Moderator: • Margie Whittaker, RN, Mission Hospital Presenters: • Julie Vaupel-Phillips, RN, CHOC Children’s • John Brady, RN, St. Mary Medical Center • Esther Montoya, RN, OneLegacy Breakout Session A: “Wait!! This patient is NOT brain dead… How can they be a donor?” Donation After Cardiac Death Case Studies
45
Embed
Moderator: Margie Whittaker, RN, Mission Hospital Presenters: Julie Vaupel-Phillips, RN, CHOC Children’s John Brady, RN, St. Mary Medical Center Esther.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Moderator:• Margie Whittaker, RN, Mission HospitalPresenters:• Julie Vaupel-Phillips, RN, CHOC Children’s• John Brady, RN, St. Mary Medical Center• Esther Montoya, RN, OneLegacy
Breakout Session A:“Wait!! This patient is NOT brain dead…
How can they be a donor?”
Donation After Cardiac Death Case Studies
W A I T ! ! T H I S P AT I E N T I S N O T B R A I N D E A D … H O W C A N T H E Y B E A N O R G A N D O N O R ?
Moderator:
Margie Whittaker, RN
Manager SICU
Mission Hospital
TRANSPLANT TIME LINE1954 First Successful Kidney
Transplant
1962 First Successful Cadaveric
Kidney Transplant
1963 First Successful Lung
Transplant
1967 First Successful Heart and
Liver Transplant
“HOW TO BE…”
Being in action!
The answers are in the room
“Report out” on Questions to Run-on: • Scribe • Spokesperson
All Teach / All Learn
QUESTIONS TO RUN ON…
How will you apply what you learned
today during future end of life care plans?
How will you remember to include
donation?
OBJECTIVES
By the end of this presentation, the attendee will be able
to:
1. Identify best practices in DCD
2. Recognize the importance of collaboration and
communication in donation
3. Describe strategies to improve the DCD process
Pediatric Donation After Cardiac Death (DCD)Julie Vaupel-Phillips, MHA, RN, CCRN Director of PICU and ETS Services CHOC Children’s Hospital
Donation Facts• In the USA 1% all deaths are considered brain death.
• One organ donor has the potential to save up to 8 people by donating organs and may provide 50 people with tissue and cornea transplants.
• There are more people on the organ wait lists than organs available. 18 people die each day waiting for an organ transplant
• Literature shows that parents want to be asked about organ donation, including donation after cardiac death.
• Families of children are more likely to agree to organ donation than families of adult patients.
Donation after Cardiac Death (DCD)
• DCD offers an option to patients and families who may
wish donation to occur after life sustaining equipment is
withdrawn, and death is determined by cardiopulmonary
criteria.
• For DCD to occur, patient death is determined by
cessation of cardiac & respiratory function, rather than by
the absence of cerebral and brain stem function.
• DCD is generally practiced in the USA
Donation after Cardiac DeathThings to think about:
• Some children die despite all our efforts
• Death is not a failure
• Death is a natural part of life.
• Donation is a family driven process.
• The family has already made the decision to allow the patient to die.
• The families decision to donate must be separate from their decision to withdrawal of support.
• Family participation is essential
• The patient must always be provided comfort measures
Donation after Cardiac Death at CHOC Children’s Hospital
• 2005, Q3 1 DCD
• 2006, Q1, Q3 2 DCDs
• 2007, Q3 1 DCD
• 2008, Q3 1 DCD
• 2009 0 DCD
• 2010 0 DCD
• 2011, Q1, Q2
Things to Consider with PEDS DCD• The parents may change their mind at any time.
• Expect that the parents will want to be present in the OR and hold their child at the time of death.
• Expect that the OR will not be comfortable with the parents coming into the OR.
• Try to time the OR for evening, night or early am when there are fewer cases in the department.
• Request an OR room that has an easy egress but is private so that the family can be as comfortable as possible.
• Huddle frequently and often.
Case Study• 3 month old female
• Twin A
• Found unresponsive in crib
• Asystolic when arrived in ED
• Metabolic workup positive for fatty acid oxidative defect
• Parents informed of poor prognosis
• Family requested withdrawal of support and asked about organ donation
• OneLegacy contacted
• Consent obtained for Organ Donation
Case Study• Patient prepared for transport to OR.
• Patient 4.2 kg, no local recipients.
• Stanford University accepts liver and kidneys.
• OR Booked for 16:00
• Flight plans set for transplant team to fly from Palo Alto.
• Parents request to be close to the OR but will not be present in the OR. Family in secluded area of the OR.
• Family Care Coordinator and Priest support the family.
• 20 minutes from OR time, the transplant team experiences an in-flight emergency
• Flight is diverted to Sacramento
Case Study• Family is informed but are willing to wait the 3-4 hours it
may take to get the team down to Orange County.
• Transplant team arrives (8 pm) and patient brought back to the OR.
• Parents placed in secluded OR room.
• Withdrawal of LST performed by the PICU Intensivist.
• Patient was pronounced dead 11 minutes after withdrawal of life support.
• Parents immediately informed, baby blanket and toy returned to them.
• Surgery starts after 5 minutes of observation period.
• Liver and Kidneys successfully recovered.
Words of Advice…• Support internal staff and each other
• Expect the unexpected
• Develop a plan − For family-demographics, communicate and explain what will
occur, what they will see and hear, and all the what if’s
− For patient-palliative care, terminal extubation person,
− For staff-roles and responsibilities
• Post case debrief (OPO & hospital) for staff involved• Learn something from every case• DCD is patient/family centered care
Their lives depend on it!
Thank you.
St Mary Medical Center Apple Valley
Donation After Cardiac Death
Case Review
John Brady, RN, CCRN, CNRN
ICU Nurse Manager
Donation at St. Mary Medical Center
Organ donors 2000-2011
7 Organ Donors
• 5 brain dead
• 2 DCD (2006 and 2011)
• 17 organs recovered
• 14 organs transplanted
• 3 organs for placed for research
Day 1: Admission
45/MStatus post cardio-pulmonary arrestAreflexicMedical history methamphetamine
use, high cholesterol, & diabetesDown time 45 minutesTransfer in from local hospital for
options with the family.The family consented for both brain
death and DCD donation, said their
final goodbyes, left the hospital and
requested post OR follow-upHospital planned for EEG on Day 3
Day 3
EEG showed activity, Patient NOT
BRAIN DEADDCD Policy reviewed Huddle with all Champions: Attending
Physician, Nurse Manager, Charge
Nurse, Bedside Nurse, Respiratory
Therapist, Palliative Care, Risk
Manager and House Supervisor
Day 3
Patient placed on CPAP and shallow breaths were observed; attending physician determined that there was a high probability that the patient would not survive longer than 60 minutes
Palliative Care informed the family that EEG showed activity
Family confirmed that they wanted to proceed with donation
The Next StepsAttending physician
aware that he will be pronouncing the patient
OR scheduled for 18:30pm
16:00pm patient’s sister called the unit hysterical; the bedside nurse referred caller to speak with the patient’s mother
The Next StepsAttending physician
became concerned with recent phone call from patient’s sister and requested a second teleconference with the family to confirm donation choice
Patient’s mother contacted Palliative care and verified consent for donation
OR Delayed
Attending physician left hospital at 19:00pm and delegates pronouncement to Hospitalists or ED physician; no new OR time set
Risk Manager contacted the Medical Director who instructed the Attending to return to SMRM to pronounce the patient in OR
The Gift of Life
OR: Pt extubated 20:35pm; pronounced by Attending Physician at 20:59pm (24 minutes)
Practices for Success:–Communication and collaboration is key –All inclusive clinical trigger card & early
referral– Implementation of supportive P&P’s–Pt. and family centered care philosophy
QUESTIONS TO RUN ON…
How will you apply what you learned
today during future end of life care plans?
How will you remember to include
donation?
WHAT WE LEARNED?
Practices for Success: Communication & collaboration is key All inclusive clinical trigger card & early referral Implementation of supportive P&P’s Pt & family centered care philosophy