Transcript Slide 1

Organ Donation
Support for education and learning
Clinical case scenarios
April 2012
NICE clinical guideline 135
What this presentation covers
• Background
• Aim of the guideline
• Clinical case scenario(s) for
o
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emergency departments (1 & 2)
adult intensive care units (3 to 6)
paediatric intensive care units (7)
• Find out more
Background
• 90% of the population support organ donation but
actual donation rate is poor
• Organ donation has a major role in the
management of organ failure
• Too few organs means long waits, costly treatment
and many potentially avoidable deaths.
Aim of the guideline
To promote the identification and fulfilment of those
that wish to donate organs
To improve:
• identification and referral of potential donors
• approach to consent for donation
• consideration of donation as part of
standard ‘end-of-life care’ planning
Clinical case scenarios for
Emergency departments
Case scenario 1, Mary
Presentation
Mary is a 56-year-old woman who collapses at home. An ambulance is
called, arriving 8 minutes after the initial collapse and finding Mary
unconscious with laboured breathing.
A BASICS (British Association of Immediate Care) trained doctor gives a
bolus of sedative; then Mary is intubated, ventilated and transferred to
the local emergency department (ED).
During the journey her pupils become dilated and fixed; she is
hypertensive then becomes hypotensive. After arriving at the ED she has
a computed tomography (CT) scan, which shows extensive
subarachnoid haemorrhage.
No additional sedation has been given since intubation.
Case scenario 1, Mary
Medical history
Mary smokes 20 cigarettes a day and drinks 6 units of alcohol at the
weekend. She is currently monitored by her GP for raised blood pressure
but has not been prescribed any therapy. She had a breast lump
removed 3 years ago; the histology report showed it to be a benign
tumour.
On examination
On initial neurological examination Mary’s pupils remain fixed and
dilated, there is no cough or gag reflex on deep endotracheal suction,
and there is no response to painful stimuli other than extensor
posturing of limbs.
Case scenario 1, Mary
In view of the plan of care, treatment will be maintained until the relatives
have arrived and been informed of the gravity of the situation.
1.1 Question
Mary is still in the ED. In view of this, should organ donation be discussed
with the family?
Case scenario 1, Mary
1.1 Answer
Yes. Organ donation should be considered as a usual part of ‘end-of-life
care’ planning regardless of where the patient receives treatment.
Emergency care staff should request that the adult intensive care unit take
over the care of this patient.
Case scenario 1, Mary
The decision to withdraw treatment has been made. However, the patient’s
clinical presentation indicates that she could be brainstem dead. She has
joined the NHS organ donor register, stating her wish that all organs be
donated.
1.2 Question
Should neurological testing be used to confirm death, or should treatment
be withdrawn and death confirmed using circulatory criteria?
Case scenario 1, Mary
1.2 Answer
Patients with suspected brainstem death usually have this confirmed by
brainstem testing. However, the patient has expressed her wish to donate
all organs, and confirming death using neurological criteria could enable
more organs to be donated.
The healthcare team caring for the patient should initiate discussions about
potential organ donation with the specialist nurse for organ donation. The
patient’s wishes support the decision to use neurological testing.
Case scenario 1, Mary
Neurological testing is undertaken. There is no available space in the
emergency department so an intensive care unit bed is requested.
1.3 Question
Should this patient be accepted by the intensive care unit, given that they
are going there for only neurological testing and assessment for organ
donation?
Case scenario 1, Mary
1.3 Answer
Yes. The patient should be clinically stabilised in an appropriate critical care
setting while the assessment for donation is performed.
Case scenario 1, Mary
1.4 Question
At what stage should discussion with the family take place regarding
organ donation?
Case scenario 1, Mary
1.4 Answer
The family should be approached only when it is clearly established that
they understand that death is inevitable or has occurred. Sufficient time
should be allowed for Mary’s husband and daughter to understand the
inevitability of her anticipated death.
They should be given a clear explanation about confirming neurological
and circulatory death using specific criteria. The approach should be
planned and at a time that suits the family’s circumstances, and should
be made by the multidisciplinary team (MDT), including the specialist
nurse for organ donation.
Continues on slide 16
Case scenario 1, Mary
1.4 Answer, continued
The MDT involved in the initial approach should have the necessary
skills and knowledge to provide to those close to the patient appropriate
support and accurate information about organ donation, informing them
that donation is a usual part of end-of-life care.
Those approaching the family should assess what family support may be
needed, for example local faith representative, family liaison officer,
bereavement service, trained interpreter or advocate.
Case scenario 2, Benjamin
Presentation
Benjamin is a 17-year-old young man admitted to the emergency
department after being knocked off his bicycle. He has multiple trauma, with
fractures to his left leg and arm, multiple fractures of his ribs and severe
head trauma.
He has been intubated and ventilated by the paramedics.
Case scenario 2, Benjamin
Medical history
None relevant. He is a fit young man.
On examination
A CT scan shows intraventricular bleeding, subarachnoid haemorrhage
and right subdural haematoma. Chest nil. There is a small amount of free
floating fluid in the abdomen and the left base of a chest X-ray is hazy. A
12-lead electrocardiogram (ECG) is normal.
Case scenario 2, Benjamin
Benjamin is referred to neurosurgeons, who decide that no intervention is
applicable. Treatment is withdrawn after discussion with the family.
Benjamin is asystolic 10 minutes after withdrawal of treatment.
2.1 Question
Should this patient have been identified and referred as a potential donor?
Case scenario 2, Benjamin
2.1 Answer
Yes. All patients who are potentially suitable donors should be identified as
early as possible, through a systematic approach. While recognising that
clinical situations vary identification should be based on either of the
following criteria, see recommendation 1.1.2.(see notes)
Case scenario 2, Benjamin
2.2 Question
Was this a missed potential donor?
Case scenario 2, Benjamin
2.2 Answer
Yes. On checking the organ donor register the patient was found to be
registered to donate all organs. The family was not asked about organ
donation and the patient was not referred to the specialist nurse for organ
donation.
If a patient lacks capacity to make decisions about their end-of-life care, the
healthcare team should seek to establish whether taking steps, before
death, to facilitate organ donation would be in the best interests of the
patient. Life-sustaining treatments should not be withdrawn or limited until
the clinical potential for the patient to donate has been assessed, in
accordance with legal and professional guidance.
Case scenario 2, Benjamin
2.3 Question
Should this patient have been a donor after circulatory death (DCD) or
donor after brainstem death (DBD)?
Case scenario 2, Benjamin
2.3 Answer
This patient could have been potentially either.
The patient should be clinically stabilised in an appropriate critical care
setting while an assessment for donation is performed – for example, in an
adult intensive care unit or in discussion with a regional paediatric intensive
care unit.
The MDT involved in the initial approach should have the necessary skills
and knowledge to provide to those close to the patient appropriate support
and accurate information about organ donation.
Continues on slide 25
Case scenario 2, Benjamin
2.3 Answer continued The skills and competencies required of the individual members of the team
will depend on their role in the process. However, all healthcare
professionals involved in the identification and referral of potential donors to
the specialist nurse for organ donation, and the subsequent consent
processes, should have knowledge of the basic principles, and the relative
benefits, of donation after circulatory death versus donation after brainstem
death.
The team should ensure that brainstem tests are performed if possible
because this gives the family of a potential donor the certainty of a
diagnosis of death and also allows more organs to be used than after
circulatory death.
Clinical case scenarios for
Adult intensive care units
Case scenario 3, Eric
Presentation
Eric is a 17-year-old young man with Duchenne muscular dystrophy,
admitted with severe pneumonia to the adult intensive care unit.
Past medical history
Eric was diagnosed with Duchenne muscular dystrophy at the age of 7
years. He has been in a wheelchair since the age of 10, and has had
progressive respiratory failure since he was 12. He has used domiciliary
night-time mask ventilation since he was 14 and had scoliosis surgery at
16. He has had worsening cardiorespiratory failure for 18 months and two
admissions to the adult intensive care unit in the past 12 months.
Case scenario 3, Eric
On examination
Eric has severe neuromuscular weakness. The adult intensive care unit
team makes two failed attempts to extubate him back to mask ventilation.
The consultant considers successful long-term separation from the
ventilator unlikely.
His parents tell the nursing staff that they think their son will never come off
the ventilator and that they do not wish him to suffer any more
3.1 Question
Might this young man be considered as a potential organ donor?
Case scenario 3, Eric
3.1 Answer
Yes. Organ donation should be considered as a usual part of end-of-life
care planning in all children with life-limiting conditions
Next steps
The nursing staff tell the intensive care consultant about the family’s views
and consideration is given to withdrawing life-sustaining respiratory support
3.2 Question
How might the potential for organ donation be realised in this patient?
Case scenario 3, Eric
3.2 Answer
All potential organ donors should be identified as early as possible, using
a systematic approach.
Case scenario 3, Eric
The nursing staff report that Eric’s parents have made enquiries about
organ donation.
3.3 Question
While Eric’s and the family’s wishes regarding organ donation are being
assessed, how should Eric be cared for, and where should this care be
delivered?
Case scenario 3, Eric
3.3 Answer
Eric should remain stabilised in an appropriate critical care setting.
Consideration should be given to discussing his management with the
regional paediatric intensive care unit.
A dialogue with the tertiary paediatric centre may also clarify details relating
to other relevant comorbidities, such as significant cardiac failure and the
ability to donate certain organs.
Case scenario 3, Eric
3.4 Question
The medical team seeks to ascertain whether the young man had
expressed any views regarding organ donation. How would they go about
this?
Case scenario 3, Eric
3.4 Answer
The medical team may go about this in any of the following three ways:
• ascertain whether or not he had registered to donate on the NHS organ
donor register
• ascertain whether he had made an advance statement, or
• in the absence of an advance statement, ascertain whether he had
expressed views on organ donation to his parents.
Case scenario 3, Eric
3.5 Question
It becomes apparent that Eric has made an advance statement. What
obligation are the medical team under to follow his wishes?
Case scenario 3, Eric
3.5 Answer
If the advance statement is deemed to be valid (that is, Eric was regarded
as having mental capacity at the time it was written), the medical team have
a duty to take into account his views whenever possible, accepting that they
may be overridden by a person with parental responsibility.
Case scenario 4, Janet
Presentation
Janet is a 35-year-old woman admitted to intensive care following an
overdose of chloroquine (60 x 250 mg). She is found at home
unresponsive. Paramedics are called; they find Janet in asystole, she had
aspirated, and begin full advanced life support.
She arrives in the emergency department with cardiopulmonary
resuscitation in progress, having had four doses of adrenaline, and
ventilated. Her estimated down time is 3 hours. A CT head scan shows
diffuse hypoxic brain injury and she is transferred to intensive care.
Case scenario 4, Janet
Medical history
Janet has no known GP, so a history is provided by her partner of four
months: paracetamol overdose five years ago, drinks at least one bottle of
wine and half a bottle of gin per day, smokes 20 cigarettes per day.
On examination
Both pupils are fixed and dilated, and there is no response to painful stimuli.
There is no cough reflex on deep endotracheal suction. Liver function tests
are abnormal. Chest X-ray shows bilateral diffuse infiltrate consistent with
aspiration. There has been no urine output for the past 5 hours. She is
hypotensive, with a blood pressure of 70/30 mmHg for 6 hours despite
active treatment.
Case scenario 4, Janet
A clinical decision is made that no further treatment should be instigated.
No family is known. The coroner agrees that consideration for organ
donation can proceed.
4.1 Question
Janet does not appear to be a suitable candidate to become a donor.
Should she be referred to the specialist nurse for organ donation?
Case scenario 4, Janet
4.1 Answer
Yes. Consideration for organ donation should be a usual part of ‘end-of-life
care’ planning. All patients who are potentially suitable donors should be
identified as early as possible. The patient's known wishes and feelings, in
particular any advance statement or registration on the NHS organ donor
register should be ascertained
Case scenario 4, Janet
Refer the patient to the specialist nurse for organ donation so that a full
assessment can be made of her suitability for organ donation.
4.2 Question
Why refer to the specialist nurse for organ donation when the consultant in
charge of the patient should be able to make the decision about suitability
for donation?
Case scenario 4, Janet
4.2 Answer
The MDT is responsible for planning the approach for consent and
discussing organ donation with those close to the patient.
Before approaching those close to the patient the team should identify a
patient’s potential for donation in consultation with the specialist nurse for
organ donation; check the NHS organ donor register and any advance
statements or Lasting Power of Attorney for health and welfare; and clarify
coronial, legal and safeguarding issues.
Case scenario 4, Janet
Janet is referred to the specialist nurse for organ donation. All centres turn
her down as a potential organ donor because of poor organ function,
prolonged down time, subsequent hypotension and past medical history.
4.3 Question
Janet is not a potential organ donor. Do brainstem death tests need to be
performed?
Case scenario 4, Janet
4.3 Answer
Yes. In line with current professional guidelines, if neurological death is
anticipated, death should be confirmed using neurological criteria. Relatives
should be provided a clear explanation on how death is diagnosed using
neurological criteria, how this is confirmed and what happens next
Case scenario 5, Rupert
Presentation
Rupert is a 46-year-old man admitted to the intensive care unit after a
motorbike accident. He has trauma to his head and chest. An X-ray shows
a depressed fracture to his skull, fractures to both zygomatic bones and
multiple fractures of his ribs.
He has undergone neurosurgery and is now ventilated. He has not had any
sedation for more than 24 hours after surgery and remains deeply
unconscious and unresponsive to painful stimuli and has fixed and dilated
pupils. He is breathing spontaneously and coughs in response to
endotracheal suction.
Continues on slide 46
Case scenario 5, Rupert
Presentation continued The clinical team does not believe that he will make any meaningful
recovery and that it would be in his best interests to withdraw life-sustaining
treatment.
The consultant has discussed the gravity of the situation with Rupert’s wife
and explained that it is in the patient’s best interest to withdraw lifesustaining treatment. She is extremely upset and angry.
The consultant is anxious about approaching her for organ donation and is
reluctant to refer the patient to the specialist nurse for organ donation.
Case scenario 5, Rupert
Medical history
Fractured right femur 20 years ago. Drinks approximately 20–30 units of
alcohol at weekends.
On examination
Both pupils are fixed and dilated, and there is no response to painful stimuli.
Rupert continues to have a cough reflex on deep endotracheal suction.
Case scenario 5, Rupert
5.1 Question
Rupert’s wife is very upset. Should she be approached about organ
donation?
Case scenario 5, Rupert
5.1 Answer
Yes. Organ donation should be considered as a usual part of ‘end-of-life
care’ planning. All patients who are potentially suitable donors should be
identified as early as possible.
The healthcare team caring for the patient should initiate discussions about
potential organ donation with the specialist nurse for organ donation at the
time the referral criteria are met.
Case scenario 5, Rupert
The clinical team makes the decision to withdraw treatments. The team
recognises that Rupert is a potential donor after circulatory death. However,
this will mean a delay in withdrawing treatment to allow time for the organ
retrieval team to travel to the hospital.
5.2 Question
Will the delay to treatment withdrawal to support organ donation be in the
patient’s best interests?
Case scenario 5, Rupert
5.2 Answer
If a patient lacks the capacity to make decisions about their end-of-life care,
the healthcare team should seek to establish whether taking steps, before
death, to facilitate organ donation would be in the best interests of the
patient.
So long as any delay is in the patient's overall best interests, life-sustaining
treatments should not be withdrawn or limited until the potential for the
patient to donate has been assessed in accordance with legal and
professional guidance.
The patient’s wishes also need to be ascertained.
Case scenario 5, Rupert
5.3 Question
Who should approach Rupert’s wife about organ donation?
Case scenario 5, Rupert
5.3 Answer
The MDT is responsible for planning the approach. The team should have
the necessary skills and knowledge to provide to those close to the patient
appropriate support and accurate information about organ donation.
The approach to those close to the patient should only be undertaken when
it is clearly established that they understand the inevitability of the death.
Those approaching the family should assess what family support may be
needed, for example a local faith representative, family liaison officer,
bereavement service, trained interpreter or advocate.
Case scenario 6, Ahmed
Presentation
Ahmed is a 38-year-old, British Asian man admitted to the intensive care
unit after an accident at the building site he works on. He has suffered
severe trauma to his head and has also fractured his left clavicle.
He has undergone emergency neurosurgery and is now ventilated. A
postoperative head CT scan shows extensive brain damage, and although
he has not had any sedation for more than 24 hours after surgery he
remains deeply unconscious and unresponsive to painful stimuli (Glasgow
Coma Score 3) and has fixed and dilated pupils.
Continues on slide 55
Case scenario 6, Ahmed
Presentation continued The consultant suspects that Ahmed is brain-stem dead, and has discussed
the gravity of the situation with Ahmed’s older brother via an interpreter with
support from Ahmed’s younger brother who speaks more English.
He has explained that nothing more can be done to save Ahmed and that
he intends to perform brain-stem death tests later on in the day. They are
all extremely upset.
Case scenario 6, Ahmed
Medical history
Torn calf muscle in left leg from sports injury, 12 years ago
Social history
Ahmed was born in the UK, and lives in a traditional Muslim family with his
wife, his parents and his two brothers.
On examination
Both pupils are fixed and dilated, and there is no response to painful stimuli.
There is no cough reflex on deep endotracheal suction.
Case scenario 6, Ahmed
6.1 Question
The consultant is anxious about approaching Ahmed’s older brother due to
the language barrier even with the support of the younger brother and an
interpreter. Should he be approached about organ donation?
Case scenario 6, Ahmed
6.1 Answer
Yes, Organ donation should be considered as a usual part of ‘end-of-life
care’ planning. All patients who are potentially suitable donors should be
identified as early as possible.
Ahmed fulfils the criteria for referral to the specialist nurse for organ
donation on the grounds of having a Glasgow Coma Score of 3 and having
fixed and dilated pupils. However, organ donation should not be raised with
Ahmed’s family until it is clear that they have accepted the inevitability of
their loss.
Continues on slide 59
Case scenario 6, Ahmed
6.1 Answer continued The team should have the knowledge needed to provide accurate
information about organ donation.
Identifying important cultural and religious issues before approaching the
family may have a substantial effect on their willingness to consent to organ
donation.
For example, traditional British Asian families may expect discussions to be
held with the senior male members of the family rather than the patient’s
wife as next of kin.
Case scenario 6, Ahmed
The healthcare team caring for the patient should initiate discussions about
potential organ donation with the specialist nurse for organ donation at the
time the referral criteria are met.
6.2 Question
How should organ donation be raised with Ahmed’s family?
Case scenario 6, Ahmed
6.2 Answer
The MDT is responsible for planning the approach. The team should have
the necessary skills and knowledge to provide to those close to the patient
appropriate support and accurate information about organ donation. The
approach to those close to the patient should only be undertaken when it is
clearly established that they understand the inevitability of the death. Those
approaching the family should assess what family support may be needed,
for example a local faith representative, family liaison officer, bereavement
service, trained interpreter or advocate. In this case they may consider
involving the local Imam. The team should check if Ahmed has
• given an advanced statement?
• registered on the NHS organ donor register?
• discussed his wishes with those close to him?
A clinical case scenario for
paediatric intensive care units
Case scenario 7, Peter
Presentation
Peter is an 18-month-old baby boy. In the morning his parents awake to
find that Peter’s head is trapped between the bars of the bedstead and he is
not breathing.
They call 999 and are given advice on basic life support over the telephone
before transfer to the local hospital emergency department. Peter is
intubated and ventilated on arrival, and after the third round of adrenaline,
spontaneous circulation returns.
Peter is transferred to the regional paediatric intensive care unit, where
standard neurointensive care begins, but within 24 hours his pupils are
fixed and dilated. A CT brain scan suggests devastating hypoxic-ischaemic
brain injury. All sedative infusions are stopped to allow formal
neurological examination.
Case scenario 7, Peter
Medical history
None of note, normal development, vaccinations up to date.
On examination
On initial neurological examination, pupils are fixed and dilated, there is no
apparent cough reflex on deep endotracheal suction, and there is no
response to painful stimuli other than extensor posturing of limbs.
Case scenario 7, Peter
7.1 Question
Does this child reach the recommended trigger criteria for the healthcare
team to initiate discussions regarding potential organ donation with the
specialist nurse for organ donation?
Case scenario 7, Peter
7.1 Answer
Yes. Peter has had a catastrophic brain injury and has met the following
clinical trigger factors: the absence of one or more cranial nerve reflexes,
and a Glasgow Coma Scale score of 4 that is not explained by sedation.
Case scenario 7, Peter
Ventilation and enteral feeding via a nasogastric tube is continued.
Neurological testing is repeated 48 hours later and brainstem death is
confirmed using standard neurological criteria.
7.2 Question
Which other authorities should be informed at this stage?
Case scenario 7, Peter
7.2 Answer
This death is unexpected because neither the death nor the preceding
collapse were anticipated 24 hours before its occurrence (see ‘Working
together to safeguard children’, chapter 7).
Therefore, the healthcare team should notify the local child death review
office and initiate a ‘rapid response’ enquiry. Ideally this should occur on
admission of the child to the paediatric intensive care unit so that a scene of
incident visit can occur in a timely fashion.
Case scenario 7, Peter
The rapid response process is followed and a multi-agency home visit led
by a consultant community paediatrician takes place. There are no social
care concerns. The sleep environment and circumstances of the collapse
are assessed and a provisional report is provided for the coroner and
pathologist. The hospital consultant paediatrician discusses the case with
the coroner, who agrees that the subject of organ donation may be
discussed with the family.
7.3 Question
How should the MDT plan its approach to discuss organ donation with the
family of the child?
Case scenario 7, Peter
7.3 Answer
Sufficient time should be allowed for the parents to spend time with their
son and to understand the inevitability of his death. Discussions regarding
neurological death and organ donation should be held at different times,
unless the parents initiate these discussions in the same conversation.
The MDT should include the medical and nursing staff caring for the
patient, the specialist nurse for organ donation.
Key family members should be identified before discussions occur and all
meetings should take place in a private setting. Use open-ended questions
and positive language, such as ‘by becoming an organ donor, your son has
the opportunity to save the lives of other children’.
Find out more
Visit www.nice.org.uk/guidance/CG135 for the:
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guideline
NICE pathway
quick reference guide
‘Understanding NICE guidance’
costing report and template
baseline assessment
clinical triggers poster
clinical case scenarios (PDF)
NB. Not part of presentation
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