1. Organ Donation 101

2. Who is CDT? Center for Donation & Transplant Responsible for:
Organ Procurement Organization (OPO)
Serve 43 Hospitals
Responsible for:
Organ procurement & allocation
Community education & public relations
Ensuring that families have the option to donate & that they are asked in an appropriate & sensitive manner 2

3. Agenda Current need for donation How does organ donation happen?
Brain death
Donation after cardiac death (DCD)
Medicare policies for hospitals
Authorization for donation
Donor management
CDT aftercare 3

5. 10,000

6. 120,000 on waiting list

7. Trends

8. Why are there so few organ donors?
Oxygen loss after death
Perfusion is forever lost
Oxygen no longer enters, C02 doesn’t exit
Organs can’t last long under conditions
Tissues can remain viable up to 24 hrs later, if cooled.
All deaths are evaluated for tissue donation

9. Organ Preservation Times
Heart: 4 hours
Lungs: 4-6 hours
Liver: 12 hours
Pancreas: hours
Kidneys: 72 hours
Small Intestines: 4-6 hours

10. How are there organ donors?
Ventilator
Continues oxygenation /perfusion of organs
Brain death-declared dead via neurological criteria. Perfusion maintained until recovery
Terminal extubation- death expected after removal of vent. Perfusion decreases and is ultimately lost, but only for minimal time before procurement.

11. Brain Death

13. Declaration of Brain Death
Prior to brain death testing, correct:
Hypotension
Hypothermia
Drug Intoxication
Core temp must be ≥ 32°C (89.6° F) 13

15. Declaration of Brain Death
Proximate Cause
1st Exam
Apnea Test
Referral
Attestation
Declaration of Brain Death Timeline
Determine proximate cause. Establish irreversibility.
1st Exam- test for brain stem reflexes
Apnea Test- To confirm no spontaneous respirations
Attestation by 2nd MD- Required only for donation
A confirmatory test can:
Help to determine proximate cause
Take the place of or be done in addition to a clinical exam 15

17. 2014 Stats on Brain Death 10,000 + deaths
~200 had some potential for organ donation
How many were declared brain dead?

18. 2014 Stats on Brain Death 58 brain deaths 37 consented & recovered
64% conversion rate (37/58)
120 organs transplanted
3.24 organs per donor

19. Organ Donation after Cardiac Death (DCD)

21. Donation after Circulatory Death
DCD
Donation after planned withdrawal of care and cardiac death
Patient may have neuro function, but are likely to expire within 60 minutes of withdrawal, based on MD assessment
Circulation not present at time of organ recovery
Kidneys, liver, pancreas, & in rare cases lungs and even heart

22. The Original Procurement Practice
When organs were first recovered, all organ donors were DCD donors
DCD declined after Uniform Brain Death Act
More organs were able to be recovered from brain-dead donors
Increasing DCD donation is essential & feasible
Waiting list = 120,000 & growing
Legislation, surgical advances, & new medicines have made DCD a safe & routine procurement practice

23. Examples of DCD Patients
Patient is missing neuro, but not yet brain dead
55 yr old s/p trauma. In ICU, MD tells family pt has non-recoverable head injury
Family won’t wait for brain death but wants donation
Patient with poor prognosis, facing imminent death
Unstable, may die on vent before brain death testing can be completed
Family still wants donation or pt is a registered donor

24. Examples of DCD Patients
Patient’s airway likely to collapse quickly after extubation
Examples:
Some spinal fractures
ALS patients
COPD/respiratory failure
Note: In a very limited number of cases, some patients may provide own consent
DCD preserves option of donation for pt’s who will not meet criteria for brain death

25. What is the real potential for DCD?
Over 90% of those on the waiting list are in need of a kidney
90% of ICU patients die after a decision to limit therapy (Critical Care Medicine, 2001)
Such requires complex conversations, usually between healthcare staff and families
ICU Population
110,000
More DCD
Earlier withdrawal = less patients progressing
to brain death
More potential DCD donors
Less brain deaths
Waiting list

26. Potential for DCD Donor Growth 1997-2013
This rise is driven by the decrease of brain-dead potential donors coupled with the increase in implementation of DCD policies/protocols as hospitals, particularly after the Joint Commission implemented a DCD standard in 2007. 26

27. Medicare Donation Policies
How Do Hospitals Enable Organ Donation?

28. Medicare’s 2 Donation Rules for all hospitals
Hospital Referral
Required referral law
Requesting Consent
Must be a certified designated requestor to ask families for consent

29. Rule 1: Medicare’s Required Referral
When the death of a person in a hospital has occurred or is imminent, the hospital shall contact the federally designated organ procurement organization in order to make a preliminary determination of the suitability of the person for organ donation.

30. Why is there Required Referral?
Rule allows identification of ALL potential
CDT can’t be in all of its 43 hospitals 24/7
Before rule, 25-50% of all donation potential was lost!!!!

31. Required Referral Rule
Death has “Occurred”
Call in EVERY death that has happened within 1 hour after death

32. Required Referral Rule
Death is “Imminent”
Refer vented pts dying “imminently”

33. “Imminent Death”
Medicare defines imminent death as a vented patient that meet ANY of the following:
GCS of 5 or less
Any brain injury or missing brain stem reflexes
Terminal extubation is likely or pending
Call within 1 hr of a patient meeting imminent death criteria

34. Tips for Identifying Imminent Death
Always look for clinical triggers upon admission to unit
Periodically assess GCS
Use “clinical intuition” to make early referrals
If busy, have bedside RN, charge RN, unit secretary, or other staff make referral for you

35. Stats on Imminent Deaths
200 had some potential
58 brain deaths- 37 donors
~50 DCD candidates- 21 donors

36. Rule 2: Medicare’s Requestor Rule
To approach a family about organ or tissue donation, one must be a “certified designated requestor,” someone trained by an OPO on how to approach families for consent.

37. Why is there a Requestor Rule?
Perception of conflict of interest
CDT has specially trained requestors
Consent rate stats:
When CDT approaches: 50% or higher
When staff approaches: 10% or less

38. Decoupling Studies show: “Death” + “Donation” @ same time = Negative
“Donation” alone = Positive
Negative
Positive

39. De-coupling De-coupling: Separating “death” from “donation”
When process broken, consent rates drop
Referral
BD testing/ BD Declared/ family talking about EOL
Hospital informs family of BD/family wants EOL
Team Huddle
Approach for Donation
CDT Evaluation
De-coupling

40. Talking with Families NYS registration = legal authorization
Currently less than 25% of NYS adults
Hierarchy of consent
LEGAL HIERARCHY
Spouse (or Civil Union Partner in VT) or domestic partner
Adult child
Parent
Adult sibling
Domestic partner
Other (Grandparents in VT)

41. Talking with Families We never persuade! CDT is designated requestor
Special staff trained in bereavement, grief counseling, social work, etc
Approach rules
We never converse at the bedside
Avoid euphemisms for death
Answer questions simply and honestly
Ensure family is approached in a caring & compassionate manner
We never persuade!
There is NO right or wrong decision. CDT respects all decisions.

42. Requesting- Tips & Best Practices
Simple—Never bring up donation
If family brings up donation to you, contact CDT
Use effective transitional language
“There are some end of life specialists here who would now like to speak with you”
“This is (name), he/she is a member of the healthcare team, and he/she has some additional information about the EOL process.”
Identify NOK making medical decisions

43. After Consent What happens?

44. After consent- Brain death
Donor management = by CDT
Why?
Hospital testing needed:
Blood draws
Node procurement
Echo/bronch
Organ placement via UNOS
This is what can take a LONG time
Total time from consent to procurement
Usually hours

45. What UNOS Does Liver to Buffalo to pt w/highest MELD score
Kidney to Vermont to pt who is perfect match
For one donor, we could have 4 or more different surgery teams come in to procure
Pt in
Pittsburgh receives kidney & pancreas
Kidney & pancreas to Pittsburgh
Heart & lungs to New York City to two different pts

46. After consent- DCD Donor management = by hospital staff
Why?
Hospital testing needed:
Blood draws
Bronch
Labs
Organ Placement
Total time from consent to procurement
Usually 4-12 hours

47. Family Aftercare

48. Donor Aftercare & Support
Families receive an aftercare packet within 6 weeks of donation
Donor Quilt
Community participation:
Donor Memorial Service
Donor Family-Recipient Picnic
Volunteer Program

49. Questions? www.donatelifecdt.org 518-262-5606
218 Great Oaks Blvd, Albany, NY 12203 49