A Clinical Balancing Act: Honoring the DNR Decision While Preserving the Option of Donation Brian J. Kimbrell, MD, FACS Trauma / Surgical Critical Care Director St. John’s Regional Medical Center Oxnard, CA

“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

Question to Run-On What ideas would most help you in your work with patients and families facing end-of-life decisions?

A Clinical Balancing Act: Honoring the DNR Decision While Preserving the Option of Donation Brian J. Kimbrell, MD, FACS Trauma / Surgical Critical Care Director St. John’s Regional Medical Center Oxnard, CA

DNR Decision What does the DNR decision mean to the family? No Chest Compressions? No Shock? No Medications? No Labs? No Fluids? “Do not harm?” or “Do not treat?”

DNR Decision What does the DNR decision mean to the healthcare team? Routine decision in the Critical Care Unit Interpreting DNR decision varies by hospital, unit, physician, nurse

Donation Decision Understanding the donation option clinically: Maintaining blood pressure Normalizing electrolytes Managing oxygenation and organ perfusion Balancing Intake and Output Assessing brain death accurately How can a family give the gift of life when the organs are not preserved for transplantation?

Balancing DNR and Donation Devastating Traumatic Brain Injury (TBI) + Overall Clinical Deterioration + DNR Decision by Next-of-Kin + Fatal Diagnosis (Brain Death?) “Step Down” in clinical management? - or - Maintain clinical management and prevent secondary injury to organs?

Case Study Patient: 41 y/o Male s/p MVC with blunt head trauma (ICH) Admitting GCS = 8 Data: post-craniectomy, GCS=6, BP=140/80, H/H=14/38, UO=200mL/hr, pH=7.4, Na=135, Cr=0.8/BUN=10, ICP=15 Management: IV fluids, Mannitol, no pressors, sedation, Neurosurgery on case

Case Study 2 days post-admission: Data: GCS=5, BP=100/60, H/H=10/30, UO=200mL/hr, pH=7.35, Na=155, Cr=1.1/BUN=20, ICP=45 Family conference with Physician Physician Progress Note : “Discussed DNR with family. No Heroic Measures.” Management: IV fluids, Mannitol, no pressors, sedation, RN calls OneLegacy

Case Study 4 days post-admission: Data: GCS=3, BP=90/50, H/H=8/25, UO=200mL/hr, pH=7.30, Na=170, Cr=1.3/BUN=22, ICP=60 Physician Progress Note: “Pt. appears brain dead. Discussed grave prognosis with family. Neurosurgery to evaluate.” Management: IV fluids, sedation Family Conference with Physician

Case Study 5 days post-admission: Data: GCS=3, BP=90/50, H/H=8/25, UO=300mL/hr, pH=7.28, Na=180, Cr=2.0/BUN=30, ICP=60 Brain Death Note #1 Neurosurgery Progress Note: “Attempted apnea test. Pt did not breathe for 2 minutes but became unstable. Apnea test aborted. PT is brain dead, based on clinical exam. Discussed with family. Will require brain death confirmatory test. Second brain death note to follow.” Management: IV fluids, sedation, high dose Levophed and Neosynephrine

Assessing the Balancing Act Admission: Data: post-craniectomy, GCS=6, BP=140/80, H/H=14/38, UO=200mL/hr, pH=7.4, Na=135, Cr=0.8/BUN=10, ICP=15 5 Days Post-Admission: Data: GCS=3, BP=90/50, H/H=8/25, UO=300mL/hr, pH=7.28, Na=180, Cr=2.0/BUN=30, ICP=60 Does our patient data reflect preservation of the family’s donation option?

Assessing the Balancing Act Devastating TBI + Overall Clinical Deterioration + DNR Decision + Fatal Diagnosis (Brain Death) Maintain clinical management and prevent secondary injury to organs.

Pathophysiology of Traumatic Brain Injury Physiologic collapse frequently accompanies TBI: Hypotension Endocrine Dysfunction Pulmonary Dysfunction Hematologic Dysfunction

Hypotension: “Autonomic storms” Systemic and pulmonary vasoconstriction Associated with herniation Can recur unpredictably Smooth muscle ATP depleted = vasomotor hypotension Diuretics Pathophysiology of Traumatic Brain Injury

Hypotension: Closely monitor Intake and Output – DI? Anticipate BP spike followed by BP drop Consider Fluid Resuscitation Titrate Vasopressors Consider Hormone replacement – T4 Pathophysiology of Traumatic Brain Injury

Endocrine Dysfunction: Hypothalamic injury -> pituitary dysfunction Thyroid dysfunction –T4 Infusion Glycemic control disrupted –Insulin infusion Pathophysiology of Traumatic Brain Injury

Endocrine Dysfunction: Relative deficiency of corticosteroids –Solumedrol Infusion Reduction of Antidiuretic Hormone / Diabetes Insipidous –ADH, Vasopressin Infusion Pathophysiology of Traumatic Brain Injury

Pulmonary Dysfunction: Neurogenic pulmonary edema –Multifactorial –Systemic hypertension + LV dysfunction Primary pneumatocyte dysfunction Pathophysiology of Traumatic Brain Injury

Pulmonary Dysfunction: Iatrogenic injury due to aggressive resuscitation Exacerbated by intubation, aspiration, atelectasis Concurrent blunt lung injury common –Parenchymal injury problematic in immunosuppressed recipients Pathophysiology of Traumatic Brain Injury

Hematologic Dysfunction: Thrombocytopenia –Platelets as needed Coagulopathy/DIC –FFP / Cryo as needed Hypothermia –Keep them warm! Pathophysiology of Traumatic Brain Injury

23 What Are Traumatic Brain Injury Guidelines? Hospital approved guidelines for treating patients with Traumatic Brain Injury

24 What Are Traumatic Brain Injury Guidelines? Prevent secondary injury, even with grave prognosis Secondary injury includes other organs, as well as the brain Maintain Organ Perfusion Volume Load Monitor & Maintain adequate CVP, MAP Oxygenation

25 Continuous fluid resuscitation Correct electrolyte abnormalities Rule of 100’s: SBP >100mm Hg U/O >100ml/hr PaO2 >100 What Are Traumatic Brain Injury Guidelines?

26 Why Implement TBI Guidelines? Ensure consistent management of the critically ill patient Maintain homeostasis for accurate brain death assessment Prevent “secondary injury” to organs, even with grave prognosis Provide a clinical bridge between determination of brain death and family’s decision on donation

Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation (Salim et al. J Trauma 2005; 58: ) LAC + USC Standardized organ donor management protocol Before-after study (January 1998) of ADM institution –January 1995-December 2002

LAC+USC Study (Salim et al. J Trauma 2005; 58: ) Vasopressors if MAP <70. –Dopamine –Levophed –Vasopressin Hormones for maximal vasopressors. –Insulin –Solumedrol –T4

LAC+USC Study (Salim et al. J Trauma 2005; 58: )

Results 878 patients referred, 460 (53.4%) patients potential organ donors and 161 (34.3%) actual donors. # patients referred increased 57% # of potential donors increased 19% # of actual donors increased 82% # of patients lost to cardiovascular collapse decreased 87% # of organs recovered increased 71%

How to Implement TBI Guidelines in Your Hospital? Clinical Educator Critical Practice Committee Critical Care Leadership Critical Care Physicians or Medical Director Sample Guidelines available at:

DNR Decision What does the DNR decision mean to the family? No Chest Compressions? No Shock? No Medications? No Labs? No Fluids? “Do not harm?” or “Do not treat?”

Summary Critical care teams can honor the DNR decision while preserving the option of donation. Pathophysiology of TBI can be anticipated and treated. TBI Guidelines can be implemented to prevent “step down” in clinical management, and preserve the family’s donation option.

Question to Run On What ideas would most help you in your work with patients and families facing end-of-life decisions?

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