Transcript Palliative Care: Achieving Comfort for those with Limited

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
• Esther Montoya, RN, OneLegacy
WAIT!! THIS PATIENT IS NOT
BRAIN DEAD…HOW CAN
THEY BE AN ORGAN DONOR?
Moderator:
Margie Whittaker, RN
Manager SICU
Mission Hospital
TRANSPLANT TIME LINE
 1954 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withdrawn, and death is determined by cardiopulmonary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 Death
Things 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.
Donation After Cardiac Death
Case Review
St Mary Medical Center Apple Valley
John Brady, RN,
CCRN, CNRN
ICU Nurse Manager
Donation at St. Mary Medical Center
 Organ donors 2000-2011
 7 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/M
 Status post cardio-pulmonary arrest
 Areflexic
 Medical history methamphetamine
use, high cholesterol, & diabetes
 Down time 45 minutes
 Transfer 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 Steps
 Attending 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 Steps
 Attending 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 Delayed
 Attending 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 Coordinator
OneLegacy
1000
791
800
600
400
560
559
2005
2006
848
920
391
269
200
0
2003
2004
2007
DCDDonors
2008
2009
DCD vs. Brain Dead Donors
(United States)
5416
6000
5984
5799
6187
5000
4000
5359
5477
6081
5822
3000
2000
1000
269
391
560
559
791
848
920
0
2003 2004 2005 2006 2007 2008 2009 2010
BDDonors
DCDDonors
OneLegacy DCD History
30
25
24
25
19
20
14
15
10
5
25
21
16
3rd Qtr
7
2
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
0
DCD Donors
OneLegacy Brain Dead vs.
DCD Donors
400
350
3rd Qtr
416
450
326
339
371
359
381
358
324
284
300
250
7%
200
150
6%
4%
4%
4%
5%
4%
7%
6%
100
50
2
7
14
16
25
19
24
25
21
0
2003 2004 2005 2006 2007 2008 2009 2010 2011
Brain Dead
DCD
OPO DCD Comparison
100
80
60
40
76
60
20
0
72
23
MIOP
MAOB
2008
PADV
2009
CAOP
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
DCD & Organs Transplanted
7.00
6.00
Average=1.84
5.00
4.00
CAOP
PADV
MAOB
MIOP
Average=1.66
3.00
2.00
Average=1.80
1.00
Average=1.48
0.00
2008
2009
2010
Potentially 84 More Lives Saved
California Donor Registry
Designated Donors Among Recovered Donors
50%
45%
40%
37%
33%
35%
30%
25%
20%
28%
25%
46%
42%
38%
41%
37%
33%
30%
27%27%
19%
15%
10%
5%
0%
Organ Donors
2007
Tissue Donors
2008
2009
2010
Eye Donors
2011 YTD
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
2011
3rd Qtr
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