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Organ, Tissue, and Eye Donation
The Bridge to Life
Keith Rischer RN, MA, CEN
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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.
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Ethical Issues Regarding Transplant
Definition of death Respect for the dead Organs for sale
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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 20080
10,00020,00030,00040,00050,00060,00070,00080,00090,000
100,000
Deceased Donors Transplants - Living and Deceased Donors Wait List
*Based on OPTN data through March 31, 2008
www.OPTN.org
The Growing Need
Organ Donors vs Wait Listed Patients
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400
450
500
550
600
650
700
750
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Org
an D
onors
1999 2000 2001 2002 2003 20042005 2006 2007 2008
Holding the Gains…..But More Improvement is Needed
Collaborative Starts Here
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We pledge to provide the bridge
between the loss of life and the gift of life
Through organ & tissue donation & transplantation.
We believe that life is a gift to share
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LifeSource Service Area
ND
SD
MN
WI
Douglas County
St. Croix County
Pierce County
Fargo
Sioux Falls
Rochester
Saint Paul office
•Duluth
Rapid City •
•Bismarck
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Corneas (1905)
Heart/Heart Valves (first fresh valve – 1955) (first heart – 1967)Lungs (1963)
Liver (1963)
Pancreas (1969)
Kidneys (1954)
Intestines (1987)
Skin (1822)
Bone/Connective Tissues (1668)
Blood Vessels (1955)
What organs & tissues can be donated?
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Overview of the Donation Process
Identification
Referral
Family Approach – team huddle
Assessment and Donor Management
Allocation – UNOS
Recovery
Family Follow-Up
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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, CDENational Donor Family Council
“The process of donation begins………
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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
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The Process: Legislative Initiatives
HCFA (Health Care Financing Administration), 1998Name changed to Centers for Medicare and Medicaid
Services (CMS) 2001
1. Call 1-800-24-SHARE on ALL deaths. There are no exclusions.
2. Approach of a potential donor’s family must be done by a procurement organization representative or an individual trained by the procurement organization.
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Donor Designation
Donor designation is the practice of ensuring that an individual’s documented wishes about
donation are fulfilled.
“giving the donor a voice”
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Decisions are made with respect to personal choice
(Informed and Voluntary)
Autonomy
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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
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Potential Organ Donor ReferralDevastating Brain Injury / Ventilator Dependent
BRAIN DEATH EXAMINATION
Exam c/w brain deathDeath determined by neuro
criteria
Donation discussed with family (LifeSource)
Patient supported during organ evaluation & allocation
Surgical recovery• Withdrawal of support
• Pronouncement of death• Surgical recovery
Patient evaluated as potential DCD candidate
• Family/MD initiate topic W/D med treatment• LifeSource Coord discussion with family• Family supportive of donation
Exam Not c/w brain death
Donation after Cardiac Death
Donation after Brain Death
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Brain Death
Definition: Complete and total cessation of all brain function, including the brain stem.
Causes:• Intracerebral hemorrhage• Head trauma• Anoxia• Brain tumor
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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
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Family Communication: Brain Death
Patient looks alive
Heart is beating
Chest is moving
Patient is warm
Patient’s skin has color
No outward evidence
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Phrases to Avoid
HarvestLife support
One chance in a millionKeep alive until donation
Only a miracle can save him now
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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.
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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.
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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
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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
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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
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Organ Matching (allocation)
DonorInformation
DonorInformation
RecipientInformationRecipient
Information
United Network for
Organ Sharing (UNOS)
United Network for
Organ Sharing (UNOS)
• Blood type• Size• Severity of illness• Wait time
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Procurement Surgery
Recovery done at donor hospital
• Surgeons from transplant centers
• LifeSource preservationist
When are we going to the OR?
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Donation After Cardiac Death
Organ donation after the cessation
of all cardiopulmonary function
(cardiac death) rather than
organ donation after the cessation
of all brain function (brain death).
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Potential Organ Donor ReferralDevastating Brain Injury / Ventilator Dependent
BRAIN DEATH
EXAMINATION
Exam c/w brain deathDeath determined by neuro
criteria
Donation discussed with family (LifeSource)
Patient supported during organ evaluation & allocation
Surgical recovery• Withdrawal of support
• Pronouncement of death• Surgical recovery
Patient evaluated as potential DCD candidate
• Family/MD initiate topic W/D med treatment• LifeSource Coord discussion with family• Family supportive of donation
Exam Not c/w brain death
Donation after Cardiac Death
Donation after Brain Death
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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
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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
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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
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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
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Complications
Infections Rejections
• Hyperacute: remove organ• Acute: Increased immunosuppressives• Chronic: conservative management
Hemorrhage Fluid and electrolyte imbalances Pulmonary atelectasis
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• Ongoing Support
• Family Connection newsletter
• Holiday booklet
• Communication between donor families and recipients
• Local donor family quilt
Donor Family Services Provides
A Bereavement Book is given to families at the time of their loved one’s death
Family follow-up
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You are………
the bridge.