Neurologically-Aware Donors: Donation After Circulatory Death Noël Stout, LPN, CTBS Myrna Garcia, BA Family Support Coordinators

Objectives: Provide context for honoring the neurologically-aware patient’s desire to donate organs within a non-traditional clinical picture. Provide information surrounding the referral, discussion and legal authorization from neurologically-aware patients for organ donation after circulatory death.

“Neurologically-Aware” Patients Examples: High cervical spine fractures; quadriplegia Degenerative neurological diseases in the end- stages; Amyotrophic Lateral Sclerosis, Multiple Sclerosis, Huntington’s Chorea Ventilator dependent and family/patient have chosen to withdraw life-sustaining measures

Consider Neurologically-Aware patients as potential referrals! General Triggers: Vented, GCS <5, heart-beating and/or family planning to d/c life-sustaining interventions Non-traditional Triggers to consider in addition: Ventilator dependent, GCS higher than 5, likely to die immediately after extubation, any mention of donation by family or patient

Process As in all DCD discussions, decision to withdraw life-sustaining measures must already have been made by the family OPO and medical staff meet to determine the best way to discuss organ donation with family If patient is communicative, he/she must be included in the discussion

Ethical Considerations The hospital Ethics Committee may review the case. The committee felt it appropriate for the intensivist to speak with the patient regarding withdrawal of care. Once the patient, family and Intensivist have agreed upon the withdrawal of care, the hospital Ethics Committee can permit the OPO staff to approach the patient.

Discussion Assess patients method of communication and neurological state – Family members/hospital staff involvement Assess sedation level Determine patient’s understanding of their condition Determine who will be in room for donation discussion Thorough staff huddle prior to approach

Authorization No difference from traditional paperwork process – Confirm Registry status – Complete Written Authorization, if not registered – Obtain DCD Procedures Authorization Heparin administration

Case Study 56 year old female, registered donor admitted s/p fall from deck CT scan revealed severe cord laceration at C2 level with contusion from C1-C3 No acute intracranial injury identified Family given prognosis of vent dependent quadriplegia – Withdrawal of care brought up by family

The Intensivist Conversation Family/Family Support Coordinator present “Once for yes, twice for no” Neurological state assessed Confirming pt’s understanding of ventilator- dependent quadriplegia Discussed life-sustaining measures will be withdrawn Clarify that this would result in her death

The OPO Approach Family and hospital staff present Confirm that at the time of death, organ donation would occur Authorization completed by husband Patient included in process Questions answered

The Recovery Comfort care measures per hospital protocol Significant Hospital OR staff preparation – Withdrawal of care in OR or ICU per patient/family wishes – No pre-OR prep done

Case Collaboration Donor Alliance Staff ICU Director ICU MDICU RN OR Director OR Charge ChaplainHD Family/ Patient

What have we learned? Early Referral is preferred Be proactive Involve the right people Conversations early and oftenCollaboration is key