1. Prediction of death in adults– an educated guess in DCDs Maria C. Nauman RRT, CPTC Resource Triage Coordinator California Transplant Donor Network

2. Objective Why we needed to change our practice Describe how we changed our practice Review our process for DCDs Review some of the challenges of the tool 2014 Data

3. Why change our method? Not reaching our goal of 10% DCD cases More Objective Article on predicting death – Dr Alan Yee, Neurologist, CPMC – Probability Tool 2012 initiated changes to our practice

4. Factors influencing time to death after withdrawal of life support in neurocritical patients A.H. Yee, A.A. Rabinstein, P. Thama, et al. Neurology 2010; 74; 1380 Retrospective study (2002-2008) Neuro ICU 149 pts Compared those who died 60 Excluding those who were declared BD, not intubated, or had insufficient data Correlation associated with earlier death after withdrawal of life sustaining measures – Absent corneals, cough, extension, O2 index <4.2

5. Probability Tool

6. 1. Enter FiO2, MAP, and PaO2 to generate oxygenation index. FiO2 Mean Airway Pressure PaO2Oxygenation Index Oxygenation index: http://www-users.med.cornell.edu/~spon/picu/calc/oxyindex.htm 2. Enter Y or N as appropriate to generate probability. Corneal reflex?Cough reflex? Motor response 3- 6? Oxygenation index >4.2? Probability Y = Yes1 - No motor response N = No2 - Decerebrate posturing/extension 3 - Decorticate posturing/flexion 4 - Withdrawal 5 - Localizes 6 - Obeys commands

7. Monthly Review Decision Huddle Evaluation Tool Review Referral

8. HistoryDiagnosticsSBTsClinical pictureLabsVentRespiratory status

9. 2014 Data ScoreCasesAccuracy <703789% 70-801457% >801887.5%

10. Problems How to score when the reflex is intermittent How to score when we have to assess by phone Assessments such as NIF and leak test – Equipment not available for NIF – Technique dependent Not having updated clinical information – ABGs, diagnostics It’s still an educated guess!

11. Questions?