Organ Donation 101

Who is CDT? Center for Donation & Transplant Responsible for: Organ Procurement Organization (OPO) Serve 43 Hospitals Responsible for: Organ procurement & allocation Community education & public relations Ensuring that families have the option to donate & that they are asked in an appropriate & sensitive manner 2

Agenda Current need for donation How does organ donation happen? Brain death Donation after cardiac death (DCD) Medicare policies for hospitals Authorization for donation Donor management CDT aftercare 3

10,000

120,000 on waiting list

Trends 2001-2013

Why are there so few organ donors? Oxygen loss after death Perfusion is forever lost Oxygen no longer enters, C02 doesn’t exit Organs can’t last long under conditions Tissues can remain viable up to 24 hrs later, if cooled. All deaths are evaluated for tissue donation

Organ Preservation Times Heart: 4 hours Lungs: 4-6 hours Liver: 12 hours Pancreas: 12-18 hours Kidneys: 72 hours Small Intestines: 4-6 hours

How are there organ donors? Ventilator Continues oxygenation /perfusion of organs Brain death-declared dead via neurological criteria. Perfusion maintained until recovery Terminal extubation- death expected after removal of vent. Perfusion decreases and is ultimately lost, but only for minimal time before procurement.

Brain Death

Declaration of Brain Death Prior to brain death testing, correct: Hypotension Hypothermia Drug Intoxication Core temp must be ≥ 32°C (89.6° F) 13

Declaration of Brain Death Proximate Cause 1st Exam Apnea Test Referral Attestation Declaration of Brain Death Timeline Determine proximate cause. Establish irreversibility. 1st Exam- test for brain stem reflexes Apnea Test- To confirm no spontaneous respirations Attestation by 2nd MD- Required only for donation A confirmatory test can: Help to determine proximate cause Take the place of or be done in addition to a clinical exam 15

2014 Stats on Brain Death 10,000 + deaths ~200 had some potential for organ donation How many were declared brain dead?

2014 Stats on Brain Death 58 brain deaths 37 consented & recovered 64% conversion rate (37/58) 120 organs transplanted 3.24 organs per donor

Organ Donation after Cardiac Death (DCD)

Donation after Circulatory Death DCD Donation after planned withdrawal of care and cardiac death Patient may have neuro function, but are likely to expire within 60 minutes of withdrawal, based on MD assessment Circulation not present at time of organ recovery Kidneys, liver, pancreas, & in rare cases lungs and even heart

The Original Procurement Practice When organs were first recovered, all organ donors were DCD donors DCD declined after Uniform Brain Death Act More organs were able to be recovered from brain-dead donors Increasing DCD donation is essential & feasible Waiting list = 120,000 & growing Legislation, surgical advances, & new medicines have made DCD a safe & routine procurement practice

Examples of DCD Patients Patient is missing neuro, but not yet brain dead 55 yr old s/p trauma. In ICU, MD tells family pt has non-recoverable head injury Family won’t wait for brain death but wants donation Patient with poor prognosis, facing imminent death Unstable, may die on vent before brain death testing can be completed Family still wants donation or pt is a registered donor

Examples of DCD Patients Patient’s airway likely to collapse quickly after extubation Examples: Some spinal fractures ALS patients COPD/respiratory failure Note: In a very limited number of cases, some patients may provide own consent DCD preserves option of donation for pt’s who will not meet criteria for brain death

What is the real potential for DCD? Over 90% of those on the waiting list are in need of a kidney 90% of ICU patients die after a decision to limit therapy (Critical Care Medicine, 2001) Such requires complex conversations, usually between healthcare staff and families ICU Population 110,000 More DCD Earlier withdrawal = less patients progressing to brain death More potential DCD donors Less brain deaths Waiting list

Potential for DCD Donor Growth 1997-2013 This rise is driven by the decrease of brain-dead potential donors coupled with the increase in implementation of DCD policies/protocols as hospitals, particularly after the Joint Commission implemented a DCD standard in 2007. 26

Medicare Donation Policies How Do Hospitals Enable Organ Donation?

Medicare’s 2 Donation Rules for all hospitals Hospital Referral Required referral law Requesting Consent Must be a certified designated requestor to ask families for consent

Rule 1: Medicare’s Required Referral When the death of a person in a hospital has occurred or is imminent, the hospital shall contact the federally designated organ procurement organization in order to make a preliminary determination of the suitability of the person for organ donation.

Why is there Required Referral? Rule allows identification of ALL potential CDT can’t be in all of its 43 hospitals 24/7 Before rule, 25-50% of all donation potential was lost!!!!

Required Referral Rule Death has “Occurred” Call in EVERY death that has happened within 1 hour after death

Required Referral Rule Death is “Imminent” Refer vented pts dying “imminently”

“Imminent Death” Medicare defines imminent death as a vented patient that meet ANY of the following: GCS of 5 or less Any brain injury or missing brain stem reflexes Terminal extubation is likely or pending Call within 1 hr of a patient meeting imminent death criteria

Tips for Identifying Imminent Death Always look for clinical triggers upon admission to unit Periodically assess GCS Use “clinical intuition” to make early referrals If busy, have bedside RN, charge RN, unit secretary, or other staff make referral for you

Stats on Imminent Deaths 200 had some potential 58 brain deaths- 37 donors ~50 DCD candidates- 21 donors

Rule 2: Medicare’s Requestor Rule To approach a family about organ or tissue donation, one must be a “certified designated requestor,” someone trained by an OPO on how to approach families for consent.

Why is there a Requestor Rule? Perception of conflict of interest CDT has specially trained requestors Consent rate stats: When CDT approaches: 50% or higher When staff approaches: 10% or less

Decoupling Studies show: “Death” + “Donation” @ same time = Negative “Donation” alone = Positive Negative Positive

De-coupling De-coupling: Separating “death” from “donation” When process broken, consent rates drop Referral BD testing/ BD Declared/ family talking about EOL Hospital informs family of BD/family wants EOL Team Huddle Approach for Donation CDT Evaluation De-coupling

Talking with Families NYS registration = legal authorization Currently less than 25% of NYS adults Hierarchy of consent LEGAL HIERARCHY Spouse (or Civil Union Partner in VT) or domestic partner Adult child Parent Adult sibling Domestic partner Other (Grandparents in VT)

Talking with Families We never persuade! CDT is designated requestor Special staff trained in bereavement, grief counseling, social work, etc Approach rules We never converse at the bedside Avoid euphemisms for death Answer questions simply and honestly Ensure family is approached in a caring & compassionate manner We never persuade! There is NO right or wrong decision. CDT respects all decisions.

Requesting- Tips & Best Practices Simple—Never bring up donation If family brings up donation to you, contact CDT Use effective transitional language “There are some end of life specialists here who would now like to speak with you” “This is (name), he/she is a member of the healthcare team, and he/she has some additional information about the EOL process.” Identify NOK making medical decisions

After Consent What happens?

After consent- Brain death Donor management = by CDT Why? Hospital testing needed: Blood draws Node procurement Echo/bronch Organ placement via UNOS This is what can take a LONG time Total time from consent to procurement Usually 12-24 hours

What UNOS Does Liver to Buffalo to pt w/highest MELD score Kidney to Vermont to pt who is perfect match For one donor, we could have 4 or more different surgery teams come in to procure Pt in Pittsburgh receives kidney & pancreas Kidney & pancreas to Pittsburgh Heart & lungs to New York City to two different pts

After consent- DCD Donor management = by hospital staff Why? Hospital testing needed: Blood draws Bronch Labs Organ Placement Total time from consent to procurement Usually 4-12 hours

Family Aftercare

Donor Aftercare & Support Families receive an aftercare packet within 6 weeks of donation Donor Quilt Community participation: Donor Memorial Service Donor Family-Recipient Picnic Volunteer Program

Questions? www.donatelifecdt.org 518-262-5606 218 Great Oaks Blvd, Albany, NY 12203 49