First Person Consent Uniform Anatomical Gift Act of 1968

• Not-for-profit Organ Procurement Organization
(OPO) & Tissue Recovery Agency
• Regulated by Centers for Medicaid and Medicare
Services (CMS) and FDA
• Offices in North Liberty, Altoona, & Sioux City
• Communication Center operates 24/7/365
• 2 dedicated tissue recovery suite locations with
off-site recovery capabilities
Andrew Wilson, Medicolegal Death Investigator
First Person Consent
Uniform Anatomical Gift Act of 1968
Chapter 1064. Sec. 4. Section 142C.3, subsection 8,
Code 2001
• Legalized the transplantation of human organs and
tissues. Since 1972, all 50 states and the District of
Columbia have adopted this act.
• Partner with Iowa Lions Eye Bank
Centers for Medicare & Medicaid Services (CMS)
• Requires CMS funded hospitals to refer ALL cardiac and
imminent deaths to OPO
• Mandates that only trained personnel discuss opportunity of
donation with potential donor families
HIPAA
•
Allows healthcare professionals to disclose protected
patient information to OPOs
Every 10 minutes, there is another
name added to the national organ
transplant waiting list
Every day, 22 people die while waiting for
a life saving transplant
As of February
121,545
1st,
2016:
ONE donor can save the lives of up to
8 people and enhance the lives of more than
300 people.
604
This number does not include those waiting for
tissue transplants.
1. Timely Organ Donation Consult
2. Preserve Opportunity with CBIGs
3. Grave Prognosis & Timely Brain Death
Testing
4. Planned donation conversation with family
• Ensure consult with IDN made
• Keep IDN updated of changes in patient status
• Collaborate with physicians on implementing
CBIGs
• Huddle with IDN coordinator
• Support family through grave prognosis
• Prepare family to speak with IDN
• Assist IDN coordinator with donor management
Donation starts with ONE.
• Provide aggressive and thorough treatment
when there is hope for recovery
• Perform or consult for neuro assessment
• Preserve the Opportunity with CBIGs
• Huddle with IDN coordinator
• Declare brain death (circulatory death in DCD)
• Prepare family to speak with IDN
Consult IDN if patient is on ventilator & meets
one of the following criteria:
1.
2.
3.
4.
Has lost 2 or more brain stem reflexes
Has a GCS of 5 or less
Family asks about donation
Withdrawal of care conversation
initiated by family
or healthcare team
• Pupils
• Corneals
• Cough
• Gag
• Motor response
• Oculocephalic (Doll’s eyes)
• Oculovestibular (Ice Water Calorics)
• Spontaneous respirations
IDN Coordinator returns call.
Provide:
Medical history
Brain stem reflexes
Vital Signs/Labs
Use of pressors/sedation
Plan of Care
Communicate to IDN:
– Changes in patient status
– Loss of additional brain stem reflexes or brain
death testing planned
– Family making end-of-life decisions
– Patient cardiac arrests on ventilator
Notify IDN that patient is on ventilator.
Provide:
Hospital Name/Unit/Phone number
Your Name
Patient’s name and DOB
Cause of Admission
Based on information, IDN may:
1. Come onsite for further assessment
2. IDN may “follow” by phone
3. IDN may notify you to call back with time of
death
• Follow hospital policy for notification to
medical examiner of patient death
• IDN obtains permission for organ donation for
all donors regardless of cause of death
• Cushing’s Triad
– Hypertension followed by
hypotension
– Bradycardia
– Respiratory irregularity
• Loss of all brain stem reflexes
Many patients become unstable as brain stem herniates.
Preserve opportunity for donation with Catastrophic Brain
Injury Guidelines (CBIGSs)
Catastrophic Brain Injury Guidelines
1. Maintain SBP > 100
2. Treat Diabetes Insipidus
3. Maintain PaO2 > 100 and pH 7.35-7.45
4. Maintain core temperature of 36 – 37.5 C
5. Monitor and treat electrolytes
6. Monitor and treat low Hgb & Hct
Phase 1
Communicate seriousness of injury
“____ has suffered severe damage to his/her brain. We are
doing everything we can to help him/her recover.”
Phase 2
Communicate grave prognosis
“Despite everything that we have done, ____ is getting worse.
He/she may not recover.”
Phase 3
Communicate Brain Death Testing
“As you know, _____ has suffered a devastating brain injury. It
appears that his/her brain has stopped working and cannot
possibly recover. We will begin testing to be certain about
this.”
Phase 4
Brain Death Discussion
When all treatment options have been exhausted and despite best efforts the
patient dies, the option of donation can provide a positive outcome to a tragic
situation.
Hope for Recovery…can become…Hope through Donation
Life saving transplants
Aggressive Treatment
Deteriorating condition
Support of donation management
“The testing is complete. _____ has lost all brain function.
This is permanent. This means that he/she is medically and
legally dead.”
Preparing family for negative outcome
Grave prognosis
Donation discussion
Preserving the option
Declaration of death &
Support of family
Death by Neurological
Criteria (Brain death):
Irreversible cessation of
spontaneous brain
functions. [2-3% of deaths]
Death by Circulatory
Criteria (DCD):
1.
2.
3.
4.
Prerequisites
Clinical Examination
Apnea test
Ancillary test only if indicated
Irreversible cessation of
spontaneous respiratory
and circulatory function.
Coma, irreversible, and cause known
Neuroimaging explains coma
No CNS depressant drug effect
No evidence of residual paralytics
or severe acid-base, electrolyte, endocrine abnormality
Normothermia (> 36 C)
Systolic Blood Pressure > 100 mmHg
No spontaneous respirations
Pupil Test
Examination performed by 2 physicians (per Iowa Law)
Pupils nonreactive to bright light
Corneal reflex absent
Oculocephalic reflex absent
Oculovestibular reflex absent
No facial movement to noxious stimuli at supraorbital
nerve, temporomandibular joint
Gag reflex absent
Cough reflex absent to tracheal suctioning
Absence of motor response to noxious stimuli in all 4 limbs
Corneal Test
Courtesy The Cleveland Clinic
Courtesy The Cleveland Clinic
Oculocephalic Reflex
Oculovestibular Reflex
Courtesy The Cleveland Clinic
Gag Reflex
Courtesy The Cleveland Clinic
Pain Response
Courtesy The Cleveland Clinic
Hemodynamically stable
Ventilator adjusted for PaCO2 34-45 mmHg
Preoxygenate with 100% FiO2 for 10 min
Baseline ABG
PEEP of 5 cm of water
Oxygenate via suction catheter 6 L/min or T piece
Disconnect ventilator
Observe for respirations
ABG at 8 – 10 min
Reconnect ventilator
Courtesy The Cleveland Clinic
Positive Apnea Test
20 mmHg rise of CO2 above baseline or increase CO2
to 60 mmHg and no spontaneous respirations
When to abort test:
- Patient instability
- Respirations observed
1st exam performed at least 24 hours following CPR
or brain injury
Completed if clinical exam inconclusive or apnea test not
completed in its entirety
• Term newborns 37 weeks gestational age up to
30 days
Cerebral angiogram
EEG
Transcranial doppler
- 24 hour time interval between the 2 examinations
• 31 day to 18 year olds
- 12 hour time interval between the 2 examinations
• Non-recoverable, irreversible neurological
injury (or other end-stage disease process)
resulting in ventilator dependency
• Family makes determination to withdraw lifesustaining measures
• Medically suitable (determined by IDN)
• Patient likely to expire within 60 minutes of
extubation
Donation Huddles –
1. Determine next steps in plan of care
2. Determine registry status, legal NOK, family
dynamics, & needs of family
3. Identify right time, right place, and right person to
introduce donation to the family
Goal is to ensure healthcare team & IDN work together
to develop plan to discuss donation with family
• Attending physician continues to medically
manage patient
• RN accompanies patient to the OR and stays
during withdrawal of care process
• Withdraw of care occurs in the OR
• Recovery of organs occur only after patient
pronounced dead by primary care team
Iowa Donor Network serves as the hospital’s designated
requestor. CMS regulations require that a designated
requestor approaches families with the opportunity for
donation.
•
•
•
•
•
IDN speaks directly to the family
Family made aware of First Person Consent
Family is aware of donation opportunity
Family is provided information about the process
Family makes the best donation decision for them
after speaking to IDN
“This is _________.
He/She is part of our
end-of-life care team.”
IDN assumes financial and medical responsibility for the patient
once patient is declared & authorization for donation is obtained
Conversation with family:
1. Introduced as member of health-care team
2. Expression of condolences & conversation about loved one
3. Meaningful transition from conversation about loved one
and loss to the donation conversation
4. References to recipients & putting a “face” on those waiting
5. Use value-positive language
6. Utilize empowering offer of donation
Brain Death Physiology:
Brain Injury
Full code
Central venous access & arterial line placement
ABO testing, serology testing, clinical labs
Hourly vitals monitoring & I/O documentation
Chest xray, bronchoscopy, EKG, Echocardiogram, Cath
Antibiotic coverage
NG/OG
Height & Weight
Loss of thyroid
hormones
(T3 & T 4)
Catecholamine surge
followed by depletion of
catecholamines
Decline in serum cortisol,
antidiurectic hormone &
insulin
UNSTABLE
PATIENT!!
High Doses
of Vasopressors
Hormone Replacement Therapy:
Pre-medicate in rapid succession as follows:
• Helps to reduce vasopressors required
to maintain hemodynamic stability
• May reverse metabolic & hemodynamic
instability
• Stimulates aerobic metabolism
• Increases number of organs suitable for
transplant
•
•
•
•
1 amp 50% Dextrose IV push over 1-2 minutes
2 grams Solumedrol IV push over 4 minutes
20 units of regular insulin IV push
20 mcg T4 IV push
Start Infusion:
• Start continuous infusion at 25 ml/hr or 10 mcg/hr
• See IDN coordinator for T4 titration orders
• Allows continuous monitoring of
hemodyamics (BP, CO, SV, SVV) by connecting
to an arterial line
• Helps determine appropriate treatment
• Protocol that involves adjusting the ventilator,
managing fluids, and other activities to
increase lung viability
– Fluids versus pressors
Criteria: P/F ratio < 400
• Early bronchoscopy (no lavage)
• Pressure Control (total PIP of 40)
• PC 25
• Peep 15
• Adjust rate to keep PCO2 normal
•
•
After 2 hours:
•
•
•
•
•
Volume Control
VT 6-7 ml/kg (ideal body weight)
Peep 5
Adjust rate to keep PCO2 normal
Chest Xray 30 min later; Calculate P/F ratio
•
Organ recovery
takes place at donor
hospital
Local and possibly
out of state
surgeons
Normally 24-48
hours from consent
to recovery
What Happens in the OR
“In the final moment’s of Jason’s life, we were
praying for a miracle. We didn’t get the miracle
we were hoping for, but we got another one
that will bring so much joy to others. He will be
helping save, enhance and benefit so many
lives. That’s the ultimate miracle. By his selfless
decision, he can now live on in others,
continuing to do the work he was created for.”
Anesthesia
is present
to manage
and
ventilate
Recovering
surgeon
dissects to
isolate each
organ
Cannula is
placed in
abdominal
aorta &
portal vein
Aorta is
clamped and
preservation
solution
infused
Cross-Clamp
Heart
Lungs
Liver
Pancreas
Kidneys
Small
Intestine
Aortic Root
Portal Vein
Aorta distal to renal arteries
Eye
Heart Valve
Bone
Skin
Adipose Tissue
Saphenous
Veins &
Femoral Veins
Connective Tissue
Denovo cartlige
Fresh skin allograft
Structural bone grafts
Humacyte vascular graft
Initial Mailing at Time of Donation:
After donation phone call
• Donor Medallion Program
• ‘Donate Life’ lapel pins
• ‘Donate Life’ bracelets
1 week letter
1 month phone call
Additional Correspondence:
• Donor/Recipient correspondence
• Notice of donor family events
• Hand-embossing
• Quilts
6 month letter
1 year anniversary card
2 year Tissue Disposition
Allostem bone graft
Spinal cervical grafts
1. Refer all patients meeting clinical triggers within 2-4
hours to Iowa Donor Network
2. Collaborate with attending physician and IDN to
preserve donation opportunities with CBIGs
3. Introduce family to end-of-life decisions with
discretion and sensitivity, allowing IDN to discuss
donation opportunities with family
4. Sign-up on the donor registry to make your wishes
known and tell your family
Andrew Wilson
are the link between a potential
donor, who can offer hope, and the
recipients, who are waiting for a lifechanging gift.
Medicolegal Death Investigator
[email protected]
Main Office:
550 Madison Ave
North Liberty, IA
Regional Office:
320 Adventureland Dr NW
Altoona, IA 50009