• Volume Load• Monitor & Maintain adequate CVP, MAP• Oxygenation

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Continuous fluid resuscitation

• Correct electrolyte abnormalities

Rule of 100’s: • SBP >100mm Hg• U/O >100ml/hr• PaO2 >100


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Why Implement TBI Guidelines?

• Ensure consistent management of the critically ill patient• Maintain homeostasis for accurate brain death

assessment• Prevent “secondary injury” to organs, even with grave

prognosis• Provide a clinical bridge between determination of brain

death and family’s decision on donation

Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation(Salim et al. J Trauma 2005; 58: 991-994)

• LAC + USC Standardized organ donor management protocol

• Before-after study (January 1998) of ADM institution– January 1995-December 2002

LAC+USC Study(Salim et al. J Trauma 2005; 58: 991-994)

• Vasopressors if MAP <70.– Dopamine– Levophed– Vasopressin

• Hormones for maximal vasopressors.– Insulin– Solumedrol– T4

LAC+USC Study(Salim et al. J Trauma 2005; 58: 991-994)

Results

• 878 patients referred, 460 (53.4%) patients potential organ donors and 161 (34.3%) actual donors.

• # patients referred increased 57%• # of potential donors increased 19%• # of actual donors increased 82%• # of patients lost to cardiovascular collapse decreased 87%

• # of organs recovered increased 71%

How to Implement TBI Guidelines in Your Hospital?

Clinical Educator

Critical Practice Committee

Critical Care Leadership

Critical Care Physicians or Medical Director

Sample Guidelines available at:

www.onelegacy.org

DNR Decision

What does the DNR decision mean to the family?

• No Chest Compressions?• No Shock?• No Medications?• No Labs?• No Fluids?

“Do not harm?” or “Do not treat?”

Summary

• Critical care teams can honor the DNR decision while preserving the option of donation.

• Pathophysiology of TBI can be anticipated and treated.

• TBI Guidelines can be implemented to prevent “step down” in clinical management, and preserve the family’s donation option.

Question to Run On

What ideas would most help you in your work with patients and families

facing end-of-life decisions?

Transition to Breakout Session #2

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Documents

A Clinical Balancing Act: Honoring the DNR Decision While Preserving the Option of Donation Brian J. Kimbrell, MD, FACS Trauma / Surgical Critical Care