Organ, Tissue, and Eye Donation The Bridge to Life

1. Organ, Tissue, and Eye DonationThe Bridge to Life Keith Rischer RN, MA, CEN

2. Today’s Objectives… • Discuss the current ethical issues surrounding organ donation and transplantation. • Discuss the steps required in the organ procurement process. • State the criteria for selecting a transplant recipient. • Describe the criteria required to establish brain death. • Compare and contrast the organ procurement process for donation after brain death vs. cardiac death. • State the interventions necessary to prevent organ rejection.

3. Ethical Issues Regarding Transplant • Definition of death • Respect for the dead • Organs for sale

4. The Growing Need Organ Donors vs Wait Listed Patients *Based on OPTN data through March 31, 2008 www.OPTN.org

5. We believe that lifeis a gift to share We pledge to provide the bridge between the loss of life and the gift of life Through organ & tissue donation & transplantation.

6. LifeSource Service Area • Duluth ND • MN Bismarck Fargo Douglas County Saint Paul office St. Croix County SD Pierce County WI Rochester • Rapid City Sioux Falls

7. What organs & tissues can be donated? Corneas (1905) Heart/Heart Valves (first fresh valve – 1955) (first heart – 1967) Lungs (1963) Liver (1963) Kidneys (1954) Pancreas (1969) Intestines (1987) Skin (1822) Bone/Connective Tissues (1668) Blood Vessels (1955)

8. Overview of the Donation Process Identification Referral Family Approach – team huddle Assessment and Donor Management Allocation – UNOS Recovery Family Follow-Up

9. “The process of donation begins……… with the incident causing the death and continues through the bereavement. Every health care professional who interacts with the family is part of the process, and every step impacts on the family’s ultimate decisions regarding donation.” Margaret B. Coolican, RN, MS, CDE National Donor Family Council

10. The Identification Process • Call 1-800-24-SHARE (1-800-247-4273) • Donation is not mentioned to the family prior to making the referral call. • Clinical Trigger Card – quick process reference • Refer all patients within one hour • Call is mandated, you do not need permission to call

11. The Process: Legislative Initiatives HCFA (Health Care Financing Administration), 1998 Name changed to Centers for Medicare and Medicaid Services (CMS) 2001 Call 1-800-24-SHARE on ALL deaths. There are no exclusions. Approach of a potential donor’s family must be done by a procurement organization representative or an individual trained by the procurement organization.

12. Donor Designation Donor designation is the practice of ensuring that an individual’s documented wishes about donation are fulfilled. “giving the donor a voice”

13. Decisions are made with respect to personal choice (Informed and Voluntary) Autonomy

14. Clinical Triggers for Donation Imminent Brain Death Ventilated Severe neurologic injury Loss of two or more brain stem reflexes Pupillary Corneal Oculocephalic / Dolls eyes Oculovestibular / Cold calorics Oropharyngeal

15. Potential Organ Donor Referral Devastating Brain Injury / Ventilator Dependent Donation after Brain Death Donation after Cardiac Death BRAIN DEATH EXAMINATION Exam c/w brain death Death determined by neuro criteria Exam Notc/w brain death Donation discussed with family (LifeSource) • Family/MD initiate topic W/D med treatment • LifeSource Coord discussion with family • Family supportive of donation Patient supported during organ evaluation & allocation Patient evaluated as potential DCD candidate • Withdrawal of support • Pronouncement of death • Surgical recovery Surgical recovery

16. Brain Death Definition: Complete and total cessation of all brain function, including the brain stem. Causes: Intracerebral hemorrhage Head trauma Anoxia Brain tumor

17. Brain Death Testing Confirmatory Testing Cerebral angiogram EEG Cerebral blood flow Observation period • Clinical Exam • Absent brain stem reflexes • No motor response to pain • Apnea

18. Family Communication: Brain Death Patient looks alive Heart is beating Chest is moving Patient is warm Patient’s skin has color No outward evidence

19. Phrases to Avoid Harvest Life support One chance in a million Keep alive until donation Only a miracle can save him now

20. Family Understanding Families who donate and families who do not donate voice similar understandings of brain death; however, Upon closer questioning, families who do not donate had a much less accurate understanding of brain death. Franz et al. “Explaining Brain Death: A Critical Feature of the Donation Process,” Journal of Transplant Coordination 7 (1):14-21, March 1997.

21. Nurse’s Key Donation Roles Facilitate the identification and referral process The Physician’s key role is to help the family understand brain death. The LifeSource Donation Coordinator’s key role is to help the family understand donation options.

22. Organ Donor Assessment Past & current medical/social history Laboratory assessment General and organ specific blood work Serological studies Cultures Physical assessment 12-lead EKG, echo, angiogram CXR, bronchoscopy

23. Organ Donor Management Begins after brain death with donor designation or family authorization Extensive testing to determine organ function Monitoring and responding to rapid clinical changes Optimizing hemodynamic status IV access Triple lumen central line Peripheral IV Arterial line

24. Assessment/Management Goals Goal: Adequate organ perfusion SBP normal value for age HR normal value for age UO 1-2 cc/Kg/hr Final PaO2 >350 CVP 4-8 (mmHg) Normothermia

25. Organ Matching (allocation) DonorInformation RecipientInformation United Network for Organ Sharing (UNOS) • Blood type • Size • Severity of illness • Wait time

26. Recovery done at donor hospital Surgeons from transplant centers LifeSource preservationist When are we going to the OR? Procurement Surgery

27. Organ donation after the cessation of all cardiopulmonary function (cardiac death) rather than organ donation after the cessation of all brain function (brain death). Donation After Cardiac Death

28. Potential Organ Donor Referral Devastating Brain Injury / Ventilator Dependent Donation after Brain Death Donation after Cardiac Death BRAIN DEATH EXAMINATION Exam c/w brain death Death determined by neuro criteria Exam Notc/w brain death Donation discussed with family (LifeSource) • Family/MD initiate topic W/D med treatment • LifeSource Coord discussion with family • Family supportive of donation Patient supported during organ evaluation & allocation Patient evaluated as potential DCD candidate • Withdrawal of support • Pronouncement of death • Surgical recovery Surgical recovery

29. When Patient is a Potential Tissue and/or Eye Donor LifeSource Tissue Services or Minnesota Lions Eye Bank Donation Coordinators will work with you: To assess the patient’s donation opportunities Plan the family connection

30. Corneal Transplantation • Regional anesthesia – outpt procedure • Donor corneal graft sutured into place • Postop • Antibiotic ointment, pressure patch, shield • Lie on non-operative side to decrease intraocular pressure • Watch for rejection: cloudy cornea, reduced vision • Potential eye donor at time of death • Head of Bed 30 degrees • Antibiotic drops • Close eyes and small ice pack • Discuss eye donation with family

31. Criteria for Selection for Organ Recipient • Life expectancy of less than 1 year • Age generally less than 65 years old • Absence of active infection • Stable psychological status • No evidence of drug or alcohol abuse • Ability to follow instructions regarding meds and self care • Cardiac – • New York Heart Association class III or IV • Normal of slightly increased pulmonary vascular resistance

32. Heart Transplantation Comparable body weight and ABP compatibility into recipient less than 6 hours after procurement Posterior wall of recipient atria left anchor the donor heart Watch carefully for concealed postop bleeding Transplanted heart is denervated and unresponsive to vagal stimulation (HR about 100). Responds slowly to exercise or position change 75% survival after 3 years To detect rejection – endomyocardial biopsies

33. Complications • Infections • Rejections • Hyperacute: remove organ • Acute: Increased immunosuppressives • Chronic: conservative management • Hemorrhage • Fluid and electrolyte imbalances • Pulmonary atelectasis

34. Family follow-up Donor Family Services Provides • Ongoing Support • Family Connection newsletter • Holiday booklet • Communication between donor families and recipients • Local donor family quilt A Bereavement Book is given to families at the time of their loved one’s death