A Priority Approach to Maximizing the Gift from Donation After Cardiac Death

1. A Priority Approach to Maximizing the Gift from Donation After Cardiac Death Martin D. Jendrisak, MD, FACS Medical Director Gift of Hope Organ and Tissue Donor Network

2. SRTR Data

5. Donation Stats as of July 15, 2011

6. Transplant Partners Gift of Hope 180 Donor Hospitals 9 Transplant Centers DSA of 12 Million Referral Transplant Consent Management Recovery Allocation

7. Catastrophic Neurologic Injury Evaluation and Treatment in the Critical Care Setting • Clinical Trigger to donation Referral • Donation option is part of end of life care planning • Ensures this option is not denied to families • Timely notification of OPO is critical to process • Futility of Continuation of Care • Establish by health care providers • Family understanding and acceptance Death Determination

8. Death Determination • By Neurologic Criteria (DBD) • Cessation of all brain activity (brain death) • Clinically established • Confirmatory testing when indicated • By Circulatory – Respiratory Criteria (DCD) • Permanent absence of circulation and respiration • Hospital DCD policy followed

9. IOM Committee Recommendation: 2006 DNDD – Donation after a neurological determination of death DCDD – Donation after a circulatory determination of death

10. Brain Death Determination Yes No ME/Coroner Notification - Hospital Decision & Planning for Withdrawal of Care Consent for Donation Consent for Donation Yes No ME/Coroner Release - GOH ME/Coroner Release - GOH Withdrawal of Care Death Pronouncement Yes No Implement DCD Protocol: Time Critical ME/Coroner Notification - Hospital Implement donor management protocols Donor Testing Organ Evaluation Organ Allocation Coordinate Surgical Recovery OR Access

12. Donor Management Requires a Collaborative Approach between OPO and Donor Hospital Staff • Phases: • Identification • Referral & Initial Evaluation • Management of the Potential Donor • Brain Death and Consent • Donor Management • Special Interventions • Organ Specific Testing and Assessment

13. De-escalation of Care Definition: Strategic reduction in the level of care in the setting of patient non-recovery Examples: Withhold or reduce vasopressor support, transfusions, fluid and electrolyte resuscitation, pulmonary care, laboratory monitoring, etc. Consequence on Donation: Renders organs not transplantable Per CMS and Contractual Obligation: Hospitals and providers must provide adequate medical support to give families the option for organ donation. Best Practice: (1) Early contact with GOH and (2) Provide full medical care until GOH determines non-donor status.

14. Donor Management - Goals • Optimize Organ Viability • Proper Assessment of Organ Quality • Maximize Organ Utilization • Optimize Outcomes of Transplantation

15. Consequences of the Pathophysiology of Brain Death • Myocardial Dysfunction • Hemodynamic Instability • Neurogenic Pulmonary Edema • Diabetes Insipidus • Organ Dysfunction

16. Detrimental Physiological Effects of Brain Death • Hemodynamic: • “Catecholamine storm” • Cardiac dysfunction • Increase SVR • Capillary alveolar membrane damage • Hormonal • Endocrinopathy • Pituitary – ADH, TSH, ACTH • Immunologic • Activation of inflammatory mediators • IL-6, IL-10, ??? • Upregulated HLA Class II Expression • Upregulated Expression of Adhesion Molecules

17. GIK Study

18. Plexmark Study

19. Cytokine Response to Steroids in DBD

20. DCD PROCESS • OPO evaluates donation candidacy • OPO coordinates organ procurement/allocation • Patient care team withdraws support, provides comfort measures and pronounces death • Organ recovery initiated after death – time critical • Adherence to “Dead Donor Rule” • Organ can be recovered only after death • Organ recovery process does not hasten death

21. DCD • 90 minute time limit • Warm ischemia limits transplant opportunity • Kidneys – generally transplanted • Liver, lungs, pancreas maybe transplanted if organ flush within 20 minutes and donor age<40 • DCD evaluation tool

22. Donation After Cardiac Death Tool

23. Donation After Cardiac Death Tool

24. DCD TOOL LIMITATIONS • 80% positive predictive value • 20% donors missed • Focused on uncertainty of the DCD process • Clinician input may add complexity to the decision process

25. DCD PRACTICE CHANGE • Started 3/1/2010 • Omit DCD tool • Omit reliance on clinician prediction ability • Pursue all opportunities • Potential for transplantable organs • Maximize the gift • Family driven • Monitor practice through data analysis

28. Conclusions • New DCD Practice Paradigm Maximizes The Gift • No missed donor opportunity • 20% increase in donation with transplantable organs • Meet donor/family wishes 100% of time • Demand On Donation Resources Acceptable • Identifies/excludes futile efforts (age>60)

29. Conclusions (Cont’d) • Adds Clarity About DCD Process/Manages Expectations • 2 out of 3 attempts (on average), transplantable organs are recovered • 3 out of 4 actual donors expire under 20 minutes to permit extra-renal organ recover/transplantation • Clarity of message benefits family/staff