Predicting DCD Viability in Catastrophic Neurologic Disease

Transcription

1 Predicting DCD Viability in Catastrophic Neurologic Disease!! Determining which clinical factors prior to withdrawal of life sustaining measures are associated with earlier time to death Design: Retrospective multivariate analysis of 149 neurocritical care patients undergoing withdrawal of life support Setting: Single center, NICU Mayo Rochester Comparison: 75 patients who died < 60 minutes vs. 74 patients who died > 60 minutes Yee 2010

2 !! Findings: Predicting DCD Viability in Catastrophic Neurologic Disease!! These four factors predicted death within 60 minutes!! All 4 factors present 93% chance!! 3 of the 4 factors present 85% chance Absent corneal reflex Absent cough reflex Extensor response or no motor response to painful stimuli Oxygenation index (OI) > 4.2 with OI = F i O 2 * MAP/P a O 2 Yee 2010

3 Predicting Viability for DCD!!Ability to predict death within minutes Study design: Prospective observational multicenter study of all potential DCD donors in Netherlands Method: Multivariable logistic regression analysis Factors It is associated not possible with death to reliably within identify minutes: potential DCD donors!! Mechanical and a ventilation, donation use procedure of norepinephrine, should ine, be absence initiated of reflexes, neurologic for every deficit potential as cause donor of death, absence of cardiovascular comorbidity!! Use of analgesics, sedatives did not significantly influence moment of death!! Clinical judgment of intensivist predicted death within minutes!! sensitivity 73% and 89% and specificity 56% and 25% Wind 2012

4 CTDN Contraindications to Organ Donation Absolute Creutzfeldt-Jakob disease and other neurodegenerative diseases associated with infectious agents HIV disease Metastatic cancer Melanoma Age >80 (organs) Age >90 (tissue) Relative Treated cancer within 3 years of donation (except nonmelanomatous skin cancer and in situ cervical cancer) Leukemia or Lymphoma Prommer 2014; Neidlinger, personal communication

5 General Indications for Notifying OPO!! Cases of clinical brain death!! Severely brain-injured patients (includes anoxic injury)!! Glasgow coma scale (GCS) < 5!! Plans to discontinue mechanical or pharmacologic support!! Situations where family request information about organ or tissue donation!! All Death possibly eligible for tissue donation (call within 1 hour of death)!! Note: Coroner cases are not criteria for exclusion

6 Palliative Care Needs

7 Palliative Care!! Communication around sensitive issues!! Experience with end-of-life care!! Focus of care includes supporting family and surrogates!! Holistic focus on multiple domains of care including psychosocial and spiritual issues!! Expert symptom management!! Potential bereavement support

8 Need for Palliative Care!! Substantial psychiatric morbidity among families of ICU patients Design: Surrogate decision-makers for 289 ICU patients Setting: 21 hospitals in France Measurement: Validated instrument assessing PTSD symptoms, HADS, 36-item General Health Survey Findings:!! 33% had symptoms of post-traumatic stress at 3 months!! Higher rates among family members!! Felt information provided was incomplete!! Shared in decision-making!! Relative died in the ICU!! Relative died after end-of-life decisions!! Shared in end-of-life decision-making Azoulay 2005

9 Need for Palliative Care!! Traumatic memories of relatives regarding brain death, request for organ donation and interactions in the ICU Design: Qualitative study of relatives of patients who had died of brain death and were approached regarding organ donation Setting: Switzerland Method: In-person interviews 5-17 months after death (mean 11 mos) 40 relatives of 33 brain-dead individuals 31 consented to donation 9 declined donation Kesselring 2007

10 Findings: Need for Palliative Care!! Described experiences as a difficult process of several stages!! Long-term memories influenced by their decision-making style and perceived quality of interaction with health professionals!! Those most at risk for traumatic memories had ambivalent decision-making style and encountered organ-focused professionals rather than person-focused Kesselring 2007

11 Need for Palliative Care!! Potential palliative care needs for relatives of brain dead intensive care patients Design: Qualitative study of relatives of patients who had died of brain death and were approached regarding organ donation Setting: 20 ICUs throughout United Kingdom Method: Relatives approached 6 months after death 130 families approached 30 (22%) agreed to participate, with 1 relative later withdrawing due to bereavement 29 families 4 declined donation 3 inquired but ineligible 22 consented to donation Lloyd-Williams 2008

12 Need for Palliative Care Findings:!! Valued physical care relative received!! Communication and breaking of bad news areas of concern!! Facilities left little privacy or ability to say final good-byes!! Bereavement follow-up did not routinely occur Lloyd-Williams 2008

13 Donation and Family Experience!! Several studies have demonstrated that donation!! Helped families with the grieving process!! Offered meaning in the face of senseless tragedy!! Was the first time they felt a sense of control in the situation Pelletier 1992; Batten 1987; Sque 2005

14 Examples of Palliative Care Integration

15 Example of Palliative Care Involvement!! Virginia Commonwealth University!! Routine PC involvement in controlled DCD donation!! DCD protocol automatically triggers PC consultation to provide care during discontinuation life sustaining support and throughout the dying process!! Expert management of symptoms!! Advocate for and support the surrogates/family!! Continue care if patient survives beyond 90 minutes Kelso 2007

16 Process for Controlled DCD Donation Step 1 Patient Patient with devastating meets criteria to be a potential DCD donor neurologic injury identified in ED. Care assumed by interdisciplinary Discussion treating MDs, OPO, surrogates to gain approval for organ donation trauma team. Trauma chaplain works closely with family from outset. Step 2 Once DCD Protocol Testing to determine viable organs/tissue initiated and potential PC consulted. recipients PC team identified* reserves a bed in Palliative Care Unit. Step 3 Chaplain introduces family to PC team. PC team Life-sustaining treatments discontinued (location [OR/ICU] facility dependent) meets family and works to Step 4 PC team reviews care establish rapport, learn about plan with other staff. PC patient, Medications possibly provided support life attending present in OR with to ease EOL symptoms and prep for possible procurement review. Begin to review and chaplain and family. Donated plan withdrawal Death with occurs family. within quilts Death provided, does not music occur if within Warm Ischemic Time desired. Warm Ischemic PC attending Time oversees ( minutes) ventilator discontinuation and Step 5 If patient dies within symptom management. 90 minutes. PC team attends to family Surrogates while procurement leave patient Step 6 Patient Formal transferred debriefing out for of begins. and If organ patient procurement does not die, staff mentioned. OR/ICU to Routine routine inhospital support comfort care the patient team arrives is transferred to the bereavement PCU for ongoing management families not mentioned. Kelso 2007 * If by patient PC team. is a viable donor all care and expenses are assumed by OPO from this point forward

17 Example of Palliative Care Involvement!! Mayo Clinic, Arizona!! Case of palliative care involvement in DCD case and recommendations for future involvement!! 49 y/o man with a stroke while repairing his motorcycle. Unresponsive on arrival. CT/CTA basilar artery thrombus. Received tpa with eventual hemorrhagic transformation. ICU/Neurology discuss with family and they decide to withdraw supportive measures. Family raised idea of organ donation knowing his advance directive.!! ICU consulted palliative care to assist with discussions and support Prommer 2014

18 Process for Controlled DCD Donation Step 1 Patient Patient with devastating meets criteria to be a potential DCD donor neurologic injury identified in ICU. ICU/Neurology discussed with Discussion treating MDs, OPO, surrogates to gain approval for organ donation surrogates and decision made to withdraw supportive measures. Step 2 PC and OPO representative Testing to determine viable organs/tissue discuss and potential organ donation recipients with identified* the family. Step 3 Huddle between PC, Step 4 PC team discussed ICU, Life-sustaining RT, anesthesia, treatments OPO discontinued (location process with [OR/ICU] family and facility dependent) representative to coordinate prepares them, escorts family process. PC recommended Medications provided to ease EOL symptoms OR. and Premedication prep for possible with discontinuation of unnecessary procurement opioid and benzo prior to meds and meds for symptom Death occurs within extubation. Death does PC not provided control. occur within Warm Ischemic Time support Warm Ischemic and directed Time symptom ( minutes) management in the OR. Step 5 Patient died within warm ischemic time and PC escorted Step 6 Surrogates leave patient Patient No known transferred affect of out PC family out of OR and procurement of involvement and organ procurement OR/ICU on bereavement to routine inhospital or team then entered OR. Liver and mitigating team arrives distress comfort of health kidneys transplanted 3 patients. 2 care professionals involved in organ others received corneal transplants. donation process. Prommer 2014 * If patient is a viable donor all care and expenses are assumed by OPO from this point forward

19 Best Practices

20 Optimizing the Donation Discussion!! What factors of the conversation are associated with consent to proceed with donation? Study design: Observational study 707 potential brain dead donors referred to 3 OPOs Methods: Multivariate analysis to determine predictors of family consent 3 factors independently associated with consent: 1) Decoupling - temporal separation of discussion of death and donation discussion 2) Hospital & OPO staff both participate in donation discussion 3) Discussion occurs in private setting Gortmaker 1998

21 Factors Associated with Donation # of key factors present % of cases N=707 Rate of family consent P-value 0 11% 28% < % 55% 2 36% 68% 3 28% 74% Gortmaker 1998

22 Factors Influencing Families Consent!! Exploration of the factors associated with the decision to donate among families of potential organ donors Study design: Chart review and interviews health care practitioners, OPO staff, and families of all donor-eligible patients 1994 to 1999 followed by multivariate analysis Setting: 9 trauma hospitals southwestern Pennsylvania and northeastern Ohio Findings: 420 Cases 238 Donation 182 Declined Siminoff 2001

23 Factors Influencing Families Consent!! Findings: Factors associated with greater likelihood of consenting to donation Family and Patient Characteristics White Younger patients Male patients Patient died from trauma Prior Beliefs or Knowledge of Values Positive belief about organ donation Knowing patient had a donor card Prior explicit discussions about donation Belief based on patient prior values Decision Process Variables Families who raised possible donation themselves Hospital-based clinician (NOT a physician) broaching donation followed by conversation with OPO staff Family talking to OPO staff prior to being asked to make a decision Greater number of conversations with OPO staff Topics in Conversation Correlating with Consent Costs of donation Impact of donation on funeral arrangements, disfigurement Assurances around family choice about organs to donate Donation has the potential to help others Siminoff 2001

24 Factors Influencing Families Consent!! Findings: Factors associated with families declining donation Health Care Provider Characteristics Health care providers were poor predictors of who would consent to donation. Correct in LESS THAN HALF the cases. Decision Process Variables Health care workers asking apologetically about donation or mentioning they are legally required to ask about donation Siminoff 2001

25 Regulations Regarding Donation!! CMS and Health Care Financing Administration (HCFA) Regulations:!! Require hospitals to notify local OPO!! Imminent deaths!! If family raise the issue of compassionate extubation!! If family raises the issue of organ donation!! Health care workers should involve OPO staff early in the process!! Only trained health care workers or OPO staff approach families about donation!! Joint Commission!! Require hospitals to have a DCD policy

26 Recent Consensus Policy Statement!! Regarding Consent for Donation!! When patients themselves have consented to organ donation, hospital critical care and organ procurement organization (OPO) representatives s should respect the patient s donation decision and provide this information to surrogate decision makers.!! After clinicians lead discussions with patients or surrogates about the decisions to withdraw life-sustaining therapies, discussions about DCD donation should proceed promptly and be coordinated jointly by clinicians and OPO representatives.!! Consent for DCD donation should be obtained by individuals with appropriate experience and training. Gries 2013

27 Recent Consensus Policy Statement!! Regarding palliative care!! Hospitals that participate in DCD donation should ensure that experienced personnel with competency in palliative care are available to participate in end-of-life care if needed. Gries 2013

28 Conclusion!! Demonstrated clear palliative care needs of surrogates and health care providers throughout the donation process!! Skills, attitudes, and aptitude of palliative care teams align with those necessary to optimize the process and potentially have lasting benefit for those undergoing the process of deceased organ donation

29

30 References!! Azoulay, B., et. al. Risk of Post-traumatic Stress Symptoms in Family Members of Intensive Care Unit Patients. Am J Respir and Crit Care Med. 2005; 171: !! Batten, H. et. al. Kind Strangers: The Families of Organ Donors. Health Affairs (2): !! Davis, D., et. al. The Organ Donation Breakthrough Collaborative: Has it Made a Difference? Am J Surgery. 2013; 205(4): !! Gortmaker, S.L., et. al. Improving the Consent Process to Increase Family Consent for Donation. J Transpl Coord. 1998;8(4):210-7.!! Gries, C. et. al. An Official ATS/ISHLT/SCCM/AOPO/UNOS Statement: Ethical and Policy Considerations in Organ Donation after Circulatory Determination of Death. Am J Respir Crit Care Med.2013; 188(1) Lewis, J., et. Al. Development of the University of Wisconsin Donation After Cardiac Death Evaluation Tool. Progress in Transplantation. 2003; 13(4): !! Lloyd-Williams, M., et. al. The End-of-Life Care Experiences of Relatives of Brain Dead Intensive Care Patients. J of Pain and Symptom Mgmt 2009; 37(4): !! Kelso, C.M., et. al. Palliative Care Consultation in the Process of Organ Donation after Cardiac Death. JPM 2007; 10(1):

31 References!! Kesselring, A. et. al. Traumatic Memories of Relatives Regarding Brain Death, Request for Organ Donation and Interactions with Professionals in the ICU. Am J Transplant. 2007; 7(1): !! Pelletier, M. The Organ Donor Family Members Perception of Stressful Situations During the Organ Donation Experience. J Adv Nurse. 1992; 17(1): !! Prommer, E., Organ Donation and Palliative Care: Can Palliative Care Make a Difference? JPM 2014; 17(3): !! Saidi, R.F, et. al. Challenges of Organ Shortage for Transplantation: Solutions and Opportunities. Int J Org Tranplant Med 2014; 5(3): !! Sque, M. et. al. Organ Donation: Key Factors Influencing Families Decision-Making. Transplant Proceed. 2005; 37(2): !! Siminoff, L., et. al. Factors Influencing Families Consent for Donation of Solid Organs for Transplantation. JAMA. 2001; 286(1): !! Wind, J., et. al. Prediction of Time of Death After Withdrawal of Life-Sustaining Treatment in Potential Donors After Cardiac Death. Crit Care Med. 2012; 40(3): !! Wind, J., et. al. Variability in Protocols on Donation After Circulatory Death in Europe. Critical Care. 2013; 17: R217.!! Yee, A. et. al. Factors Influencing Time to Death After Withdrawal of Life Support in Neurocritical patients. Neurology. 2010; 74:

32 Acknowledgements!! Nikole Neidlinger, MD!! Medical Director, California Transplant Donor Network!! Jill Noonan, JD, RN, CTBS!! Donation Process Consultant, SFGH Liaison California Transplant Donor Network