Dr Alison Ingham (ITU Consultant and CLOD Bangor)

Dr Liz Williams (Associate Specialist Palliative Care)

Usual not UnusualUsual not UnusualUsual not UnusualUsual not UnusualUsual not UnusualUsual not UnusualUsual not UnusualUsual not Unusual

All parts of the NHS must

embrace organ donation as a

usual, not an unusual event.

Local policies, constructed

around national guidelines,

should be put in place.

Discussions about donation

should part of all end-of-life

care when appropriate.

Recommendation 4a

� To facilitate good end of life care for patients and their families on ICU following withdrawal of treatment

� To make organ and tissue donation a usual part of end of life care

� To facilitate good documentation of end of life care

� Audit of current practice

� Initial pathway development

� Consultation

� Final draft

� Trial / pilot phase

� Audit

� Final pathway and all Wales use

Withdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatmentWithdrawal of active treatment

� 73% deaths on ITU in Glan Clwyd occurred after withdrawal of active treatment.

� 72% deaths on ITU in Bangor occurred after withdrawal of active treatment.

Time from treatment withdrawal to

death

Was DNAR form completed? Yes No

Was end of life conversation with family

well documented?

Yes No

Clear documentation of what treatments

are to be withdrawn?

Yes No

Were inappropriate medications

discontinued?

Yes No

Were IV fluids discontinued? Yes No

Were PRN

medications

prescribed?

Analgesic Yes No

Anxiolytic Yes No

Secretions Yes No

Nausea / vomiting Yes No

Is there documentation that family were

given bereavement leaflet / information?

Yes No

Were the family asked about tissue

donation?

Yes No

Is it obvious from the notes exactly who

was present at the time of death (family

and staff)?

Yes No

Time from withdrawal to deathTime from withdrawal to deathTime from withdrawal to deathTime from withdrawal to deathTime from withdrawal to deathTime from withdrawal to deathTime from withdrawal to deathTime from withdrawal to death

35%53%56%% died within 2 hours

6 min to 77 hours

10 min to 12 hours

5 min to 17 hours

Range

180 min55 min110 minMedian

203823No. patients (total 81)

WrexhamGlan ClwydBangor

RangeRangeRangeRangeRangeRangeRangeRange

T im e fro m w ith d ra w a l o f c a re to tim e o f d e a th (W re xh am )

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

0 2 4 6 8 10 12 14 16 18 20

P a tie n t n u m b e r

Ho

urs

Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death Time from withdrawal to death -------- BangorBangorBangorBangorBangorBangorBangorBangor

� 25% patients die within 1 hour

� 56% patients die within 2 hours

AuditAuditAuditAuditAuditAuditAuditAudit

75%?89%IV fluids discontinued

50%?16%55%Inappropriate medications

stopped

45%55%61%Clear documentation of which treatments to be

withdrawn

50%97%100%End of life conversation

with family well documented

45%53%61%DNAR completed

WrexhamGlanClwyd

Bangor

0

10

20

30

40

50

60

70

80

90

100

pe

rce

nta

ge

an a lg esia an xio lytic secretio n s an tiem etic

B an g o r

G lan C lw yd

W rexh am

AuditAuditAuditAuditAuditAuditAuditAudit

10%73%18%

Obvious who was present at time of

death

0%5%0%Family asked about tissue donation

0%15%0%Documented that family were given bereavement leaflet

WrexhamGlan ClwydBangor

� We do well but there is room for improvement

� Short and easy to use

� Replace all other documentation – less work

� Make organ and tissue donation usual

� Help to complete cremation forms

� Developed from the Liverpool Care Pathway

� Welsh collaborative Pathway Project 1999

� Multidisciplinary practice based on guidelines and evidence.

� Now used across Wales in a variety of settings

Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last Integrated care pathway for the last

hours/days of life.hours/days of life.hours/days of life.hours/days of life.hours/days of life.hours/days of life.hours/days of life.hours/days of life.

For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to For use in ITU following a decision to

withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.withdraw futile treatment.

� A guideguideguideguide to provide care for family and patient

� Multi disciplinary document replacing all medical, nursing and paramedical notes

� Each professional encouraged to exercise own judgement within guidelines

� Series of suggested goals of treatment

� Variances to the care suggested are recorded

FlowchartFlowchartFlowchartFlowchartFlowchartFlowchartFlowchartFlowchart

� Instructions

� Criteria

� Goal 1 Donation after Cardiac Death

� Carried out by ITU physician

� Discontinuing non essential medication

� PRN medication for common end of life symptoms

� Discontinuing inappropriate interventions

� Carried out by ITU nurse

� Communication

� Religious issues

� Family care

� Completed by ITU nurse

� Hourly observations

� In accordance with Academy of Medical colleges code of practice (2008)

� Cause of death

� Family needs

� Special need of deceased

� Tissue donation

� Communication with other Medical agencies

� Monitor and audit

Drug ChartDrug ChartDrug ChartDrug ChartDrug ChartDrug ChartDrug ChartDrug Chart

Trial PhaseTrial PhaseTrial PhaseTrial PhaseTrial PhaseTrial PhaseTrial PhaseTrial Phase

� Plan to re-audit after first 20 uses

� Please tell us what you think

� Make changes as necessary

Any Questions?Any Questions?Any Questions?Any Questions?Any Questions?Any Questions?Any Questions?Any Questions?