Donor Identification and Referral

1. Donor Identification and Referral Dr Huw Twamley 21st May 2013 NORTH WEST 1

2. Session Objectives 2 • Understand difficulties with donor identification and referral • Recognise benefits of improving elements of the process • Increased identification and referral • Timely referral • Responsiveness to referral • Consider which of the proposed methods of identification and referral may work in your hospital Organ Donation Past, Present and Future

3. Regional Data NORTH WEST 3

4. 100 98 97 95 95 93 91 89 89 88 87 86 80 84 60 Referral rate (%) 40 20 0 North South South South South Eastern London Midlands Northern Scotland Yorkshire Northern East West West Wales Ireland Central Team -------- National rate DBD referral rate 5th NORTH WEST 1 April 2012 to 31 March 2013, data as at 4 April 2013 4 Organ Donation Past, Present and Future

5. 100 19 25 14 10 21 3 29 5 24 28 8 17 30 22 11 20 4 31 15 1 13 9 12 26 16 32 23 7 80 6 60 Referral rate (%) 2 33 27 40 20 0 18 0 10 20 30 Number of neurological death suspected patients Hospital National rate 95% Lower CL 95% Upper CL 99.8% Lower CL 99.8% Upper CL North West DBD referral rate 1 April 2012 to 31 March 2013, data as at 4 April 2013 5 Organ Donation Past, Present and Future

6. 100 80 81 80 72 72 65 60 60 59 Referral rate (%) 56 54 54 52 40 42 20 0 North South South South South Eastern London Northern Scotland Midlands Northern Yorkshire East West West Wales Ireland Central Team -------- National rate DCD referral rate NORTH WEST Tied 3rd 1 April 2012 to 31 March 2013, data as at 4 April 2013 6 Organ Donation Past, Present and Future

7. 100 18 16 22 20 17 25 5 26 15 80 33 30 31 19 12 23 32 4 1 11 21 60 13 3 8 6 24 Referral rate (%) 14 9 40 7 28 20 2 29 27 0 10 0 10 20 30 40 50 60 70 80 Number of imminent death anticipated patients Hospital National rate 95% Lower CL 95% Upper CL 99.8% Lower CL 99.8% Upper CL North West DCD referral rate 7 Organ Donation Past, Present and Future

8. Timely Identification and Referral of Potential Organ Donors Huw Twamley Regional CLOD North West Region Organ Donation Past, Present and Future

9. UK rates of referral 91% 52% Organ Donation Past, Present and Future

10. Cause of death in MC III DCD donors • UK Potential Donor Audit (October 2009 – March 2012) • 7504 patients referred as potential DCD donors • 877 actual DCD donors

11. Potential Donor • 83 year old • PEA Out of hospital cardiac arrest • “Downtime” 15-20 minutes • Hypoxic brain injury • Known Hypertensive • Urea 16.4 Creat 94 • Prev Basal cell Carcinoma

12. Overall timings Organ Donation Past, Present and Future

13. Aims of Strategy • 100% Identification of potential Donors • 100% Referral of Potential Donors • 100% Timely Referral • Implement NICE Guidance The consideration of donation should be core ICU / ED and part of all end of life care plans. Timely referral promotes this possibility Organ Donation Past, Present and Future

14. NICE Guideline 135 Organ Donation Past, Present and Future

15. British Medical Association 2012 The research data -------- showed that the use of clinical triggers and a requirement to refer according to standard criteria led to an increase in both referrals and donors. It is hoped that implementation of the NICE guideline will result in early and consistent donor referral. Organ Donation Past, Present and Future

16. General Medical Council 2010 I”f a patient is close to death and their views cannot be determined, you should be prepared to explore with those close to them whether they had expressed any views about organ or tissue donation, if donation is likely to be a possibility.” “You should follow any national procedures for identifying potential organ donors and, in appropriate cases, for notifying the local transplant coordinator.” Decisions to limit or withdraw treatments in potential DCD donors MUST be in compliance with national End of Life Care policy. Organ Donation Past, Present and Future

17. UK Donation Ethics Committee “There is no ethical dilemma if the treating clinician wishes to make contact with the SN-OD at an early stage, while the patient is seriously ill and death is likely, but before a formal decision has been made to withdraw life-sustaining treatment.” [“Benefits] include establishing whether there are contra-indications for organ donation…… Other practical and organisational factors might be relevant – if the SN-OD is based at a distant location then early contact can help to minimise distressing delays for the family.” Organ Donation Past, Present and Future

18. Objectives, benefits and outcomes All potential donors are identified and referred All patients are given the option of donation Access to clinical advice Prompt donor optimisation Resolution of potential legal obstacles Early assessment of marginal donors Early tissue typing / screening Planning the family approach Reduction in delays for families and units All donors are referred in a timely fashion SN-ODs are deployed in a way that improves responsiveness Increased donor numbers Improved consent / authorisation rates Increase in donor organs Better experience for families and staff Organ Donation Past, Present and Future

19. NHSBT Strategy Implementation not publication Key area for collaboration between hospitals and donor care teams Very clear emphasis on benefits How not who Suite of options Clarity over implementation Organ Donation Past, Present and Future

20. Strategy proposals Every hospital should have a written policy for the identification and timely referral of all potential donors Every donating area within a given hospital adopts a consistent approach As far as possible ‘decouple’ early referral from individual clinician Donation Committees and SN-OD teams should collaborate to develop and implement a policy that ensures that all potential donors are identified and referred in a timely fashion. Organ Donation Past, Present and Future

21. 1. Daily visit by SN-OD Organ Donation Past, Present and Future

22. 2. Early daily phone call Organ Donation Past, Present and Future

23. 3. Daily ICU team safety brief Organ Donation Past, Present and Future

24. North Bristol Trust ICU Safety Brief Organ Donation Past, Present and Future

25. 4. Standard Operating Procedure Organ Donation Past, Present and Future

26. Midlands Standard Operating Procedure Organ Donation Past, Present and Future

27. 5. Nurse led referrals Organ Donation Past, Present and Future

28. Summary 28 Organ Donation Past, Present and Future Donation should be a element of end of life care Make identification and referral routine business of the unit. This decouples early referral from the individual clinician caring for the patient Implement or develop a solutions /policy for your individual hospitals adopt to timely referral Ensure consistency within a given hospital

29. 29 Organ Donation Past, Present and Future

30. What are the barriers to implementing the NICE guidelines in your unit? Any solutiions? • Whichever is the earlier, either: • Use trigger factors in patients with a catastrophic brain injury • The absence of one or more cranial nerve reflexes • AND a GCS of 4 or less that is not explained by sedation • And / or a decision is made to perform brainstem death tests. • The intention to withdraw life-sustaining treatment in patients with a life-threatening or life-limiting condition which will, or is expected to, result in circulatory death. 30 Organ Donation Past, Present and Future