The purpose of this presentation is to explain the donation process and is intended to inform the audience of the issues and challenges involved. This is presentation number 5 of a package of presentations which includes the following topics: Why we need to talk about donation Pathways to Donation 3. Brain Death 4. Donor Management Following Brain Death 6. Retrieval Surgery - Information for Operating Room Staff 7. Understanding Eye and Tissue Donation 8. Supporting Donor Families 9. Donation after Cardiac Death (DCD) 10. National Framework DonateLife staff are encouraged to add individual speaking notes, relevant jurisdictional information and to focus on local issues. Version 1 – 16 December 2010 Version 1 - 16 December 2010

Declaration of Death In Australia the two legal definitions of death are: Irreversible cessation of circulation of blood in the body of a person - cardiac death or Irreversible cessation of all function of the brain of a person - brain death This presentation is about donation AFTER death – not living donation. There are NOT 2 kinds of death but 2 ways of determining death. Up until 1977 there was no definition of death in Australian law. The Australian Law Reform Commission set about devising a legal framework to govern practice. This became necessary because the modern technology of ICU’s ventilators etc meant that the dying process was being impeded and there needed to be a legislative basis for the removal of therapy. Each state & territory has legislation which: provides definition of death; regulates practice (ie qualifications as to who can certify death); outlines consent; prohibits trade and prevents disclosure. It is possible for people to donate organs after brain death AND after cardiac death. Donation after cardiac death is in fact where donation first began – after someone's heart stopped beating, the surgeons performed a laparotomy and removed the kidneys. With the advent of intensive care, ventilators and more sophisticated drugs and treatments it was noted that people were dying on ventilators – their brains had died but because the ventilator provided artificial respiration and oxygenation, the heart continued to beat circulating blood and oxygen to the organs. This allows for more organs than just kidneys to be retrieved. Donation after brain death remains the most common pathway to organ donation. Very few people die as a result of brain death. As a way of increasing the number of organs available for transplantation, donation after cardiac death is being revisited. Also, many people want to be organ donors but obviously they can’t choose how they die. The difference between DCD of the early days and the DCD of today is that now the person’s death is “controlled” through a planned time of Withdrawal of Cardio Respiratory Support (WCRS). The ANZICS Statement on Death and Organ Donation; Australian New Zealand Intensive Care Society (ANZICS) 2008, 3rd Edition, Pp 39 Version 1 - 16 December 2010

How and where you die determines what you can donate ICU Brain Death Heart Lungs Liver Kidneys Pancreas Intestine Eye tissue Bone tissue Skin tissue Heart valves ICU Cardiac Death Lungs Liver Kidneys Pancreas Eye tissue Bone tissue Skin tissue Heart valves WARD / OUT OF HOSPITAL Cardiac Death Eye tissue Bone tissue Skin tissue Heart valves ICU BRAIN DEATH: All organs and tissue – reinforce that brain death only occurs in 1 % of all deaths. To be suitable you must be brain dead and on a ventilator in ICU. Link it back to the small number of multi-organ donors each year – this is one of the reasons – VERY FEW people die in the circumstances needed for organ donation. ICU CARDIAC DEATH: VERY important - in some very specific circumstances a person who has died from cardiac death can donate some organs and potentially ALL tissues BUT they must be in an ICU at the time of their death WARD/OUT OF HOSPITAL CARDIAC DEATH: ONLY tissues Briefly explain the reason why, for organ donation, a person needs to die in the ICU. Explain that brain death occurs when a person is on a ventilator - “a person dies on a ventilator” and because of this, O2 is still being supplied to the lungs which then supplies O2 to the heart and because the heart does not need the brain to take a beat (internal pace maker – if supplied with O2 will continue to beat) the other organs are getting a blood and O2 supply. “Even though the person has died their organs are still working because the person is still on the ventilator” Maybe use a scenario to explain Person involved in a car accident and has massive head injury. Ambulance officers ventilate them at the scene of the accident and take them to the hospital were everything is done to save their life. They are taken up to the ICU and despite all the interventions and management the injury is too severe and they become brain dead. Because of the treatment they have been receiving they are still on a ventilator and therefore are still getting an O2 supply to their organs. “Even though the person has died their organs are still working because the person is still on the ventilator” Organ donation is now a possibility. Same scenario BUT the person is in the ICU on a ventilator but NOT brain dead. However the injury is so severe that the person is not going to survive and the decision is made to withdraw cardio-respiratory support as there is nothing more that can be done to save the person. In this scenario it MAY be possible for the person to donate some organs after death BUT this does not happen very often. Same scenario BUT the person dies at the scene. If they donated their organs in this scenario they would NEVER work in the recipients. However TISSUE donation is possible because tissues do not require the same strict circumstances with a blood supply to be successfully transplanted. Version 1 - 16 December 2010

Pathway to Organ Donation Brain Death Catastrophic neurologic injury Death declared NOK + coroner consent Donor Information Collection Tissue typing serology Organ offer + Allocation Operating Theatre DCD Irreversible cardio respiratory or neurologic illness / injury Treatment futile & withdrawal planned NOK + coroner consent Donor Information Collection Tissue Typing + serology Organ offer + Allocation Treatment withdrawn – cardiac death likely within 60 mins Death declared Operating Theatre If the person is being considered as a potential organ donor, regardless of whether death occurs because of brain death or cardiac death, the steps which occur along the way are identical. If you look at the two pathways you will see that the only significant difference is the point in the process at which death occurs. This presentation is about what each of those steps involves and how they relate. Version 1 - 16 December 2010

Who is a potential organ donor? Intubated + ventilated Died from brain death or imminently dying and withdrawal of cardiorespiratory support is planned Sufficient BP for organ perfusion No evidence of: Current malignant disease Age limits 1 – 80 years Call the donor coordinator regarding medical suitability to donate Donors are identified primarily in the ED and ICU. There are very few exclusions to donation. There are age limits for donation but they are not absolute in nature. The ANZICS Statement on Death and Organ Donation; Australian New Zealand Intensive Care Society (ANZICS) 2008, 3rd Edition, Pp 41 Australasian Transplant Coordinators Association Incorporated, 2008 National Guidelines for organ and tissue donation, 4th Edition, Pp 8. Version 1 - 16 December 2010

Supporting the donation process Everyone advocates for donor and family Priority is family values and principles Team approach Roles and responsibilities All health care professionals involved in the care of dying patients and families have a role in the donation. Throughout this process, the priority remains the comfort and dignity of patients as well as the care and support of their families and loved ones. The donation process is a ‘team approach’ Treating intensivist +/- Hospital Medical Director Organ Donor Coordinator HSN organ and tissue donation Bedside nurse/Social Worker/Pastoral Care The team has responsibility for Advocating for the donor and their family Ensuring the legal requirements are met (consent processes) Facilitating the medical requirements (donor assessment) Communicating with each other for a smooth process The Organ Donor Coordinator is the one constant person throughout the donation process and a coordinator is involved from beginning to end. Their most important role, aside from advocating for the donor and their family is that of communication. As the coordinator organises the donation they are the ‘go to’ person for every aspect and for everyone – family, ICU staff, laboratory, transplanters, theatres, transport, tissue banks etc etc. They are also like a traffic cop in maintaining timing, control and order! The Organ Donor Coordinator has responsibility for: Facilitating the donation process from beginning to end Providing the clinical communication link between the ICU and the Transplanting Units Managing organ referral and coordination of retrieval teams Ensuring donor family follow-up and documentation DonateLife Agencies Version 1 - 16 December 2010

Who is a potential eye/tissue donor? Any person who has died may be able to donate eyes and tissues Circulatory death in hospital wards (the majority for eyes) Brain dead organ donors Donation after cardiac death organ donors NB. Speaking notes to be tailored to include state/territory specific information. Version 1 - 16 December 2010

Refer Contact Nurse Donation Specialist (NDS) 0411323006 If families/patients raise donation as part of end of life care Patient is deemed as a potential donor by ICU/ ED consultant Contact Nurse Donation Specialist (NDS) 0411323006 for any queries regarding organ and/or tissue donation DonateLife 24/7 pager- 93470408