University of Wisconsin Organ Procurement Organization Organ Donation End of Life care in the Operating Room Matthew Bock Surgical recovery coordinator University of Wisconsin Organ Procurement Organization 1-866-UWHC OPO (1-866-894-2676)

Perspective

Remembering why we’re here Save lives through transplantation Supporting the family’s choice Honoring the patient’s wishes

Donation after Cardiac Death (DCD)

Uniform Determination of Death Act, 1980 Irreversible cessation of circulatory and respiratory function - OR- Irreversible cessation of all functions of the entire brain, including the brain stem Scientists began the process of redefining death and in 1980, the Harvard Medical School issued a report entitled the “Uniform Determination of Death Act” which revised the definition of death as follows: An individual is considered dead, if sustaining: 1. Irreversible cessation of circulatory and respiratory function; or 2. Irreversible cessation of all functions of the entire brain, including the brain stem. This definition allowed doctors to determine that a person’s brain had died even though machines were able to keep the heart and lungs working. This resulted in the term “brain death” as an additional term to “cardiac death.” Therefore, there are two ways in which death can be declared.

Two ways to donate Deceased Organ Donation Donation After Cardiac Death (DCD) Donation After Brain Death

DCD Severe neurological injury Does not meet criteria for brain death Family has elected to withdraw support Brain Death Severe neurological injury Meets Brain death criteria: -Clinical exam -Apnea test

DCD Severe neurological injury Does not meet criteria for brain death Family has elected to withdraw support Brain Death Severe neurological injury Meets Brain death criteria: -Clinical exam -Apnea test

Clinical Diagnosis of Brain Death Unresponsive to all stimuli No spontaneous respiratory activity All brain stem reflexes are absent: Pupillary response to light Corneal reflexes Oculo-vestibular reflex (caloric response) Oculocephalic reflex (doll’s eye phenomenon) Gag reflex

Apnea Test 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

Apnea Test 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

Brain Death Severe neurological injury Meets Brain death criteria: -Clinical exam -Apnea test DCD Severe neurological injury Does not meet criteria for brain death Family has elected to withdraw support

DCD Severe neurological injury Does not meet criteria for brain death Family has elected to withdraw support Brain Death Severe neurological injury Meets Brain death criteria: -Clinical exam -Apnea test

Severe Neurologic Injury Trauma MVA, Fall SDH Anoxia Cardiac Arrest, near drowning

Brain Death Severe neurological injury Meets Brain death criteria: -Clinical exam -Apnea test DCD Severe neurological injury Does not meet criteria for brain death Family has elected to withdraw support

Two ways to donate Donation After Brain Death Patient is maintained on ventilator for organ recovery Organs dissected insitu 3-4 hour surgery Donation After Cardiac Death (DCD) Patient is extubated in the Operating Room or ICU Surgery begins 5 minutes after cessation of cardiac function and declaration by patient’s physician Rapid recovery with organs procured en bloc.

Two ways to donate Donation After Brain Death Patient is maintained on ventilator for organ recovery Organs dissected insitu 3-4 hour surgery Donation After Cardiac Death (DCD) Patient is extubated in the Operating Room or ICU Surgery begins 5 minutes after cessation of cardiac function and declaration by patient’s physician Rapid recovery with organs procured en bloc.

Two ways to donate Donation After Brain Death Patient is maintained on ventilator for organ recovery Organs dissected insitu 3-4 hour surgery Donation After Cardiac Death (DCD) Patient is extubated in the Operating Room or ICU Surgery begins 5 minutes after cessation of cardiac function and declaration by patient’s physician Rapid recovery with organs procured en bloc.

“We don’t do that here”

ICU nurse RT OPO staff No family yet

Who is involved? Cardiothoracic Team Hospital Anesthesia Surgical Technician/Scrub Nurse Circulating Nurse Abdominal Transplant Team - Surgeon - Physician Assistant - Surgical Recovery Coordinator Cardiothoracic Team - Surgical Fellow

Paperwork Consent x2 Time out Post Op disposition Death packet

Prep & drape Femoral cutdown Cover patient and back table Unnecessary staff exits the room

DCD Withdrawal in the OR Accommodating the Family

Meds, Withdrawal & Declaration

How long can we wait?

Rapid En-bloc recovery

Organ Preservation Time Heart: 4-6 hrs Lungs: 4-6 hrs Liver: 12 hrs Pancreas: 18 hrs Kidneys: 24 hrs

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