neurologically-aware donors: donation after circulatory death noël stout, lpn, ctbs myrna garcia,...
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Neurologically-Aware Donors:Donation After Circulatory Death
Noël Stout, LPN, CTBSMyrna Garcia, BA
Family Support Coordinators
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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.
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“Neurologically-Aware” PatientsExamples:• 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
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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
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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
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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.
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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
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Authorization• No difference from traditional paperwork
process–Confirm Registry status–Complete Written Authorization, if not
registered–Obtain DCD Procedures Authorization• Heparin administration
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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
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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
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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
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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
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Case Collaboration
Donor Alliance
Staff
ICU Director
ICU MD
ICU RN
OR Director
OR Charge
Chaplain
HD
Family/Patient
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What have we learned?Early Referral is preferred
• Be proactive• Involve the right people
Conversations early and often
Collaboration is key