Welcome!

Mary Nachreiner, Community/Family Services UW OPO 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 58 Organ Procurement Organizations in U.S. 8 hospital-based OPO’s

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 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-Enhancing Procedure No Mechanical Ventilator Needed One Donor Can Help From 50 to 100 People Organ Donation The Patient Must be Maintained by a Mechanical Ventilator Organs Must be Properly Preserved and Transplanted Quickly Life-Saving Procedure One Donor Can Help 8 People

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 Tyler Degand was 14 years old when a rare strain of influenza B landed him in the hospital, on a ventilator, struggling to stay alive. Now 16, Tyler enjoys the every day activities of a high school sophomore, including the excitement of learning to drive

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 17 people die/day waiting for an organ

Source: Organ Procurement and Transplant Network 04/13/2011 The National Story Type of Transplant Waiting Kidney 88,314 Liver 16,159 Lung 1,777 Heart 3,176 Heart-Lung 65 Kidney-Pancreas 2,223 Pancreas 1,383 Intestines 264 Totals 110,693 Source: Organ Procurement and Transplant Network 04/13/2011

Source: Organ Procurement and Transplant Network 4/8/2011 Our Local Stories Wisconsin 1780 Illinois 4937 Michigan 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: Is Mechanically Ventilated AND Has a Severe Neurologic Insult/Injury ONE of the Following: A Physician is Evaluating for Brain Death OR Has a Glasgow Coma Scale (GCS) < 5 Plans to Discuss Withdrawal Life-Sustaining Therapies GCS is a neurological scale of a person’s level of consciousness. Establishing clinical triggers is important for the hospital and OPO because clinical triggers will ensure the family is provided the opportunity to all donation options if it is appropriate. What are the clinical triggers for organ donation? A mechanically ventilated patient with a severe brain injury- ·     For whom a physician is evaluating for brain death OR ·     A patient with a Glasgow Coma Scale (GCS) of 5 or less OR ·     For whom a physician has ordered that life-sustaining therapies be withdrawn Please note that a patient does not need to meet all three clinical triggers before notifying the OPO, when a patient meets any of the three clinical triggers, that is when you should make that initial phone call to the OPO. Some of you may be looking at the clinical triggers and thinking to yourselves, I’ve taken care of patients that had a GCS of 5 and were in full treatment mode, and were not at the point of talking to the family about donation, so why would I call the OPO? Are we calling too soon? What I want to stress to you is that when a patient meets clinical triggers, the phone call you are making is only a notification to the OPO. It does not mean that you have to approach the family, it does not mean that patient Is going to donate , or that all hope for patient survival is gone, or that you should stop treatment--it is only a notification. The process for notifying the OPO is not the same as the requesting process for organ donation. They are two very separate processes and should not be confused with each other.

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 Ensures adequate time for potential donor screening, medical management and allocation of organs

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 Break down the clinical picture to those 3 parameters: Neuro injury; ventilated; and one of the other 3 questions. Most patients meet clinical triggers in the ED but are referred in ICU/CCU

The Referral Process Statline Pages On Call Referral From Yes OPO Coordinator Referral From Hospital: 1-866-894-2676 (Statline) Yes Statline: Is Patient Ventilated? Statline Refers to Tissue Agency No Keep in mind that many patients actually meet clinical triggers in the ED, but the referral is often made from the ICU. Note: this can be the ED of a local hospital prior to transfer

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 That’s right. All deaths and imminent deaths get called-in to the same phone number. It goes to a Triage Center called STATLINE out in Colorado, and Statline works with many donation agencies around the country. They are going to ask for: Your hospital name, city and state Caller’s name and title, hospital unit, phone number Patient’s Name, age, gender, race Whether or not patient has a heartbeat If no heartbeat, when the CTOD If yes, is the patient mechanically ventilated… Your answers to these questions will determine whether Statline will page the OPO for Solid Organ Donation or the Tissue/Eye Bank for Tissue/Eye Donation WHO CAN MAKE THIS CALL? It can be anyone on your staff – physician, nurse, unit clerk, chaplain, nurse supervisor/manager. Now some of you may have a question as to what imminent death is, and we’re getting to that, so don’t fret. Does anyone know what percentage of us will die in a way that solid organ donation is even possible? Get their answers… 2-4% - it’s a small number. Public perception, as we’ve just demonstrated by some of your answers, is that most of us can donate our organs if we’re reasonably healthy. However, organ donation can only happen if one dies in a hospital setting, because in order to donate one’s solid organs, we have to still have a heartbeat AND be mechanically ventilated. Most of us won’t die that way. So though I and many of you may want to donate, the likelihood that we’ll be in that situation at the end of life is pretty slim.

How Does Donation Occur? Two Opportunities… Donation After Brain Death (DBD) Donation After Cardiac Death (DCD) Brain death: Irreversible cessation of all functions of the entire brain, including the brain stem Cardiac Death: Irreversible cessation of circulatory and respiratory function

Brain Death vs. Cardiac 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 LEGAL TIME OF DEATH Irreversible 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 Example of a angiogram. The scan on the left delineates normal blood flow. The scan on the right is a brain dead patient where the blood flow to the brain has been cut off from the swollen brain shown by the fuzzy area inside the skull. 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 Instead of “Recover” “Harvest” “Deceased Donor” “Cadaver” “Mechanical or “Life Support” “Ventilated 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