Transcript National Donate Life Month 2006

Donate Life:
End-of-life Opportunities for
Patients and Families
Bill Snyder, RN, BSN, CPTC
Senior Procurement Coordinator
University of Wisconsin Hospital and Clinics
Organ Procurement Organization
Key Questions
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Why is Organ Donation So Important?
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What is the OPO?
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What is Your Role?
– Clinical Triggers
– 2 donation types
Why is Organ Donation So Important?
Why is Organ Donation So
Important?
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The list is growing at the rate of one person every 13
minutes, and 20 people die daily while waiting on the list.
More than 90% of Americans approve of organ donation,
yet less than half say “yes” when approached at the time
of donation.
Only 2-4% of deaths are eligible for solid organ donation
National Transplant Waiting List
Type of Transplant
Kidney
Liver
Lung
Heart
Heart-lung
Kidney-pancreas
Pancreas
Intestines
Totals
Waiting
78,957
15,768
1,966
2,803
83
2,266
1,552
213
101,216
Transplanted in ‘08
16,514
6,318
1,478
2,163
27
836
437
185
27,958
Source: Organ Procurement and Transplant Network - As of
03/20/09
Wisconsin Transplant Waiting List
Type of Transplant
Kidney
Liver
Lung
Heart
Heart-lung
Kidney-pancreas
Pancreas
Intestines
Total
Waiting
1,057
206
64
79
0
53
12
2
1,436
Transplanted in ‘08
445
155
40
29
0
49
15
0
734
Source: Organ Procurement and Transplant Network, As of 03/20/09
Challenges:
Donors, Transplants and Patients Waiting
95000
85000
75000
65000
55000
45000
35000
25000
15000
5000
Number of Patients
Waiting
Number of Transplants
Performed
Number of Organ
Donors
88
90
92
94
96
98
00
02
04
* Data based on snapshot of the UNOS, OPTN waiting list and transplants on the last day of each year *
2006
What is the OPO?
What is the
Organ Procurement Organization?
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One of 58 OPO’s
Service 104 Hospitals
in Wisconsin, Illinois
and Michigan
Population base: 3.2
Million people
30+ staff members
– Hospital Donation
– Procurement
Coordinators
– Recovery Team
– Family Support
– Community education
Legislation and Organ Donation
CMS Conditions of Participation
Effective August 22, 1998, the Centers for Medicare and
Medicaid Services (CMS) enacted legislation mandating:
All hospitals are required to report all deaths and
imminent deaths to their designated OPO
Designated Requestor training (3.5 hour course)
The Joint Commission
Donation
after cardiac death policies
Surveyors
ask hospital leadership about donation
conversion rates
Legislation and Organ Donation
(cont.)
HIPAA Regulations
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OPO/Tissue/Eye agencies operate as an extension of
your hospital
OPO has a Letter of Agreement with your hospital
and CMS Conditions of Participation grant us access
to any relevant patient information, medical records,
etc.
Allowing us to have access to medical records, you are
in no way violating patient confidentiality
Your Role in Donation
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Recognize when to notify the OPO
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Make the referral
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Continue patient care
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Provide care to families
– Effective requesting (consent)
– Supply information during a donation case
When Do I Notify the OPO?
Clinical Triggers
1.
2.
Mechanically ventilated
Severe neurologic insult/injury
· For whom a physician is evaluating for brain death
OR
· A patient with a Glasgow Coma Scale (GCS) < 5
OR
· Plan to discuss withdrawal life-sustaining therapies
Clinical Triggers (cont.)
Severe Neurological Injury
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Trauma
CVA
Primary CNS Tumor
Anoxia
– Cardiac Arrest/MI
– Drug Overdose
– Drowning/Hanging
Clinical Triggers (cont.)
Timely Referral
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Referral made within 1 hour of a patient
meeting clinical triggers
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JCO/CMS regulation
Majority of organ donors meet clinical triggers
in the Emergency Department, but most
referrals are made from the ICU or CCU
Clinical Triggers (cont.)
How Do Clinical Triggers and Timely Referrals
Improve the Donation Process?
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Clarifies when to notify the OPO
– The initial referral is not the time to be talking to the
family about organ donation
– We are still in full-treatment mode
– It does not mean that the patient is going to be an
organ donor or that the OPO is going to arrive at your
hospital
– It does not mean that the patient will not recover from
the injury
Clinical Triggers (cont.)
How Do Clinical Triggers and Timely
Referrals Improve the Donation Process?
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Allows time for relationship building
Ensures adequate time for potential donor screening,
medical management and allocation of organs
Preserves the opportunity for donation for the family
Clinical Triggers (cont.)
Clinical Trigger Case Studies
#1
A sixty-nine year old male arrived at the hospital
unresponsive due to a CVA. He was intubated on
admission and then weaned off of the vent. A week later
his condition declined and was re-intubated. The
physician had a meeting with the family and they decided
to extubate the patient.
Refer? __
Not Refer? __
If not, why not?
#2
A sixty-eight year old male was admitted to the hospital
unresponsive. He was intubated on arrival. CT scan of
head showed multiple infarcts throughout the brain. He
was admitted to the ICU with a GCS of 4. His prior
medical history includes: Hypertension, hyperlipidemia,
morbid obesity, CAD, and glucose intolerance. He had a
coronary artery stent placed a couple of years ago.
Refer? __
Not Refer? __
If not, why not?
How Do I Make the Referral?
The Referral Process
How do I make a referral?
1-866-UWHC-OPO
(1-866-894-2676)
One Number: •Solid Organ
•Tissue
•Eye
•Death Reporting
The Referral Process (cont.)
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Contact 1-866-UWHC-OPO (STATLINE Call Center)
Have patient’s chart available to provide:
–
–
–
–
–
–
–
Name
Age
Ventilator status
Diagnosis
Coroner’s case?
General health and social history
Time of brain death or cardiac death
The Referral Process (cont.)
Current Criteria for Organ Donation
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Up to age 75 (for now - this can change!)
HIV –
No active malignancy
– Exception: Primary CNS tumors
Note: Only the OPO can determine
donor suitability
How Does Donation Occur?
How Does Donation Occur?
DBD vs. DCD
Two opportunities…
Donation After Brain Death
(DBD)
Donation After Cardiac Death
(DCD)
How Does Donation Occur? (cont.)
Donation After Brain Death
Meets Criteria for Brain Death:
Clinical Exam + Apnea Test
both consistent with Brain Death
Clinical Exam
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Unresponsive to all stimuli
No spontaneous respiratory activity
All brain stem reflexes are absent
– Pupillary response to light
– Corneal reflexes
– Oculo-vestibular reflex (cold-caloric response)
– Oculocephalic reflex (doll’s eye phenomenon)
– Gag reflex
Meets Criteria for Brain Death:
Apnea Test
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Make sure patient has normal body temp, blood pressure,
volume status, ABG’s
Disconnect from ventilator
Monitor continuous pulse oximetry
Administer 100% O2 at 6 L/min into the trachea
Monitor closely for respiratory movements
Check serial ABG’s, or at approx. 8 minutes
If no respiratory movement and arterial PCO2 is > 60 mm Hg,
the apnea test supports the clinical diagnosis of brain death
Meets Criteria for Brain Death:
Confirmatory Tests
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Cerebral blood flow (CBF) studies
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EEG
Cerebral angiography
Nuclear flow study
How Does Donation Occur? (cont.)
Confirmatory Test:
Cerebral Angiography
Normal Blood Flow
No Blood Flow
How Does Donation Occur?
(cont.)
Confirmatory Test :
Nuclear Flow Study
Donation After Brain Death
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Patient is declared brain dead, THAT IS
THE LEGAL TIME OF DEATH
Patient is maintained on ventilator
throughout the organ recovery
Organs are separated in situ
3-4 hour surgery
All 8 solid organs can be recovered
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Donation After Cardiac Death
Family and physician elect to withdraw life support
Patient has some brain stem reflexes, so not brain
dead, but no meaningful chance of survival
Withdrawal of life support in the OR or ICU
Surgery begins 5 minutes after cessation of cardiac
function, death declared by patient’s physician
Rapid recovery with organs procured en bloc
1-2 hour surgery
Lungs, liver, kidneys and pancreas can be recovered
Donation After Cardiac Death
Key Points
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Donation is discussed with family only after
decision to withdraw support has been made
DCD offers families expanded organ donation
opportunities
If patient’s heart/respiratory function goes
beyond 2 hours post-extubation, solid organ
donation is no longer possible
How Does Donation Occur? (cont.)
Organ Preservation Time
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Heart: 4-6 hours
Lungs: 4-6 hours
Small Intestines: 4-6 hrs
Liver: 12 hours
Pancreas: 12-18 hours
Kidneys: 48 hours
How Does Donation Occur? (cont.)
Donation Process: From Consent to Recovery
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Brain death declaration or DCD evaluation
Evaluate organ function
Consent signed
Serology and recipient compatibility testing (4 hours)
Medical-social history
Locate potential recipients (can take up to 18 hours)
Manage hemodynamics
Arrange OR time and set up of OR
What Can Be Donated?
Organs Recovered and Indications for Transplant
– Heart
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Cardiomyopathy, Coronary Artery Disease, Congenital Heart
Disease, Valvular Heart Diseases
– Lungs
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Emphysema/COPD, Cystic Fibrosis, Pulmonary Fibrosis, Primary
Pulmonary Hypertension, Congenital
– Liver
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Hepatitis A,B,C, Cirrhosis, Biliary Disease, Metabolic, Neoplasms
– Pancreas
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Diabetes Type I without Renal Disease, Hypoglycemic Unawareness,
Pancreas after Kidney Transplant
– Kidneys
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End Stage Renal Disease, Diabetes with Renal Disease
– Small Intestines
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Short Gut Syndrome, Severe Vascular Disease
What Can Be Donated? (cont.)
The Differences….
Organ Donation
The patient must be
maintained by a
mechanical ventilator
Organs must be
properly preserved and
transplanted quickly
Life-saving procedure
Tissue/Eye Donation
Occurs in the first 24
hours after the heart has
stopped beating
The tissues can be
preserved and used at a
later date
Life-enhancing
procedure
Through donation ...
...lives are changed forever