To activate program press F5 key on your computer

To activate program press F5 key on your computer

BEST PRACTICES FOR ORGAN DONATION OVERVIEW OF THE DONATION PROCESS EXIT

OVERVIEW OF ORGAN DONATION OBJECTIVES • Delineate the three criteria required to qualify as a potential organ donor • Explain the importance of a team approach to family consent • Dispel myths and misinformation associated with donation • Provide a general understanding of the donation process EXIT

OVERVIEW OF ORGAN DONATION CONTENTS • The Nationwide Shortage • Factors Influencing Donation • Myths and Misinformation • Legislative Initiative • Identification and Referral Process • Consent Process • Overview of Donation Process EXIT

The Nationwide Shortage By the end of 2004, more than 87,000 people were waiting for an organ transplant. Of those, about 6,000 died waiting. The Centers for Medicare and Medicaid Services estimates that 15,000 people die each year who qualify as potential donors. Only about 4,500 actually become organ donors. Why are we missing 10,000 potential donors yearly when so many people are dying while waiting for organs? EXIT

Factors Influencing Organ Donation Identification and Referral Potential donors that are not identified and referred by doctors or nurses will fall through the cracks; TOSA will not know about them, and their families will miss an opportunity to bring some good out of tragedy. So, knowing how to identify potential donors directly affects the number of organs recovered and the number of lives lost each year. EXIT

Factors Influencing Organ Donation Maintenance: DNR/Disconnect When physicians speak with family members about DNR and disconnect from ventilator orders they should first consult TOSA. Many potential donors are lost because terminal patients are disconnected too early. The TOSA coordinator can evaluate the patient quickly and discreetly without undue stress on the family. If the patient could be a donor, then the person can receive hemodynamic support until the family can make a decision about donation. EXIT

Factors Influencing Organ Donation DelayedPronouncement of brain death A cascade of organ failure begins at the time of brain death. Physicians who do not recognize and pronounce brain death rapidly and involve TOSA reduce the possibility that a brain dead patient can donate organs. Many times brain dead patients are lost because they suffer cardiac arrest before being referred or the organs are too deteriorated to be transplanted. When a patient meets brain death criteria TOSA must be notified immediately. Delayed brain death pronouncement can be prevented if the nurse notifies TOSA early. We will then discreetly follow the patient and urge the attending MD to pronounce brain death at an appropriate time. EXIT

Factors Influencing Organ Donation Family Refusal – (1) There are a myriad of reasons why a family might decline organ donation. Here we will deal with the most prevalent. EXIT

Factors Influencing Organ Donation Family Refusal – (2) Setting: The family should be approached in proper surroundings. The ideal setting is a quiet, private area, near but out of the ICU. This allows the family to be calm and think about what is being said to them, and a private area maintains confidentiality. Speaking to the family over the dead patient’s bed is disrespectful and unacceptable.

Factors Influencing Organ Donation Family Refusal – (3) Decoupling: The act of approaching a family for organ donation must be done in the appropriate time, with due respect for their loss. They must be given time to adjust to the loss of their loved one. Thus, two separate conversations should occur with the family. The first should involve the MD and his explanation that their loved one has died. Some time should be given the family to adjust to this horrific news. Then an appropriately trained representative from TOSA can approach the family at a later time, when they are ready to talk about their next step. EXIT

Factors Influencing Organ Donation Family Refusal – (4) Misinformation/Myths: Many myths exist about organ donation. The fact is, that organ donation provides a positive event to grieving families and saves lives of thousand of people. EXIT

LEGISLATIVE INTIATIVE On 21 August 1998 the Center for Medicare and Medicaid Services (CMS) established Federal Regulation 482.45, known as Conditions of Participation for Medicare Reimbursement (CoP). The sole purpose was to increase the number of potential organ donors reported to local Organ Procurement Organizations (OPO). It states that hospitals are required to notify their OPO of all deaths and imminent deaths in a “timely manner.” It also requires hospitals to have an agreement with at least one OPO, tissue and eye bank. The CoP relieves the bedside nurse and the physician of any responsibility to speak to families about organ donation. The OPO is now responsible for evaluating each patient referred to them and approaching the family for consent. EXIT

LEGISLATIVE INTIATIVE What About Patient Confidentiality? The issue of confidentiality is addressed in the Texas Health and Safety Act 241.153 (5). This law allows confidential patient information to be released to members of an OPO so long as it is for the purpose of determining suitability for organ donation. (For more Information: www.law.uh.edu) EXIT

Am I Violating HIPAA Rules? According to US Dept. of Health and Human Services’ Summary of the HIPAA Privacy Rule, “Covered entities may use or disclose protected health information to facilitate the donation and transplantation of cadaveric organs, eyes, and tissue.” (for more information: www.hhs.gov/ocr/hipaa)

Identifying a Potential Donor • Organ donors must be maintained on a ventilator to keep life-saving organs oxygenated. • The Glasgow Coma Scale must be ≤ 5 • There must be a neurological insult These are the criteria for “imminent death” (remember CoP requires that the OPO be notified of all imminent deaths) and are all that is required to refer a patient as a potential organ donor. EXIT

Identifying a Potential Donor Here’s a list of some types of patients who may become donors: • gunshot wound • motor vehicle accident with closed/open head injuries • cerebro-vascular accident • drug overdose • anoxic injury • hanging • drowning • cardiac arrest • primary brain tumor without mets EXIT

Referral Process Once the ICU nurse has identified a potential donor the next step is to call the donor referral line. In the ER & ICU, this toll-free number is located on or near your telephones and looks like this: The number is also located on the “death notification” sheet on file on every unit. There are two times the nurse must call this number. First is when the potential donor is identified, second is when any patient has a cardiac death (even if the pt has already been referred as a potential organ donor). EXIT

Referral Process Referring a patient does not mean they will become a donor. TOSA will quietly follow this patient daily. The family will not be spoken to until the referred patient is declared brain dead or the family mentions organ donation. If the patient improves or is ruled out by a coordinator, TOSA will close out the referral without speaking to the family. EXIT

Referral Process Remember that all patients that meet the previously mentioned criteria should be called to the donor referral line, regardless of their age, or condition. Criteria for organ donation change frequently, so someone who is ruled out today may be able to be an organ donor tomorrow. If you or an MD rule out a patient for donation, you may inadvertently prevent a family from finding comfort in the loss of a loved-one and you may prevent a dying patient from receiving a life-extending transplant. There are no exceptions to these criteria. CALL IN ALL DEAD AND IMMINENTLY DEAD PATIENTS. It is the responsibility of the OPO to rule out potential donors EXIT

Referral Process An operator will answer the donor referral line and will request the following information: • Caller’s name, hospital, unit, & call back number • Patient’s age, sex, race, diagnosis / cause of death, admission date / time, ventilator status Once this information has been recorded, the appropriate coordinator will be paged by the donor referral operator. EXIT

Referral Process After the organ recovery coordinator (ORC) has been briefed by the operator you will receive a call. The ORC will want to know the following information: • Neurological status (specifically brainstem reflexes) and any brain death testing that may have been done. • Hemodynamic status • Vasopressors & other drips • Lab work (especially kidney & liver labs) • Medical / social history EXIT

Referral Process As the patient’s nurse it is good practice to call the donor referral line with significant updates. If the patient is near brain death, the ORC may remain in the unit and consult with the patient’s attending MD, and coordinate brain death declaration. At no time should the family be spoken to about donation. If a family member mentions donation, the nurse can offer to introduce them to an ORC. EXIT

Consent Process DECOUPLING (1) Once the patient has been declared brain dead, the physician should speak with the family. His duty now is to inform the family of the death of their loved-one. It is helpful if the MD explains brain death to the family. They will want to know why their loved-one still has a heart beat if he/she is dead. The nurse should be prepared to explain the concept of brain death if the MD has not done this. (Brain death is explained in detail in our next CEU offering). There is no need to mention organ donation now. If donation is mentioned at this time the average consent rate is 47%. If donation is mentioned later the consent rate is 71%. EXIT

Consent Process DECOUPLING (2) Allow the family to see their loved-one and grieve. Support them and provide for their needs as best you can. It may be helpful to consult with Social Services or a Chaplain. When the family begins to speak of their loved-one in past tense, ask you what is next, or talk about funeral arrangements you may then introduce the ORC to them. Most people are very fragile at this time, so simply tell the family that the ORC is a nurse that has come to discuss some end of life options. EXIT

Consent Process DECOUPLING (3) This is a time when a team effort is most important. If a hospital staff member alone approaches a family member about organ donation the consent rate is about 37%. If the ORC approaches alone, consent occurs about 67% of the time. But as a team effort with a staff member and the ORC the consent rate is as high as 75%. EXIT

Consent Process Informed Consent (1) It is important that the person asking the family for permission to recover organs also be able to answer any questions they may have. They often have questions that require an intimate knowledge of brain death and the entire donation process. The requestor must also possess a belief that organ donation is beneficial to the family, and have the experience and time to work with them. All of these traits and knowledge are necessary to provide an informed consent. EXIT

Consent Process Informed Consent (2) Once the family has decided that they would like to donate, a detailed consent form is read to them. They can consent or decline each individual organ. They will be asked about tissue and eye donation at this time as well. The organs they will be asked to donate can include: Kidneys, Liver, Heart, Lungs, Pancreas and Small Bowel. The family is also asked for specific vessels and permission for research. The family is informed of specific viral and serum testing that will be performed. The ORC will also ask about funeral arrangements and will assure the family that the body will be cared for with the utmost respect, just as with any living person. EXIT

Consent Process Medical / Social History After consent is obtained, the ORC will ask the family to remain a short time to answer some very specific questions relating to medical and social history. These questions are to be answered to the best of their ability. If the family is aware of anyone who may know more detailed information about the donor, they are asked to identify them and allow TOSA to question them in the same manner. The purpose of such intrusive questioning is to ensure that the donor’s organs are as safe and free of disease as possible before beginning the organ retrieval process. EXIT

Overview of Donation Process Account Change Once written consent has been obtained the ORC will request that the donor’s account number be changed. This is done differently in each hospital. However, the procedure usually involves a clerk or nurse notifying admissions that the patient is now a donor and the account number is physically changed to ensure that all future billing goes to TOSA. The purpose of this change is to avoid bills related to organ donation going to the family or their insurance. EXIT

Overview of Donation Process Donor Management Management of the donor is now taken over by TOSA. The ORC will write a new set of orders just as if the patient was newly admitted to the ICU. The focus of care now shifts from one of saving a single life to preserving organs that will eventually save many lives. The process of evaluating organs and optimizing their function will take an average of 12 – 24 hours. In some situations it may be even longer if there is difficulty in optimizing organ function. EXIT

Overview of Donation Process DONOR MANAGEMENT Many lab tests will be run, lines are placed, a CXR is done, and protocols are followed to optimize organ function. Depending upon what organs are being recovered, an EKG, echocardiogram, cardiac catheterization, bronchoscopy, and even a bedside liver biopsy may be needed. These patients are very busy and TOSA recommends a one-on-one nursing assignment to the donor. In a later CEU offering we will review donor management in great detail. EXIT

Overview of Donation Process Organ Placement (1) Simultaneous to the donor management process is the organ placement process. A second ORC is called in to notify the United Network for Organ Sharing (UNOS) of the donor’s age, sex, height, weight, and blood group. UNOS will respond with a list of the sickest local patients that match the donor. The ORC will begin at the top of this list notifying an Organ Transplant Coordinator (OTC) of the status of this donor. EXIT

Overview of Donation Process Organ Placement (2) The OTC will notify his transplant surgeon and the surgeon will notify the potential recipient. If there is a problem with the recipient, or the surgeon declines the organ this process begins again with the next person on the UNOS list. Each call may take an hour and several call may need to be made before a suitable recipient is found. If the local list is exhausted, then a regional list is generated that covers Texas, Oklahoma, Louisiana, and New Mexico. If this list is exhausted then TOSA will begin placement on a national level. EXIT

Overview of Donation Process Organ Placement (3) Once the organs are placed the ORC must arrange ground transport for the arriving surgical teams. The OR was notified early on that an organ recovery is imminent. Now the ORC will arrange an equitable OR time that works for the OR, ICU, and arriving surgical teams. EXIT

Overview of Donation Process Organ Placement (4) With the exception of the liver and kidney team, each organ will have its own team of up to five people. There may even be two teams for the lungs. If all organs are placed there could be as many as five teams with five people in each team… 25 people in addition to the OR staff and the two ORC’s. Coordination, cooperation and communication is of utmost importance at all times…people’s lives depend on it! EXIT

Overview of Donation Process After Organ Recovery After the organs have been recovered, anatomy verified and documented, packaged and transported out of the host hospital, the ORC’s will offer to assist with post mortem care. The donor will have been closed by the liver/kidney team. The ORC will then notify either the Medical Examiner or the Funeral Home that the body is ready to be retrieved. An ORC will remain with the body until it is taken to the morgue or a transport service takes it away. A few days after the donation, a hospital development coordinator will deliver surveys to the participating hospital staff. A post donor conference may also be held if necessary. This is to allow hospital staff an opportunity to ask questions and or make comments about the case. It is also a time for staff to express their feelings about the case. Fourteen to thirty days after the recovery, letters will be sent to the family and all hospital staff that participated in the donation. Information regarding the recipients will be given with due regard to confidentiality. EXIT

Overview of Donation Process Value of the Nurse It is important to recognize the value of the nurse in this life preserving endeavor. If that one nurse who recognized that this patient met referral criteria did not call the donor referral line, none of this would happen. It is recognition and referral that are the keys to successful organ donation, and the nurse holds these keys. Additionally, the ICU nurse’s opinions and suggestions during the management phase are of immeasurable value. A skilled and dedicated OR staff make the recovery process flow smoothly. Without them, organ recovery would be impossible. We at TOSA recognize the importance of nurses and want to thank you on behalf of every transplant recipient who ever received (or will receive) an organ from your donor. EXIT

Thank You EXIT

To activate program press F5 key on your computer