DEATH: AN EVERYDAY AFFAIR

800-DONORS-7 • core.org

Living Organ Donation in a Life Support Withdrawal Patient who was not a DCD

Candidate“An Opportunity Lost-A time for Change”

Kurt Shutterly, COO


DEATH: AN EVERYDAY AFFAIR

• There is an Estimated 4,000 Deaths in the United States each day where there’s a Conscious Decision to Limit Treatment in some way.

• About 1,400 ICU deaths per day – One in five Americans die using Intensive Care

Services– Approximately 90% of these deaths following decision

to withdraw life support.


ROBERT and KATHY OSTERRIEDER


CASE REVIEW

• 52 year old Caucasian male • Admitted to UPMC Presbyterian on 5/11/2012• Complaint of blurry vision and frontal headache.

• History of Factor V Leiden Mutation • Prolonged hospital stay related to shunt failure

and new stroke in Left Lateral Medulla.


CLINICAL PICTURE 5/16/2012• Neurological Assessment:

– Intermittently following commands on vent– Progressive deterioration in neurologic status

secondary to Intracranial HTN following Thrombolysis and Embolization of Fistulae.

• Labs:– ABO O– Bun 8, Creatinine 0.7– LFT: Normal– Urine, Blood and CSF Cultures Negative

• Plan of Care: continue Heparin gtt and Full Support


FIRST REFERRAL 5/16/12

• Initiated because of imminent death• Family considering withdrawal of support• In-hospital coordinator reviewed chart

– Patient on minimal ventilator support– Care team hopeful to wean off ventilator

• Family decides to pursue Skilled Nursing Facility and against withdrawal of support

• Patient removed from Pending list • No interaction between family and OPO


SECOND REFERRAL 10/2/12 (Almost 5 Months from Initial Admission)

• Social Worker contacts CORE• Patient in and out of hospital since May and now

family considering limiting treatment. • Wife knows her husband wishes to donate and

inquiring about next steps to fulfill his wishes. • Organ Procurement Coordinator dispatched to

hospital to discuss donation options.


CLINICAL PICTURE 10/2/2012• Patient on aerosol tracheostomy mask• Limited neurological function secondary to multiple

cerebral emboli • Labs:

– Bun 2, Creatinine 0.4– LFT: Normal– WBC 12.3

• Patient on Antibiotics– Blood Cultures Positive for Coagulase Negative Staph


DISCUSSIONS WITH FAMILY & HEALTH CARE TEAM

• Discussion with family and decision to no longer treat aggressively.

• Patient has donor designation on his license.

• Family very strong proponent of donation, – asking if patient was ventilated

• Family provided option of tissue and eye donation.– antibiotics continued with negative blood culture

results.


HONORING THE DONOR’S WISHES

• Dr. Joseph Darby CCM meets with family to discuss comfort measures only (CMO).

• Family disappointed that they could not donate organs as this was the patient’s wish.

• Discussion with family regarding the donation of one kidney and the lobe of the liver prior to initiating CMO.


HONORING THE DONOR’S WISHES

• President/CEO of CORE states – “lets honor the donor and family’s wishes and make

this happen”.• Family fills out medical social questionnaire with

OPO coordinator • Meetings scheduled to define processes


HOSPITAL ACTIONS• Multi-Disciplinary Meeting with and

approval from:– Hospital Ethics– Unit Director – Risk Management– Hospital Legal Council– Patient Attending Physician– Hospital Administration


OPO ACTIONS• Serology and Tissue Typing Completed• Assist with setting up hospital meetings• Contacted UNOS Administrator to discuss

proper allocation– Unable to run deceased donor list as patient

will be a living donor– Must use Hospital Living Donor Program

• List ran and recipient identified


DISCUSSION WITH LOCAL TRANSPLANT CENTERS

• Local transplant center 1: – Declined due to quality and did not think their surgeons

would recover due to living donor.• Local transplant center 2:

– Declined due to Altruistic Donor without patient’s actual authorization.

• Local transplant center 3: – Declined for same reasons and also felt the OPO may

be pushing the limit and worried about negative media.


DISCUSSION WITH ADDITIONAL OPOs AND TRANSPLANT CENTERS

• Ohio Transplant Center: – Director declined for the same reasons and also

stated that this will be the topic at their next ethics meeting.

• Three other OPO’s contacted for assistance to find a surgeon who would recover organs on this patient without success.


OUTCOME OF ORGAN PLACEMENT

• Notified Dr. Darby – Transplant centers would not recover due to the

patient unable to give his own authorization to donate while he was still living.

• Dr. Darby met with family to discuss the outcome– patient was made CMO on 10/7/12.

• Patient CTB on 10/09/12 at 1315 – was medically unsuitable to be a tissue or cornea

donor due to infection.


REFLECTIONS FROM DR. DARBY

• “In light of the events transpiring over the last several days as it regards to the patient and his family’s determined efforts to honor his wishes to become an organ donor at the end of his life, I am now determined to make every effort possible to change our organ donation policy to allow for organ donation to take place in the future in circumstances that are determined to be appropriate.


REFLECTIONS FROM DR. DARBY

• I want to do this to honor him, his family and more importantly for those patients who might benefit from such a policy here and at other institutions well into the future. This missed opportunity should not be left squandered. I know he was a good man, father and husband. His legacy should also reflect the conversation that led to important change in the world of organ donation and transplantation.”


DR. DARBY’S COMMENTS

• “I do not believe that patients should be denied the opportunity to altruistically donate their organs at the end of their natural life as was the case here. I fully understand all of the issues surrounding the dead donor rule but it’s time to change that and help others understand that as well. I do appreciate all the efforts that our institution and administration made on behalf of the family and patient and applaud those individuals who were supportive.”


THE PRECEDENT HAS ALREADY BEEN SET

o A 20 year old suffered catastrophic ICH.o Following decision to withdraw life support,

family raised the issue of organ donation for a related patient with kidney failure.

o Ethics committee approved the procedure arguing surrogate decision maker was ethically acceptable.

o Living related donation carried out. o Patient subsequently died after withdrawal of

life support.Surrogate Consent for Living Related Organ Donation. JAMA 2004; 291 (6): 728-731


POSSIBILITIES

• Waiting list as of 01/11/2013 at 3:22 pm:– 117,271 Candidates– Approximately 80% are in need of a kidney

• There is an Estimated 4,000 Deaths each day where there’s a Conscious Decision to Limit Treatment in some way.

• About 1,400 ICU deaths per day – Approximately 90% of these deaths following decision

to withdraw life support.


POSSIBILITIES

• About 1,400 ICU deaths per day – Approximately 90% of these deaths following

decision to withdraw life support.– If 5-10% donated one transplantable kidney

this would result in 2,555 to 5,110 kidneys per year

• Still would take 18 to 36 years to reduce the Kidney list to zero

• It would help to decrease the kidney waiting list


ISSUES: WHAT DO WE CALL THESE DONORS?

• Deceased Donors– Brain Dead– DCD Donors

• Living Donors– Living Related– Living: Altruistic– Living Donation Prior to Natural Death

• Altruistic Living Donation Prior to Death• Withdrawal of Life Support Donors (WLS)• DPD: Donation Prior to Death


ADDITIONAL OBSTACLES:

• No Provision for these Donors in OPTN/UNOS• Informed Consent: First Person VS Surrogate

Consent• Potential Donor Pool: Is it worth the effort?• Costs: Who pays for Procedures and Care?• Risks: Donor Operation Only– No long term

concerns• OPTN/UNOS Policy Changes Required


FAMILY COMMENTS


“REQUEST FOR ACTION”

• Every OPO start the discussion with your staff, donor hospitals and Boards

• Consider holding a summit and asking multiple disciplines to attend

• Create a white paper• Organized approach for Legislation• Collaborative Policy Development• “Near-end-of-life Altruistic Donation


QUESTIONS

Documents

DEATH: AN EVERYDAY AFFAIR