1. Welcome!

2. Mary Nachreiner, Community/Family Services UW OPO
Donation B & B:
Basics and Burning Questions
Mary Nachreiner, Community/Family Services
UW OPO

3. Objectives Understand the Donor Referral Process
Understand Clinical Triggers and Apply Appropriately
Identify the Difference Between Donation After Cardiac Death (DCD) and Donation After Brain Death (DBD)
Appreciate the Personal Impact of Donation and Care of the Donor Family
Clarify “Burning Questions”

4. What is the UW Organ Procurement Organization (OPO)?
One of 58 OPOs
Service 104 Hospitals in Wisconsin, Illinois, and Michigan
Regulated by the Federal Government
30+ Staff Members
Hospital Development
Procurement Coordinators
Recovery Team
Family Support
Community Education
58 Organ Procurement Organizations in U.S.
8 hospital-based OPO’s

5. What are the Recovery Agencies?
Solid Organ Recovery
University of Wisconsin Organ Procurement Organization
Tissue Recovery
Musculoskeletal Transplant Foundation (MTF)
Wisconsin Tissue Bank
RTI Donor Services
ATSF
Whole Eyes/Corneal Recovery
Lions Eye Bank of Wisconsin

6. The Difference Between Organ and Tissue Donation
Tissue/Eye Donation
Occurs in the First 24 Hours After the Heart Has Stopped Beating
The Tissues Can Be Preserved and Used at a Later Date
Life-Enhancing Procedure
No Mechanical Ventilator Needed
One Donor Can Help From 50 to 100 People
Organ Donation
The Patient Must be Maintained by a Mechanical Ventilator
Organs Must be Properly Preserved and Transplanted Quickly
Life-Saving Procedure
One Donor Can Help 8 People

7. Kelly’s Legacy

8. Kelly Nachreiner Bill (AB-764)
Signed by Governor Tommy Thompson on May 9, 2000
Requires all Driver’s Education Programs in Wisconsin to Give at Least 30 Minutes of Instruction on Organ Donation
The First of Its Kind in the Country

9. Why is Organ Donation So Important?

10. Tyler Double Lung Recipient
Tyler Degand was 14 years old when a rare strain of influenza B landed him in the hospital, on a ventilator, struggling to stay alive. Now 16, Tyler enjoys the every day activities of a high school sophomore, including the excitement of learning to drive

11. Why is Donation so Important?
Every Day…
18 People in the U.S. Die Waiting
111 People are Added to the National Wait List
Only 2-4% of Deaths are Eligible for Solid Organ Donation
17 people die/day waiting for an organ

12. Source: Organ Procurement and Transplant Network 04/13/2011
The National Story
Type of Transplant Waiting
Kidney ,314
Liver ,159
Lung 1,777
Heart 3,176
Heart-Lung 65
Kidney-Pancreas 2,223
Pancreas 1,383
Intestines
Totals ,693
Source: Organ Procurement and Transplant Network 04/13/2011

13. Source: Organ Procurement and Transplant Network 4/8/2011
Our Local Stories
Wisconsin
Illinois
Michigan
80-85% Awaiting Kidneys
Source: Organ Procurement and Transplant Network 4/8/2011

14. Your Role in Donation ● Provide Care to Families
● Recognize Clinical Triggers
● Make the Referral Within 1 Hour of Clinical Triggers
● Understand How the Donation Process Works
● Effective Requesting (Consent)
● Sign Consent with Family
● Be an Advocate for Donation in Your Community

15. Clinical Triggers: What and Why?
What are Clinical Triggers?
Specific Medical Patient Parameters Requiring Notification to the OPO (Referral)
Why are Clinical Triggers Important?
Preserve the Option of Organ Donation for the Patient and Family
Ensures Adequate Time for Potential Donor Screening, Medical Management, and Allocation of Organs
Follow Requirements of Joint Commission and CMS

16. Clinical Triggers Are Met When a Patient: Is Mechanically Ventilated
AND
Has a Severe Neurologic Insult/Injury
ONE of the Following:
A Physician is Evaluating for Brain Death OR
Has a Glasgow Coma Scale (GCS) < 5
Plans to Discuss Withdrawal Life-Sustaining Therapies
GCS is a neurological scale of a person’s level of consciousness. Establishing clinical triggers is important for the hospital and OPO because clinical triggers will ensure the family is provided the opportunity to all donation options if it is appropriate.
What are the clinical triggers for organ donation?
A mechanically ventilated patient with a severe brain injury-
·     For whom a physician is evaluating for brain death OR
·     A patient with a Glasgow Coma Scale (GCS) of 5 or less OR
·     For whom a physician has ordered that life-sustaining therapies be withdrawn
Please note that a patient does not need to meet all three clinical triggers before notifying the OPO, when a patient meets any of the three clinical triggers, that is when you should make that initial phone call to the OPO.
Some of you may be looking at the clinical triggers and thinking to yourselves, I’ve taken care of patients that had a GCS of 5 and were in full treatment mode, and were not at the point of talking to the family about donation, so why would I call the OPO? Are we calling too soon?
What I want to stress to you is that when a patient meets clinical triggers, the phone call you are making is only a notification to the OPO. It does not mean that you have to approach the family, it does not mean that patient Is going to donate , or that all hope for patient survival is gone, or that you should stop treatment--it is only a notification.
The process for notifying the OPO is not the same as the requesting process for organ donation. They are two very separate processes and should not be confused with each other.

17. Clinical Triggers Severe Neurological Injuries: Trauma CVA
Primary CNS Tumor
Anoxia
Cardiac Arrest/MI
Drug Overdose
Drowning/Hanging

18. Clinical Triggers Simply a “Heads Up” Notification Does NOT Mean:
That the Patient is Going to be an Organ Donor
That the OPO is Going to Arrive at Your Hospital
All Life Saving Efforts are Pursued as They Are With Any Patient
Ensures adequate time for potential donor screening, medical management and allocation of organs

19. Only 6-7% of Patients Referred to the OPO Actually Become Donors

20. Clinical Trigger Case Studies

21. Jack is a 68 yr old WM with prostate cancer,
pancreatitis, renal failure, and liver failure due to
ETOH abuse. He is hepatitis B+. He has hepatic
encephalopathy and was intubated in the ER to
maintain his airway. His GCS is 3.
Refer? Not Refer?

22. Henry is a sixty-nine year old male who arrived at the hospital unresponsive due to a CVA. He was intubated on admission and then weaned off of the vent. A week later his condition declined and was re-intubated. The physician had a meeting with the family and they decided to extubate the patient. Refer? Not Refer?

23. Clinical Triggers: Moral of the Story
KISS: Keep It So Simple
Break down the clinical picture to those 3 parameters: Neuro injury; ventilated; and one of the other 3 questions.
Most patients meet clinical triggers in the ED but are referred in ICU/CCU

24. The Referral Process Statline Pages On Call Referral From Yes
OPO Coordinator
Referral From
Hospital:
(Statline)
Yes
Statline:
Is Patient
Ventilated?
Statline Refers to
Tissue Agency No
Keep in mind that many patients actually meet clinical triggers in the ED, but the referral is often made from the ICU. Note: this can be the ED of a local hospital prior to transfer

25. Reminder: All Deaths and Imminent Deaths Must be Reported
Statline Triage Center
1 Phone Number
Imminent Deaths: OPO Paged
Deaths: Tissue and Eye Banks Paged
That’s right. All deaths and imminent deaths get called-in to the same phone number. It goes to a Triage Center called STATLINE out in Colorado, and Statline works with many donation agencies around the country. They are going to ask for:
Your hospital name, city and state
Caller’s name and title, hospital unit, phone number
Patient’s Name, age, gender, race
Whether or not patient has a heartbeat
If no heartbeat, when the CTOD
If yes, is the patient mechanically ventilated…
Your answers to these questions will determine whether Statline will page the OPO for Solid Organ Donation or the Tissue/Eye Bank for Tissue/Eye Donation
WHO CAN MAKE THIS CALL? It can be anyone on your staff – physician, nurse, unit clerk, chaplain, nurse supervisor/manager.
Now some of you may have a question as to what imminent death is, and we’re getting to that, so don’t fret. Does anyone know what percentage of us will die in a way that solid organ donation is even possible? Get their answers… 2-4% - it’s a small number.
Public perception, as we’ve just demonstrated by some of your answers, is that most of us can donate our organs if we’re reasonably healthy. However, organ donation can only happen if one dies in a hospital setting, because in order to donate one’s solid organs, we have to still have a heartbeat AND be mechanically ventilated. Most of us won’t die that way. So though I and many of you may want to donate, the likelihood that we’ll be in that situation at the end of life is pretty slim.

26. How Does Donation Occur?
Two Opportunities…
Donation After Brain Death (DBD)
Donation After Cardiac Death (DCD)
Brain death: Irreversible cessation of all functions of the entire brain, including the brain stem
Cardiac Death: Irreversible cessation of circulatory and respiratory function

27. Brain Death vs. Cardiac Death
Irreversible cessation of all functions of the entire brain, including the brain stem
Cardiac Death
Irreversible cessation of circulatory and respiratory function

28. Donation After Brain Death

29. Brain Death LEGAL TIME OF DEATH Irreversible
Brain Death Is…
LEGAL TIME OF DEATH
Irreversible
Usually a Result of Direct Insult to the Head
(Trauma, Anoxia, Stroke, etc.)
Declared Only by Patient’s MD/Donor Hospital Designee (NOT OPO)
Declared Through Clinical Exams, Apnea Testing, and Confirmatory Exam*
*Additional Details Available

30. Angiogram Normal Blood Flow No Blood Flow
Example of a angiogram. The scan on the left delineates normal blood flow. The scan on the right is a brain dead patient where the blood flow to the brain has been cut off from the swollen brain shown by the fuzzy area inside the skull.
Normal Blood Flow
No Blood Flow

31. Donation after Brain Death
The Process
● Patient is Declared Brain Dead; This is the Legal Time of Death
● Patient is Maintained on Ventilator Throughout the Organ Recovery
● Organs are Dissected in situ (Naturally Situated in Body)
● 3-4 Hour Surgery
● Heart, Lungs, Liver, Kidneys, Pancreas, and Intestines Can be Recovered

32. Donation After Cardiac Death

33. Donation After Cardiac Death (DCD)
For Donation After Cardiac Death to Occur:
Severe Neurologic Insult or Injury
Trauma (MVA, GSW)
Cerebral Vascular Accident (CVA)
Anoxia (MI, Drug Overdose, Drowning, Hanging)
Patients Do Not Meet the Criteria For Brain Death
Gives Family the Option of Organ Donation for the Severely Brain Injured (but Not Brain Dead) Patient.
US DCD Donors Average: 10%
UW OPO DCD Donors Average: 30%

34. Donation After Cardiac Death (DCD)
For Donation After Cardiac Death to Occur:
All Medical Treatments are Futile and Long-Term Prognosis Poor
Family and Physician Elect to Withdraw Support
Referral is Made to OPO
Withdrawal of Ventilated Support in OR vs. ICU
Cardiac Death Occurs
Surgery Begins 5 Minutes After Cessation of Cardiac Function and Declaration by Patient’s Physician
Rapid Recovery with Organs Procured en bloc
1-2 Hour Surgery
Lungs, Liver, Kidneys, and Pancreas Can Be Recovered

35. Key Differences Between DBD and DCD
Donation After Cardiac Death (DCD)
Patient Extubated in OR vs. ICU
Surgery Begins 5 Minutes After Cessation of Cardiac Function and Declaration by Patient’s Physician
Rapid Recovery With Organs Procured en bloc (as a Whole)
1-2 Hour Surgery
Donation After Brain Death (DBD)
Patient is Maintained on Ventilator During Organ Recovery
Organs Dissected in situ
3-4 Hour Surgery

36. The Reward of Many Efforts

38. Burning Questions

39. FYI: Sensitive Terminology
Please Use Instead of
“Recover” “Harvest”
“Deceased Donor” “Cadaver”
“Mechanical or “Life Support”
“Ventilated Support”

40. BQ: How Long Are Each of the Organs Viable After Being Recovered?
Organ Preservation Time
Heart: 4-6 Hours
Lungs: 4-6 Hours
Liver: 8 Hours
Pancreas: Hours
Kidneys: 72 Hours
Small Intestines: 4-6 Hours

41. BQ: How Do You Determine Who Receives The Organs?
UNOS (United Network for Organ Sharing)
Allocation Criteria
Blood Type
Medical Urgency
Tissue Match
Waiting Time
Organ Size
Immune Status
Geographic Distance

42. BQ: Can a Person With Autoimmune Disorder (Not AIDS/HIV) be a Donor?
Yes

43. How Can a Patient Become a Donor if They Have No Family?
NOK Hierarchy
Healthcare Agent or Power of Attorney – But only if given the responsibility of making an anatomical gift. Most POA and living wills in use cover only the power to make health care decisions – not anatomical gifts. We are working with the WI Dept. of Health to have their standard forms changed as soon as possible.
Spouse
Adult Children
Parents
Adult Siblings
Adult Grandchildren
Grandparents
Adults Who Exhibited Special Care or Concern, Except as a Compensated Health Care Provider for That Individual
Legal Guardian
Whomever Would be Responsible for the Disposal of the Body

44. Other Burning Questions??

45. Thanks!

46. Donation after Brain Death
Brain Death Criteria
Clinical Diagnosis of Brain Death
● Unresponsive to All Stimuli
● No Spontaneous Respiratory Activity
● All Brain Stem Reflexes are Absent
Pupillary Response to Light
Corneal/Lash Reflexes
Oculo-Vestibular Reflex (Cold-Caloric Response)
Oculocephalic Reflex (Doll’s Eye Phenomenon)
Gag/Cough Reflex
Response to Intense Central Pain

47. Donation after Brain Death
Brain Death Criteria
Apnea Test
Make Sure Patient Has Normal BodyTemp, Blood Pressure, Volume Status, ABGs
Disconnect From Ventilator
Monitor Continuous Pulse Oximetry
Administer 100% O2 at 6 L/min Into The Trachea
Monitor Closely for Respiratory Movements
Check Serial ABGs or at Approx. 8 Minutes
If No Respiratory Movement and Arterial PCO2 is > 60 mm Hg, the Apnea Test Supports the Clinical Diagnosis of Brain Death

48. Donation after Brain Death
Criteria for Brain Death
Confirmatory Exams
Cerebral blood flow (CBF) studies
4 Vessel Angiogram
Transcranial Doppler
EEG