Neurologically-Aware Donors:Donation After Circulatory Death

Noël Stout, LPN, CTBSMyrna Garcia, BA

Family Support Coordinators

Objectives:

• Provide context for honoring the neurologically-aware patient’s desire to donate organs within a non-traditional clinical picture.

• Provide information surrounding the referral, discussion and legal authorization from neurologically-aware patients for organ donation after circulatory death.

“Neurologically-Aware” PatientsExamples:• High cervical spine fractures; quadriplegia

• Degenerative neurological diseases in the end-stages; Amyotrophic Lateral Sclerosis, Multiple Sclerosis, Huntington’s Chorea

• Ventilator dependent and family/patient have chosen to withdraw life-sustaining measures

Consider Neurologically-Aware patients as potential referrals!

General Triggers:• Vented, GCS <5, heart-beating and/or family

planning to d/c life-sustaining interventions

Non-traditional Triggers to consider in addition:• Ventilator dependent, GCS higher than 5, likely

to die immediately after extubation, any mention of donation by family or patient

Process• As in all DCD discussions, decision to

withdraw life-sustaining measures must already have been made by the family

• OPO and medical staff meet to determine the best way to discuss organ donation with family

• If patient is communicative, he/she must be included in the discussion

Ethical Considerations• The hospital Ethics Committee may review

the case. The committee felt it appropriate for the intensivist to speak with the patient regarding withdrawal of care.

• Once the patient, family and Intensivist have agreed upon the withdrawal of care, the hospital Ethics Committee can permit the OPO staff to approach the patient.

Discussion• Assess patients method of communication and

neurological state– Family members/hospital staff involvement

• Assess sedation level• Determine patient’s understanding of their

condition• Determine who will be in room for donation

discussion• Thorough staff huddle prior to approach

Authorization• No difference from traditional paperwork

process–Confirm Registry status–Complete Written Authorization, if not

registered–Obtain DCD Procedures Authorization• Heparin administration

Case Study• 56 year old female, registered donor admitted s/p fall

from deck

• CT scan revealed severe cord laceration at C2 level with

contusion from C1-C3

• No acute intracranial injury identified

• Family given prognosis of vent dependent quadriplegia

– Withdrawal of care brought up by family

The Intensivist Conversation

• Family/Family Support Coordinator present• “Once for yes, twice for no”• Neurological state assessed• Confirming pt’s understanding of ventilator-

dependent quadriplegia• Discussed life-sustaining measures will be

withdrawn• Clarify that this would result in her death

The OPO Approach• Family and hospital staff present

• Confirm that at the time of death, organ donation

would occur

• Authorization completed by husband

• Patient included in process

• Questions answered

The Recovery

• Comfort care measures per hospital protocol

• Significant Hospital OR staff preparation

– Withdrawal of care in OR or ICU per

patient/family wishes

– No pre-OR prep done

Case Collaboration

Donor Alliance

Staff

ICU Director

ICU MD

ICU RN

OR Director

OR Charge

Chaplain

HD

Family/Patient

What have we learned?Early Referral is preferred

• Be proactive• Involve the right people

Conversations early and often

Collaboration is key