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withdrawn, and death is determined by cardiopulmonary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