Objectives Understand the role of the UW OTD Discuss the need for organ donation From referral to recovery: An overview of the phases of the organ donation process Discuss the importance of the provider role in the organ donation process UW Organ and Tissue Donation (UW OTD) Donation Service Area Conflict of interest-none 3.5 million population 103 hospitals Wisconsin, Michigan, Illinois, Minnesota 66 counties UW OTD Shared UW OTD and other OPO Gift of Life Michigan Lifesource Wisconsin Donor Network CHALLENGES ACROSS THE NATION: DONORS, TRANSPLANTS AND PATIENTS WAITING 123,178 waiting list candidates as of 08/05/2014 Why is Organ Donation Important? Based upon OPTN year-end data provided on 08/05/2014. This work was supported in part by Health Resources and Services Administration contract 234-2005-37011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. 1
Organ Donation Statistics On average, 130 people are added to the nation s organ transplant waiting list each day ONE EVERY 10 MINUTES An average of 18 people die each day from the lack of available organs for transplant 10-15 % of those on the national waitlist die each year 50 % kidney 30 % liver 10 % heart 10% lung WAITING LIST CANDIDATES Type of Transplant Wisconsin Waitlist National Waitlist All Organs 2,351 134,702 Kidney 1,922 108,989 Liver 315 16,310 Pancreas 10 1,198 Kidney / Pancreas 50 2,122 Heart 83 4,092 Lung 31 1,675 Heart / Lung 0 55 Intestine 1 261 Based on OPTN data as of September 15, 2014 THE ROLE OF THE OPO Current Staff of 39 Employees Hospital Development and Professional Education Donor Evaluation and Management Organ Recovery Family Support Community Education 150 volunteers (donor families, recipients, living donors) 20-30 events each month 150 driver s education classes/year Governor s Residence, Gift of Life Ceremony 2013 UW OTD Deceased Donor Activity Donors After Brain Death Donors After Cardiac Death Total Donors 160 140 120 100 80 82 85 81 82 2 5 10 7 137 142 133 136 131 127 126 115 117 115 115 108 26 22 5 99 96 100 39 37 40 87 23 32 2 14 12 14 27 30 38 29 60 40 77 75 74 80 85 103 85 84 86 88 107 109 87 89 100 103 92 96 86 94 20 0 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 2
From Referral to Recovery Referral Phase Initial Referral Pt meets clinical triggers Evaluation Phase Serology testing Declaration, consent, med-soc, diagnostic testing Allocation Phase Referral Phase Initial Referral Notification to the OTD when patient meets Clinical Triggers Organ Placement, tissue typing, ongoing aggressive donor management Recovery Phase Surgical recovery and transportation Calling in a Referral 1-866-894-2676 Statline Triage Center Imminent Deaths (OPO paged) Deaths (Tissue and Eye Banks paged) Clinical Triggers A mechanically ventilated patient with a confirmed severe neurologic insult or injury For whom a physician is evaluating for brain death OR A patient with a Glasgow Coma Scale (GCS) < 5 OR A plan to discuss withdrawal of life-sustaining therapies Referral Outcome Closed Referrals are closed due to: Patient improvement Patient death on vent Patient not eligible Next of Kin declines donation (biggest limiting factor to increasing donation) Only 7% of patients referred go on to donate organs If patient is eligible and there is verbal interest/consent from family evaluation phase begins Current Criteria for Organ Donation Patients who have been declared brain dead or Patients with a severe brain injury and the family has decided to withdraw ventilator support Up to age 75 HIV Negative this may change as people are living longer with HIV This will change No active cancers the exception is primary brain or CNS tumors Note: Only the OPO can determine donor suitability 3
Declaration of Brain Death How: Hospital policy dictates the process for declaring brain death, but UW OTD recommends following the AAN guidelines Gold Standard: complete clinical exam with apnea test Who: Physician What: Documentation of death in the patient medical record Donation after Brain Death and Donation after Circulatory Death Brain Death Brain dead Patient maintained by ventilator until organs are recovered Surgical Recovery 3-4 hours in Operating Room Heart, Lungs, Liver, Pancreas, Kidneys, and intestines can be recovered Circulatory Death Not brain dead but no longterm prognosis for recovery from injury; cannot survive off ventilator Family and physician elect to remove the machines Surgical recovery 1-2 hours in operating room Lungs, Liver, Pancreas, and kidneys can be recovered Consent Phase Most Limiting Factor Two Types Next of Kin (NOK) Consent First Person Authorization YesIwillWisconsin.com Launched on: Monday, March 29, 2010 WI residents can document their authorization for organ, tissue and eye donation Removes the burden of decision from family members during a difficult time Real time access for recovery agencies Residents 15 ½ and older can register In less than three years two million WI citizens have registered Consent Phase Who: Designated Requestor (DR) and/or MD, UW OTD How: Requesting Best Practices Consent is a process not an event When families are approached they should not be surprised by the discussion Team Huddle 4
Families hospital experience affect their decisions to donate loved-ones organs Donor families compared to non-donor families More satisfied with the quality of care they received in the hospital Had a clear understanding of brain death Don t believe their loved one can recover Believe they were given sufficient time and privacy to make their decision Request for organ donation was separate from the brain death discussion Much more satisfied with the donation request process Believed that the person(s) making the request was sensitive, compassionate and trustworthy Team Huddle Definition: Short, timely, frequent exchanges of essential information among team members aimed at achieving an effective request. WHO: OTD Nurse Social Worker Chaplain Attending Physician Charge Nurse WHAT: Prognosis Patient s Authorization Eligibility to Donate Family Dynamics / Cultural Awareness Family s Knowledge and Acceptance of Prognosis Next of Kin Information Effective Consent Process Three Major Elements A.) Request for donation is made in a private setting B.) Allow the family to comprehend the death before discussion organ donation C.) Hospital staff and OTD staff collaborate in the consent process When all three elements were present, the consent rate was 2.5 times higher compared to when all three were not present. However, the study showed this was done only a third of the time Providers and Organ Donation Timely diagnosis of brain death Ensure families understand the diagnosis of brain death Collaboration with the hospital and OTD staff during the consent process Organ donor management Support family and hospital staff during the donation process Remove barriers to the donation process Medical-Social History Evaluation Phase Serology testing, 8 hrs Declaration, consent, med-soc, diagnostic testing 43 questions pertaining to donor medical history and behavioral risk Interview completed by next of kin (NOK) and/or best historian for the donor Done by OTD staff via telephone 30-45 minutes 5
Infectious Disease Testing HBSAg- Hepatitis B Surface Antigen Anti- HBC- Hepatitis B core Anti- HCV- Hepatitis C Virus HIV 1 and 2- Human Immunodeficiency Virus HTLV 1 and 2- Human T-cell leukemia/lymphoma virus RPR- Rapid Plasma Reagin test- Tests for syphilis CMV- Cytomegalovirus EBV- Epstein Barr Virus (IgG, IgM) NAT- HBV, HIV, HCV, WNV Goals for Medical Management Paradigm shift: Organ Support Not Life Support Early identification of brain death related complications Avoid cardiovascular collapse Reverse metabolic disturbances Outcome following transplantation is directly related to quality of organs procured. Poor graft function following organ transplantation results in increased patient morbidity and mortality. Medical Management: Role of Clinical Care Team Integrative multi-disciplinary collaborative approach between OTD and Clinical Care Team Intensivists Pulmonary Consultants Cardiac Consultants Nursing Respiratory Hemodynamics Ventilatory Management Echocardiography Bronchoscopy Multiple Chest films Cardiac Cath Abdominal CT O2 Challenges Multiple ABG s Critical Care Endpoint DMG 1. Mean Arterial Pressure (MAP) 60 100 mmhg 2. Central Venous Pressure (CVP) 4 10 mmhg 3. Ejection Fraction (EF) > 50% 4. Vasopressor use 1 and low dose 5. Arterial Blood Gas ph 7.3 7.45 6. PaO2:FiO2 (P:F) > 300 on PEEP = 5 7. Serum Na 135 155 meq/l 8. Blood Glucose < 150 mg/dl 9. Urine Output (averaged over 4 hours) 1-3 cc/kg/hr Allocation Phase Organ Offers, 8 hrs Match runs, tissue typing, more diagnostic testing Allocation Defined process to offer organs according to the United Network for Organ Sharing (UNOS) list of potential recipients Any organ(s) intended for transplant must be allocated to specific recipients prior to setting OR time OPC is in constant communication with transplant surgeons regarding the acceptance/decline of donor organs 6
Allocation UNet Screen Shot Donor information entered in UNOS database and matching recipients are found via match run lists Based upon: Length of wait time Antibodies Urgency Tissue typing Patient size Geography: offered to local matches first, then regional matches, and national matches Recovery Recovery Phase Set-up and transportation, 6 hrs Organ recovery performed at donor hospital OR time set in conjunction with donor hospital Transportation arranged for OPO recovery team to travel to donor hospital Team: surgeon, first assistant, surgical recovery coordinator, OPC Possibility for multiple teams HOSPITAL STAFF BRAIN DEATH Anesthesia, Circulating and Scrub Nurse DCD Physician, ICU Nurse, Circulating and Scrub Nurse, RT RECOVERY Pt remains on vent 3-4 Hour surgery Organs Separated In-Situ Machine removed Family can be present 1-2 hour surgery after Cardiac Death Organs Separated after removal ORGANS RECOVERED Kidneys, Liver, Pancreas, Lungs, Heart, and Intestines Kidneys, Liver, Pancreas, Lungs 7
Organ Preservation Time Heart: 4-6 hours Lungs: 4-6 hours Liver: 12 hours Pancreas: 12-18 hours Kidneys: 24 hours Small Intestines: 4-6 hours 98% would choose donation again 92% identified positive aspects to the donation process/experience Majority agreed that donation was comforting Associated with less depression Patients and Families What should be the standard of care for the patient and the family care in the setting of organ donation? What is the moment of silence? A moment of silence is the expression for a period of silent contemplation or reflection. It is viewed as a gesture of respect particularly in mourning for those who have recently died. Moment of Silence What is the purpose? Acknowledge the donor as a person Acknowledge the generosity for others Honor the family Bring greater awareness to organ donation Promote greater trust between the OPO and hospital staff Foster a greater connection to the donation process What You Can Do Most importantly talk with your patients about organ donation and be sure to include donation in your end-oflife issues discussions with them You and your staff are much better equipped to answer questions and dispel misconceptions than the DMV office where most people sign up. 8
Through donation... What You Can Do For out of state patients you can visit: www.donatelife.net - from that website you can access any state s Donor Registry Ask your clinic to provide a link on their website to the Donor Registry website Host a Donor Registry Drive at your office/clinic all you need is a couple of computers or laptops...lives are changed forever 9