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Breakout Session A: “Wait!! This patient is NOT brain dead… How can they be a donor?” Donation After Cardiac Death Case Studies. Moderator: Margie Whittaker, RN, Mission Hospital Presenters : Julie Vaupel -Phillips, RN, CHOC Children’s John Brady, RN, St. Mary Medical Center - PowerPoint PPT Presentation
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Moderator:• Margie Whittaker, RN, Mission HospitalPresenters:• Julie Vaupel-Phillips, RN, CHOC Children’s• John Brady, RN, St. Mary Medical Center• Esther Montoya, RN, OneLegacy
Breakout Session A:“Wait!! This patient is NOT brain dead…
How can they be a donor?”
Donation After Cardiac Death Case Studies
W A I T ! ! T H I S PAT I E N T I S N O T B R A I N D E A D … H O W C A N T H E Y B E A N O R G A N D O N O R ?
Moderator:
Margie Whittaker, RN
Manager SICU
Mission Hospital
TRANSPLANT TIME LINE1954 First Successful Kidney
Transplant
1962 First Successful Cadaveric
Kidney Transplant
1963 First Successful Lung
Transplant
1967 First Successful Heart and
Liver Transplant
“HOW TO BE…”
Being in action!
The answers are in the room
“Report out” on Questions to Run-on: • Scribe • Spokesperson
All Teach / All Learn
QUESTIONS TO RUN ON…
How will you apply what you learned
today during future end of life care plans?
How will you remember to include
donation?
OBJECTIVES
By the end of this presentation, the attendee will be able
to:
1. Identify best practices in DCD
2. Recognize the importance of collaboration and
communication in donation
3. Describe strategies to improve the DCD process
Pediatric Donation After Cardiac Death (DCD)Julie Vaupel-Phillips, MHA, RN, CCRN Director of PICU and ETS Services CHOC Children’s Hospital
Donation Facts• In the USA 1% all deaths are considered brain death.
• One organ donor has the potential to save up to 8 people by donating organs and may provide 50 people with tissue and cornea transplants.
• There are more people on the organ wait lists than organs available. 18 people die each day waiting for an organ transplant
• Literature shows that parents want to be asked about organ donation, including donation after cardiac death.
• Families of children are more likely to agree to organ donation than families of adult patients.
Donation after Cardiac Death (DCD)• DCD offers an option to patients and families who may
wish donation to occur after life sustaining equipment is
withdrawn, and death is determined by cardiopulmonary
criteria.
• For DCD to occur, patient death is determined by
cessation of cardiac & respiratory function, rather than by
the absence of cerebral and brain stem function.
• DCD is generally practiced in the USA
Donation after Cardiac DeathThings to think about:• Some children die despite all our efforts• Death is not a failure• Death is a natural part of life.• Donation is a family driven process.• The family has already made the decision to allow the
patient to die.• The families decision to donate must be separate from
their decision to withdrawal of support.• Family participation is essential• The patient must always be provided comfort measures
Donation after Cardiac Death at CHOC Children’s Hospital
• 2005, Q3 1 DCD• 2006, Q1, Q3 2 DCDs• 2007, Q3 1 DCD• 2008, Q3 1 DCD• 2009 0 DCD• 2010 0 DCD• 2011, Q1, Q2
Things to Consider with PEDS DCD• The parents may change their mind at any time.
• Expect that the parents will want to be present in the OR and hold their child at the time of death.
• Expect that the OR will not be comfortable with the parents coming into the OR.
• Try to time the OR for evening, night or early am when there are fewer cases in the department.
• Request an OR room that has an easy egress but is private so that the family can be as comfortable as possible.
• Huddle frequently and often.
Case Study• 3 month old female
• Twin A
• Found unresponsive in crib
• Asystolic when arrived in ED
• Metabolic workup positive for fatty acid oxidative defect
• Parents informed of poor prognosis
• Family requested withdrawal of support and asked about organ donation
• OneLegacy contacted
• Consent obtained for Organ Donation
Case Study• Patient prepared for transport to OR.• Patient 4.2 kg, no local recipients.• Stanford University accepts liver and kidneys.• OR Booked for 16:00• Flight plans set for transplant team to fly from Palo Alto.• Parents request to be close to the OR but will not be
present in the OR. Family in secluded area of the OR.• Family Care Coordinator and Priest support the family.• 20 minutes from OR time, the transplant team experiences
an in-flight emergency• Flight is diverted to Sacramento
Case Study• Family is informed but are willing to wait the 3-4 hours it
may take to get the team down to Orange County.• Transplant team arrives (8 pm) and patient brought back to
the OR.• Parents placed in secluded OR room.• Withdrawal of LST performed by the PICU Intensivist.• Patient was pronounced dead 11 minutes after withdrawal
of life support.• Parents immediately informed, baby blanket and toy
returned to them. • Surgery starts after 5 minutes of observation period.• Liver and Kidneys successfully recovered.
Words of Advice…• Support internal staff and each other
• Expect the unexpected
• Develop a plan − For family-demographics, communicate and explain what will
occur, what they will see and hear, and all the what if’s − For patient-palliative care, terminal extubation person, − For staff-roles and responsibilities
• Post case debrief (OPO & hospital) for staff involved• Learn something from every case• DCD is patient/family centered care
Their lives depend on it!
Thank you.
St Mary Medical Center Apple Valley
Donation After Cardiac DeathCase Review
John Brady, RN, CCRN, CNRN
ICU Nurse Manager
Donation at St. Mary Medical Center
Organ donors 2000-20117 Organ Donors
• 5 brain dead
• 2 DCD (2006 and 2011)
• 17 organs recovered
• 14 organs transplanted
• 3 organs for placed for research
Day 1: Admission
45/MStatus post cardio-pulmonary arrestAreflexicMedical history methamphetamine
use, high cholesterol, & diabetesDown time 45 minutesTransfer in from local hospital for
higher level of care
Day 2
Consult to OneLegacy
Patient made a DNR
Family wanted to extubate soon
Family initiated donation discussion with
physician
Day 2: OneLegacy Consult
Family wanted to extubate that evening
Awaiting OneLegacy’s arrival to discuss donation
Patient’s mother initiated donation topic stating…It was a difficult decision but she
wanted her son to save lives through donation.
Day 2: OneLegacy Consult
OneLegacy discussed donation options with the family.
The family consented for both brain death and DCD donation, said their final goodbyes, left the hospital and requested post OR follow-up
Hospital planned for EEG on Day 3
Day 3
EEG showed activity, Patient NOT BRAIN DEAD
DCD Policy reviewed Huddle with all Champions: Attending
Physician, Nurse Manager, Charge Nurse, Bedside Nurse, Respiratory Therapist, Palliative Care, Risk Manager and House Supervisor
Day 3
Patient placed on CPAP and shallow breaths were observed; attending physician determined that there was a high probability that the patient would not survive longer than 60 minutes
Palliative Care informed the family that EEG showed activity
Family confirmed that they wanted to proceed with donation
The Next StepsAttending physician
aware that he will be pronouncing the patient
OR scheduled for 18:30pm
16:00pm patient’s sister called the unit hysterical; the bedside nurse referred caller to speak with the patient’s mother
The Next StepsAttending physician
became concerned with recent phone call from patient’s sister and requested a second teleconference with the family to confirm donation choice
Patient’s mother contacted Palliative care and verified consent for donation
OR DelayedAttending physician left
hospital at 19:00pm and delegates pronouncement to Hospitalists or ED physician; no new OR time set
Risk Manager contacted the Medical Director who instructed the Attending to return to SMRM to pronounce the patient in OR
The Gift of Life
OR: Pt extubated 20:35pm; pronounced by Attending Physician at 20:59pm (24 minutes)
Outcomes: Right Kidney placed locally
61 Female on waiting list 2, 899 days
Left Kidney placed locally
60 Male on waiting list 2, 833 days
Liver and pancreas placed for research
What We Learned
Planning
Communication
Teamwork
DCD Data & The Story it Tells
Presented by:Esther Montoya RN, MSN ED
Donation Development CoordinatorOneLegacy
269391
560 559
791 848 920
0
200
400
600
800
1000
2003 2004 2005 2006 2007 2008 2009
DCD Donors
DCD vs. Brain Dead Donors(United States)
5416 5799 5984 6187
269 391 560 559 791 848 920
5359 608158225477
0
1000
2000
3000
4000
5000
6000
2003 2004 2005 2006 2007 2008 2009 2010
BD Donors DCD Donors
OneLegacy DCD History
27
14 16
25
1924 25
21
05
1015202530
2003
2004
2005
2006
2007
2008
2009
2010
2011
DCD Donors
3rd Qtr
OneLegacy Brain Dead vs.DCD Donors
326 339 359 371 381 358324
284
2 7 16 25 19 24 25 21
416
140
50
100
150
200
250
300
350
400
450
2003 2004 2005 2006 2007 2008 2009 2010 2011
Brain Dead DCD
4% 4%
3rd Qtr
7%7%6%5%6%
4%4%
OPO DCD Comparison
0
20
40
60
80
100
MIOP MAOB PADV CAOP
2008 2009 2010
OneLegacy (CAOP) compared to high performing OPO’s (DCD) in the US:
MIOP= Michigan-Gift of Life MAOB= New England Organ Bank-MA PADV= Gift of Life Donor Program-PA
76
6072
23
DCD & Organs Transplanted
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
2008 2009 2010
CAOPPADVMAOBMIOP
Average=1.84
Average=1.66
Average=1.80
Average=1.48
Potentially 84 More Lives Saved
California Donor Registry
19%
27%25%
27%
33%
28% 30%
38%
33%37%
42%37%
41%
46%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Organ Donors Tissue Donors Eye Donors
2007 2008 2009 2010 2011 YTD
Designated Donors Among Recovered Donors
Trends in Donation
• Registered Donors= 20.7 % in our service area, 27.3% Nationally
• DCD donors occurred at 52 out of 220 hospitals since (2003-2011)• AA= 33 23% A= 36 25%• B= 30 21% C= 44 31%
• Hospitals with DCD P&P’s:2003 = <2% 2011 = >90%
• 2010 Research/study– Clinical trigger cards introduced to selected hospitals to capture
DCD potentials.
Clinical Trigger Research
2009 2010 2011 3rd Qtr
2011 Projection
Referrals 4398 5144 3597 5383
Eligibles 549 487 362 541
Donors 382 349 270 406
DCD 24 (6%)
25 (6.9%)
21(7.4%)
30(7.3%)
What Story does the Data Tell?
• Highlights areas of potential growth by trends
– DMV and Registered donors
– DCD donation
TOGETHER WE CAN DO BETTER -PARTNERS FOR LIFE!
What we learned?
Practices for Success:–Communication and collaboration is key –All inclusive clinical trigger card & early
referral– Implementation of supportive P&P’s–Pt. and family centered care philosophy
QUESTIONS TO RUN ON…
How will you apply what you learned
today during future end of life care plans?
How will you remember to include
donation?
WHAT WE LEARNED?
Practices for Success: Communication & collaboration is key All inclusive clinical trigger card & early referral Implementation of supportive P&P’s Pt & family centered care philosophy