1. Claire Burbridge Specialist Nurse Organ Donation

2. Objectives Role of the Specialist Nurse Organ Donation – SN-OD
Why is donation important?
Case studies
Donation after Brainstem Death (DBD)
Brain Stem Death Tests
Donation after Circulatory Death (DCD)
Donation Process

3. Role of the SN-OD 24 hour on call - Expert Advice
Offer option of donation to families
Work closely with members of MDT in order to facilitate process of donation
Offer family follow-up and support
Form working relationships with key members of hospital staff
Provide education on donation
Potential Donor Audit of all deaths in ITU and ED to ensure all patients who should have been referred, were

5. Why is organ donation important?
Donors & their Families
“If staff do not ask, they let the families down. Knowing something good came out of our tragedy is a great comfort” - quote from donor family
Recipients
Best treatment for end stage organ failure
Life saving treatment
Supply<demand
The Law:
Individual autonomy and expressed wishes now lawful as part of Human Tissue Act 2004
DOH 2008 – OD should be part of all end of life care where appropriate

7. The reality is that...
THREE people die each day waiting for an organ transplant.
There is an on-going shortage of organ donors in the UK.
There are currently 6432 patients waiting for transplants in the U.K.

10. Referral to Organ Donation Team... WHO & WHEN?
All suspected BSD patients with fixed dilated pupils, prior to BSD testing and prior to conversation with the family.
Planning to withdraw treatment on a Intubated & Ventilated patient, before futility of treatment conversation with the family.
Lesley

11. NICE 135 Guideline (2011)
Identify all potential donors early by either:
Defined clinical trigger factors after catastrophic brain injury:
- absence of one or more cranial nerve reflexes
And
- Glasgow coma scale score of 4 or less not explained by sedation Or
- Intention to withdraw life-sustaining treatment, which will, or is expected to, result in circulatory death
Lesley 11

12. EVERY FAMILY HAS THE RIGHT TO BE GIVEN THE CHOICE.
Approaching families...
Families need to understand the patient has died (BSD) or that death is inevitable BEFORE they can think about donation.
Planned approach to organ donation between the Specialist Nurse, nursing and medical staff works best in offering families donation and obtaining consent.
NO religion or ethnic group opposes donation.
Each family is individual- we cannot make assumptions.
EVERY FAMILY HAS THE RIGHT TO BE GIVEN THE CHOICE.
Lesley

13. What are the contraindications to donation?
Lesley

14. Contra- indications Each case must be assessed on an individual basis.
CJD
Age, multi-organ failure, malignancy, testing positive for blood borne virologies, post operative complications or extended periods of hypoxia remain firmly within the parameters of a potential organ donor.
Each case must be assessed on an individual basis.
Note: Police or coroners involvement does not prevent donation.
Lesley

15. What Organs can be Transplanted?
Tissues
Cornea
Skin
Bone
Tendons
Heart Valves
Organs
Heart
Lungs
Liver
Kidneys
Pancreas
Multi visceral/ Small Bowel (DBD Only)
Lesley

16. Two Types of Deceased Organ Donors
Intubated & Ventilated
Patient
BRAIN STEM DEAD
Donation after Brain Death
DBD donor
Clinical decision to
Withdraw Life Supporting Treatment
Donation after Circulatory Death
DCD donor
Lesley
(Heart beating donation) (Non heart beating donation)

17. DBD Criteria Donation after Brain stem death
Neurological insult resulting in Brain Stem Death; confirmed by BSD tests.

18. What are the signs of
Brain Stem Death?

19. Signs of Brain Stem Death
Fixed and dilated pupils
No response to painful stimuli
Loss of cough and gag reflex
Apnoea
Hypertension followed by hypotension
Tachycardia/Bradycardia
Diabetes insipidus – sustained urine output over 300mls/hr
Reduction in core temperature
Why does this happen?

20. Anatomy and Physiology
The brain stem is the lowest part of the brain
It is positioned between the cerebrum and the spinal cord.
The Brain Stem controls the vital autonomic functions e.g. respiration, consciousness, vasomotor, cranial motor, sensory input
The brain stem contains the nuclei of 10 of the 12 cranial nerves
Cranial Nerve 1 and 11 have their origin in the forebrain but still proceed through the Brain stem

21. Causes of Brain Stem Death
Eastern Organ Donation Services Team – pager number
Causes of Brain Stem Death
Intra-cerebral
haemorrhage
Trauma
Tumour
Ischaemia
Can you think of anything else that would cause BSD? – Abcess, Meningitis, Blocked shunts 21

22. Essential preconditions
What things that may mimic a coma must we exclude before we can legally test?

23. Before Brain Stem Death Diagnosis
Essential Preconditions - diagnosis consistent with irreversible brain damage - the patient is apnoeic, unresponsive on the ventilator Exclusions Reversible causes of apnoeic coma must be excluded - Drug intoxication - Hypothermia - Metabolic & Endocrine disturbance
Temp >34
MAP >60
PaC02 <6KPa
Pa02 >10KPa pH Na
K+ >2 mmol/L
BM 3-20 mmol/L 23

24. Potential Donor Management
What may we need to do to stabilise these patients and keep their biochemical results within criteria/prevent organ failure.

25. Potential Donor Management
IV Access
Inotropes – Vasopressin
DDAVP
Fluids
Ventilation
Actrapid
Temperature management

28. Donation after Brain Death
Brain Stem Death is death diagnosed and time documented
Diagnosis of death is made whilst the patient is attached to a ventilator and therefore the heart is still beating.
Patient is transferred to theatre whilst connected to ventilator and infusions.
Incision is made to prepare for retrieval
Anaesthetist required from host hospital until the aorta is cross clamped then organs are retrieved (takes around 6-8 hours)
Throughout surgery normal anaesthetic drugs are given.

29. Donation after Circulatory Death
Invasive arterial monitoring continues once patient extubated
Death is pronounced by a doctor 5 minutes after irreversible loss of cardiac output.
Body is transferred into theatre - knife to skin can commence
Incision is made to cannulate aorta and commence perfusion with a preserving solution.
Organs are removed after cold perfusion
Team on standby for 3-4 hours in theatre
If patient stable after 3-4 hours- team can stand down

30. The Process..... ….What is involved?

31. The Process Identified potential donor F PMH A
Patient/family consent M
Patient assessment I
GP History L
Coroner Consent Y
Bloods (Virology/Tissue Typing)
Extra Tests (ECG,ECHO/TOE,BRONCH,CXR)
Collection and inputting of data S
Offering U
Coordination P
Theatres/Retrieval P
Last offices O
Family follow-up R T

32. Conclusion. Donation is an extraordinary process
Choice given to bereaved families
Team Approach
Only future for those with end stage organ failure

33. Eastern Organ Donation Services
In summary...
If in doubt page us on: – we are here to give advice, information and support any time day or night.
Eastern Organ Donation Services
Pager:
Tissue Services Referral Number:

35. References. 2004 The Human Tissue Act. DOH
2008 A code of practice for the diagnosis and confirmation of death. Academy of Medical Royal Colleagues
2009 Legal issues relevant to non-heart beating donation DOH
2010 Treatment and care towards the end of life: good practice in decision making General Medical Council p.p 42
2012 NICE Guideline 135 Organ donation for transplantation