Transcript Welcome! Donation B & B: Basics and Burning Questions Mary Nachreiner, Community/Family Services UW OPO.

Welcome!
Donation B & B:
Basics and Burning
Questions
Mary Nachreiner, Community/Family Services
UW OPO
Objectives
• Understand the Donor Referral Process
• Understand Clinical Triggers and Apply
Appropriately
• Identify the Difference Between Donation After
Cardiac Death (DCD) and Donation After Brain
Death (DBD)
• Appreciate the Personal Impact of Donation
and Care of the Donor Family
• Clarify “Burning Questions”
What is the UW
Organ Procurement Organization
(OPO)?
• One of 58 OPOs
• Service 104 Hospitals in
Wisconsin, Illinois, and
Michigan
• Regulated by the Federal
Government
• 30+ Staff Members
– Hospital Development
– Procurement
Coordinators
– Recovery Team
– Family Support
– Community Education
What are the Recovery Agencies?
Solid Organ Recovery
• University of Wisconsin Organ Procurement
Organization
Tissue Recovery
•
•
•
•
Musculoskeletal Transplant Foundation (MTF)
Wisconsin Tissue Bank
RTI Donor Services
ATSF
Whole Eyes/Corneal Recovery
• Lions Eye Bank of Wisconsin
The Difference Between Organ and
Tissue Donation
Organ Donation
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-Saving Procedure
•
Life-Enhancing Procedure
One Donor Can Help 8 People
•
No Mechanical Ventilator
Needed
•
One Donor Can Help From 50
to 100 People
•
The Patient Must be Maintained
by a Mechanical Ventilator
•
Organs Must be Properly
Preserved and Transplanted
Quickly
•
•
Kelly’s Legacy
Kelly Nachreiner Bill (AB-764)
• Signed by Governor Tommy
Thompson on May 9, 2000
• Requires all Driver’s
Education Programs in
Wisconsin to Give at Least 30
Minutes of Instruction on
Organ Donation
• The First of Its Kind in the
Country
Why is Organ Donation So
Important?
Tyler
Double Lung
Recipient
Why is Donation so Important?
• Every Day…
– 18 People in the U.S. Die Waiting
– 111 People are Added to the National Wait
List
• Only 2-4% of Deaths are Eligible for Solid
Organ Donation
The National Story
Type of Transplant
Kidney
Liver
Lung
Heart
Heart-Lung
Kidney-Pancreas
Pancreas
Intestines
Waiting
88,314
16,159
1,777
3,176
65
2,223
1,383
264
Totals
110,693
Source: Organ Procurement and Transplant Network 04/13/2011
Our Local Stories
Wisconsin
Illinois
Michigan
1780
4937
2976
80-85% Awaiting
Kidneys
Source: Organ Procurement and Transplant Network 4/8/2011
Your Role in Donation
●
●
●
●
●
●
●
Provide Care to Families
Recognize Clinical Triggers
Make the Referral Within 1 Hour of Clinical
Triggers
Understand How the Donation Process Works
Effective Requesting (Consent)
Sign Consent with Family
Be an Advocate for Donation in Your
Community
Clinical Triggers: What and Why?
What are Clinical Triggers?
• Specific Medical Patient Parameters Requiring Notification
to the OPO (Referral)
Why are Clinical Triggers Important?
•Preserve the Option of Organ Donation for the Patient and Family
•Ensures Adequate Time for Potential Donor Screening, Medical
Management, and Allocation of Organs
•Follow Requirements of Joint Commission and CMS
Clinical Triggers
Are Met When a Patient:
1. Is Mechanically Ventilated
AND
2. Has a Severe Neurologic Insult/Injury
AND
ONE of the Following:
• A Physician is Evaluating for Brain Death
OR
• Has a Glasgow Coma Scale (GCS) < 5
OR
• Plans to Discuss Withdrawal Life-Sustaining
Therapies
Clinical Triggers
Severe Neurological Injuries:
• Trauma
• CVA
• Primary CNS Tumor
• Anoxia
– Cardiac Arrest/MI
– Drug Overdose
– Drowning/Hanging
Clinical Triggers
• Simply a “Heads Up”
• Notification Does NOT Mean:
– That the Patient is Going to be an Organ
Donor
– That the OPO is Going to Arrive at Your
Hospital
• All Life Saving Efforts are Pursued as They Are
With Any Patient
UWHC OPO Referrals vs. Donors
2000
Referrals
1774
1800
Referrals
1891
Referrals
1816
Referrals
1497
1600
1400
1200
Referrals
1025
1000
800
600
400
200
Donors
126
Donors
143
Donors
136
Donors
142
Donors
115
0
2006
2007
2008
2009
2010
Only 6-7% of Patients Referred to the OPO Actually Become
Donors
Clinical Trigger Case
Studies
Jack is a 68 yr old WM with prostate cancer,
pancreatitis, renal failure, and liver failure due to
ETOH abuse. He is hepatitis B+. He has hepatic
encephalopathy and was intubated in the ER to
maintain his airway. His GCS is 3.
Refer?
Not Refer?
Henry is a sixty-nine year old male who
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?
Clinical Triggers: Moral of the Story
KISS: Keep It So Simple
The Referral Process
Referral From
Hospital:
1-866-894-2676
(Statline)
Statline:
Is Patient
Ventilated?
Yes
Statline Pages On Call
OPO Coordinator
No
Statline Refers to
Tissue Agency
Reminder: All Deaths and Imminent
Deaths Must be Reported
1-866-894-2676
Statline Triage Center
• 1 Phone Number
– Imminent Deaths: OPO Paged
– Deaths: Tissue and Eye Banks Paged
How Does Donation Occur?
Two Opportunities…
Donation After Brain
Death (DBD)
Donation After Cardiac
Death (DCD)
Brain Death vs. Cardiac Death
Brain Death
Irreversible cessation of all functions of the entire brain, including the
brain stem
Cardiac Death
Irreversible cessation of circulatory and respiratory function
Donation After Brain
Death
Brain Death
Brain Death Is…
• LEGAL TIME OF DEATH
• Irreversible
• Usually a Result of Direct Insult to the Head
(Trauma, Anoxia, Stroke, etc.)
• Declared Only by Patient’s MD/Donor Hospital
Designee (NOT OPO)
• Declared Through Clinical Exams, Apnea
Testing, and Confirmatory Exam*
*Additional Details Available
Angiogram
Normal Blood Flow
No Blood Flow
Donation after Brain Death
The Process
● Patient is Declared Brain Dead; This is the
Legal Time of Death
● Patient is Maintained on Ventilator
Throughout the Organ Recovery
● Organs are Dissected in situ (Naturally
Situated in Body)
● 3-4 Hour Surgery
● Heart, Lungs, Liver, Kidneys, Pancreas, and
Intestines Can be Recovered
Donation After Cardiac
Death
Donation After Cardiac Death (DCD)
For Donation After Cardiac Death to Occur:
• Severe Neurologic Insult or Injury
• Trauma (MVA, GSW)
• Cerebral Vascular Accident (CVA)
• Anoxia (MI, Drug Overdose, Drowning, Hanging)
Patients Do Not Meet the Criteria For Brain Death
• Gives Family the Option of Organ Donation for the Severely
Brain Injured (but Not Brain Dead) Patient.
– US DCD Donors Average: 10%
– UW OPO DCD Donors Average: 30%
Donation After Cardiac Death (DCD)
For Donation After Cardiac Death to Occur:
• All Medical Treatments are Futile and Long-Term Prognosis
Poor
• Family and Physician Elect to Withdraw Support
• Referral is Made to OPO
• Withdrawal of Ventilated Support in OR vs. ICU
• Cardiac Death Occurs
• Surgery Begins 5 Minutes After Cessation of Cardiac
Function and Declaration by Patient’s Physician
• Rapid Recovery with Organs Procured en bloc
• 1-2 Hour Surgery
• Lungs, Liver, Kidneys, and Pancreas Can Be Recovered
Key Differences Between DBD and
DCD
Donation After Cardiac
Death (DCD)
• Patient Extubated in OR vs.
ICU
• Surgery Begins 5 Minutes
After Cessation of Cardiac
Function and Declaration by
Patient’s Physician
• Rapid Recovery With
Organs Procured en bloc (as
a Whole)
• 1-2 Hour Surgery
Donation After Brain
Death (DBD)
• Patient is Maintained
on Ventilator During
Organ Recovery
• Organs Dissected in
situ
• 3-4 Hour Surgery
The Reward of Many
Efforts
Burning Questions
FYI: Sensitive Terminology
Please Use
“Recover”
“Deceased Donor”
“Mechanical or
“Ventilated Support”
Instead of
“Harvest”
“Cadaver”
“Life Support”
BQ: How Long Are Each of the Organs
Viable After Being Recovered?
Organ Preservation Time
•
•
•
•
•
•
Heart: 4-6 Hours
Lungs: 4-6 Hours
Liver: 8 Hours
Pancreas: 12-18 Hours
Kidneys: 72 Hours
Small Intestines: 4-6 Hours
BQ: How Do You Determine Who
Receives The Organs?
UNOS (United Network for Organ Sharing)
Allocation Criteria
•
•
•
•
•
•
•
Blood Type
Medical Urgency
Tissue Match
Waiting Time
Organ Size
Immune Status
Geographic Distance
BQ: Can a Person With
Autoimmune Disorder (Not
AIDS/HIV) be a Donor?
Yes
How Can a Patient Become a Donor
if They Have No Family?
NOK Hierarchy
•
•
•
•
•
•
•
•
•
•
Healthcare Agent or Power of Attorney – But only if given the responsibility of making
an anatomical gift. Most POA and living wills in use cover only the power to make
health care decisions – not anatomical gifts. We are working with the WI Dept. of
Health to have their standard forms changed as soon as possible.
Spouse
Adult Children
Parents
Adult Siblings
Adult Grandchildren
Grandparents
Adults Who Exhibited Special Care or Concern, Except as a Compensated Health Care
Provider for That Individual
Legal Guardian
Whomever Would be Responsible for the Disposal of the Body
Other Burning Questions??
Thanks!
Donation after Brain Death
Brain Death Criteria
Clinical Diagnosis of Brain Death
● Unresponsive to All Stimuli
● No Spontaneous Respiratory Activity
● All Brain Stem Reflexes are Absent
– Pupillary Response to Light
– Corneal/Lash Reflexes
– Oculo-Vestibular Reflex (Cold-Caloric Response)
– Oculocephalic Reflex (Doll’s Eye Phenomenon)
– Gag/Cough Reflex
– Response to Intense Central Pain
Donation after Brain Death
Brain Death Criteria
Apnea Test
• Make Sure Patient Has Normal BodyTemp, Blood Pressure,
Volume Status, ABGs
• Disconnect From Ventilator
• Monitor Continuous Pulse Oximetry
• Administer 100% O2 at 6 L/min Into The Trachea
• Monitor Closely for Respiratory Movements
• Check Serial ABGs 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
Donation after Brain Death
Criteria for Brain Death
Confirmatory Exams
•
•
•
•
Cerebral blood flow (CBF) studies
4 Vessel Angiogram
Transcranial Doppler
EEG