Declaration of Death

1. Declaration of Death Nancy W. Knudsen, MD September 25, 2013 Stand in: Glen A Franklin, MD

2. “In this world nothing can be said to be certain, except death and taxes.”

3. DCD complicates things

4. Definition of Death • Irreversible cessation of respiratory and circulatory function • Attending physician or designee not associated with the donation or transplant team declares death • Note declaring death written in patient’s chart • The declaration of death follows the guidelines set forth by the IOM • Cessation of cardiac function for 2-5 minutes • Confirmed by ECG tracing or arterial monitoring

5. National Guidelines for Death Determination • Death determined by absence of circulation by ICU physician or designee • Note written in chart • The declaration of death follows IOM guidelines: • Cessation of cardiac function for 2-5 minutes • Confirmed by absence of arterial line tracing or EKG tracing

6. Uncertainty with Declaration of Death • Who can declare death • State Law • Hospital policy • What setting • How do we determine cessation • How long to wait from declaration to procurement

7. I know my state law.. • Yes • No

8. Problems with Declaration and DCD • Cast of characters constantly changing • Rare • Personal belief and bias • Time crunch • Unsure of roles and goals • Stress

9. Death is stressful for everyone When we are emotionally upset we say we "just can't think straight". This is because unmanaged stress shuts much of the thinking brain down. Accompanying this are heart and brain patterns that create chaos in our brain's ability to process information. http://education.jhu.edu/PD/newhorizons/strategies/topics/Keeping%20Fit%20for%20Learning/stress.html

10. Huddle Prior to OR – Take a Deep Breath • Make sure everyone knows hospital policy • Roles are established, confirmed; walk through • Opportunity for concerns to be discussed from either hospital, ICU, OR, OPO staff or family • Review goal of maximizing gift of donation by minimizing warm ischemia

11. I know my hospital policy.. • Yes • No

12. In OR – Calm Environment • ICU team runs the show-focus on patient • Withdrawal of life sustaining therapy (LST) • Declaration of death • OPO personnel • Record hemodynamics, Follow hospital policy • Family may be present • Recovery teams • May prep and drape prior, In another room for withdrawal of LST

13. Optimizing the Gift • Withdrawal of LST as close to OR as possible • Time limit varies per patient hemodynamics and accepting transplant surgeon • 30 minutes to 1.5 hours • Heparin 300 units/kg IV push at the time of patient decompensation SBP<80 mmHg, SaO2<80%

14. Standardizing Practice for Best Outcome • Where to withdraw • ICU, PACU, OR • Family • Where to say goodbye • Use of extracorporeal support allows time • Minimize rush after declaration • Prep and drape prior to withdrawal of LST • Pre mortem placement of catheters for flushing

15. Challenges to DCD – Not One Size Fits All • Family • May/may not want to be present • Support them • Hospital Staff • Policy may be ICU or out of OR due to resource • OPO • Coordinating lot of moving balls • Gift • How to honor wishes with low WIT in each hospital

16. Withdrawal of LST in OR Pt/Family Comfort Standardize Process