CHHS17/246 Canberra Hospital and Health Services Clinical Procedure Organ and Tissue Donation – Adults, Adolescents, Children and Neonates Contents Contents..................................................... 1 Purpose...................................................... 3 Alerts....................................................... 3 Scope........................................................ 3 Section 1 – End of Life Care – Notification to DonateLife ACT 3 1.1. General Information....................................3 1.2. Responsibilities.......................................4 Section 2 – Consent/Authorisation Process....................4 2.1. General Information....................................4 2.2. Australian Organ Donor Register (AODR) Status..........5 2.3. Pre- Consent/ Authorisation............................5 2.4. Consent/Authorisation from the patient’s SANoK via a Family Donation Conversation (FDC)..........................6 2.5. Coroner Consent for Donation...........................6 2.6. Designated Officer Authorisation.......................7 Section 3 – ICU Admission....................................9 3.1. General Information....................................9 3.2. Admission Criteria....................................10 3.3. Consultation and Admission Process....................10 Section 4 – Organ Donation..................................11 4.1. General Information...................................11 4.2. Determination of Medical Suitability..................11 Doc Number Version Issued Review Date Area Responsible Page CHHS17/246 1.0 24/10/2017 01/07/2022 DonateLife 1 of 35 Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
Transcript
CHHS17/246
Canberra Hospital and Health ServicesClinical ProcedureOrgan and Tissue Donation – Adults, Adolescents, Children and NeonatesContents
2.4. Consent/Authorisation from the patient’s SANoK via a Family Donation Conversation (FDC)...............................................................................................................6
2.5. Coroner Consent for Donation...................................................................................6
Attachment 1 – ICU Palliative Care Plan..............................................................................25
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Purpose
To provide Canberra Hospital and Health Services (CHHS) staff with information and guidance in relation to organ and tissue donation. Individual’s wishes regarding organ and tissue donation are respected at all times.
Al
erts
Organ and tissue donation is governed by legislation and nationally accepted guidelines (refer to Sections 7 and References). As such organ and tissue donation requires strict protocols to ensure that the patient and their families’ best interests are first and foremost.
This document does not cover the retrieval of organs or tissues for living donors, ACT pathological/research purposes, nor body donation.
Scope
This document applies to the following Canberra Hospital Health Services (CHHS) staff working within their scope of practice: Registered and Enrolled nurses Medical Officers Pastoral care staff Allied health professionals Ward services and administrative staff
Section 1 – End of Life Care – Notification to DonateLife ACT
1.1. General InformationCHHS is committed to respecting patient choices about their end of life care (EOLC). To advocate and facilitate patient wishes, prompt notification to DonateLife ACT (DL ACT) needs to occur so that Donation Specialist Nursing Coordinators (DSNC) and Donation Specialist Medical (DSM) staff who are specifically trained, can investigate medical suitability and initiate discussions about organ and tissue donation with the patient and/or family in an appropriate and sensitive manner. Providing CHHS patients and their families with the opportunity to consider organ and tissue donation as part of EOLC is recognised as best practice.
All CHHS staff are responsible for ensuring DL ACT are notified of a patient’s death. DL ACT act in consultation with the treating team, transplantation surgeons and tissue banks who are responsible for determining medical suitability and offering organ and tissue donation when appropriate.
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This Standard Operating Procedure (SOP) describes for staff the process to
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1.2. ResponsibilitiesCHHS StaffStaff in ward areas are responsible for: Forwarding all requests from patients and/or families for information about donation to
DL ACT via CHHS switchboard on 6244 2222 Prompt entering of a patient’s death into ACT Patient Administration System (ACTPAS)
to notify DL ACT via the generated Health Reporting email.
Staff in the Emergency Department (ED), Intensive Care Unit (ICU) and the Neonatal Intensive Care Unit (NICU) are responsible for notifying DL ACT via CHHS switchboard on 6244 2222 in the following circumstances: At the commencement of EOLC planning and family discussions All requests from patients and/or families for information about organ and tissue
donation When a patient dies.
DL ACT DSNC – with assistance of the DSM (where appropriate) are responsible for: Determining Australian Organ Donor Register (AODR) status, medical suitability and
offering organ and tissue donation information to the patient and/or families when appropriate, PRIOR to entering into family conversations.
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Section 2 – Consent/Authorisation Process
2.1. General InformationThe consenting and authorisation process is the responsibility of the Donation Specialist Nurse Coordinator (DSNC), who is specifically trained in Family Donation Conversations. The DSNC may consult with the DSM if required.
There are 3 components of consent/authorisation for organ and tissue donation: Donor Family (Senior Available Next of Kin SANoK) Coroner (If required) Designated Officer (DO)
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An appropriate consent/authorisation is generally determined through the deceased person’s ‘expressed wish’ for donation.
Confirmation of either an ‘expressed objection’ or ‘expressed wish’ may include: A refusal, or an intent or consent, to organ donation +/- any limitation on the AODR Documentation in the persons Will, Advanced Care Directive or End Of Life Care Plan Consent for organ and/or tissue donation obtained from the donor themselves The Senior Available Next of Kin’s (SANoK) knowledge of the person’s wishes
2.2. Australian Organ Donor Register (AODR) Status Prior to all families being approached to offer organ and tissue donation, the DSNC will
check the AODR to determine if the patient has indicated their donation wishes:o Intent/ Consento Refusalo Not Found/not listed
The family will be informed of any indicated donation wish for or against donation. For organ donation, the DSNC will inform the Intensivist or delegate of the patient’s AODR status
2.3. Pre- Consent/ Authorisation Obtaining pre-mortem consent/ authorisation is possible when DL ACT is contacted by a patient, patient’s family or a health care professional. The DSNC will meet with the patient/ patient’s family at their home or at the healthcare facility prior to death. Pre-consent/ authorisation for the removal of tissue after death will be obtained from a patient or their SANoK.
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2.4. Consent/Authorisation from the patient’s SANoK via a Family Donation Conversation (FDC)
Within the FDC, families will be informed of the following: The AODR wishes of the patient Intent/ Consent – the DSNC will advocate for the patient wishes No wish registered – the DSNC will determine with the family if the patient had indicated
a donation wish in their lifetime. In which case the DSNC will explore if organ and tissue donation is the right decision for the patient and their family. If the patient had registered a refusal to donation, the family will be asked if this accurately represents the patient’s current wish regarding donation.
Explanation of the donation process Importance and outcomes of organ and tissue donation Permission to share information about the patient with other health professionals
FDC for Organ Donation: Once the patient has been deemed suitable for donation, the Intensivist/ or delegate and
DSNC will discuss the plan for the FDC The FDC will ONLY occur following End of Life Conversations (EOLC) and acceptance of
poor prognosis There should be clear separation (in time) between the EOLC and FDC conversation If the family consent/ authorise donation, the Senior Available Next of Kin (SANoK) is
required to sign the authorisation form A copy of the written authorisation is kept in the patient progress notes and the original
held by DL ACT
FDC for Tissue Donation: Once the patient has been deemed suitable for donation, the DSNC will telephone or will
meet face to face with the SANoK to discuss tissue donation If the SANoK authorise donation, the DSNC will obtain permission to record a verbal
authorisation over the telephone (when authorisation is not sought face to face) The verbal authorisation is saved securely in the DL ACT Q Drive
2.5. Coroner Consent for DonationGeneralThe process of obtaining consent from the ACT Coroner for organ and tissue donation within the ACT is outlined in the Coroners Act 1997 section 15 and the Transplant and Anatomy Act 1978 section 29.
If it is determined that a patient needs to be referred to the coroner, the Coroner is required to consent to organ or tissue donation BEFORE donation can proceed.
Organ DonationThe medical staff caring for the patient are required to contact the Coroner’s Officer and inform them of the death (Donation after Brain Death; DBD) or expected death (Donation after Circulatory Death; DCD). The Coroner’s Officer will contact the Coroner and advise
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them of death/expected death and related patient admission details. The Coroner’s Officer will advise the medical officer of the Coroner’s decision to allow or not allow donation. The medical officer will advise the DSNC of the Coroner’s decision.
The DSNC will contact the Coroner’s Officer to discuss the consent for donation and will be advised if there are any restrictions on the donation (e.g. not allowing specific organs to be retrieved).
Tissue DonationA “Direction by the Coroner” has been provided for eye tissue only. This document provides conditions whereby eye tissue donation can proceed without written consent from the Coroner.
The DSNC is still required to contact the Coroner’s Officer to determine if the Coroner’s referral is due to a suspicious death. In cases where the eye tissue is relevant to the investigation of a suspicious death, the ACT Coroner’s “Direction by the Coroner” will not apply.
Contact the Forensic Pathologist to request their consent. If there are no investigations for a suspicious death the “Direction by the Coroner” is utilised and the Coroner’s Officer will advise that eye tissue donation can occur. The name of the Coroner on duty is obtained.
Body IdentificationFor any coronial cases for organ donation, body identification is required by the family prior to cessation of circulation. The Australian Federal Police (AFP) officers will meet with the DSNC before attending to the body identification to determine the donation pathway for organ donation. The body identification process takes place, after consent/ authorisation from the SANoK and prior to donation surgery. The AFP will complete their “Statement of Life Extinct” form. Once completed, the DSNC assumes responsibility for the body and acts as the Coroner’s delegate; as stated in the Coroners Act Section 15. The AFP will give the DSNC two white name tags with the donor’s name, Date of Birth (DOB) and signature of AFP officer to apply to the donor once death has occurred.
2.6. Designated Officer AuthorisationDefinition of a Designated Officer for Organ & Tissue DonationA Designated Officer (DO) is a person, appointed under the Transplantation and Anatomy Act 1978 (ACT), who is responsible for the authorisation of organ and / or tissue donation within a health care facility.
DO authorisations are only required where the patient is in a hospital or health care facility.The DO is: Required to provide the final written authority for the removal of tissue from the body of
a deceased person for the purpose of organ and/or tissue donation for transplantation, research or education
Impartial, not advocating for or against organ or tissue donation
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Clinical understanding of the context is important Not involved in the potential donor’s current admission care
Verification of DeathA DO’s authority only pertains to deceased donors. Under section 45 of the Transplantation and Anatomy Act 1978 (ACT), a person is dead when there is:
The process to verify death is dependent on the donation pathway and whether the death is a Coroner’s case (see Table 2).
Table 2: Donation Pathway and Death Certification
The documentation used to certify death may include: Certification of Death on a Ventilator - Clinical Testing Certification of Death on a Ventilator – Non-Clinical Testing Determination of Death- Circulatory Death Death Certificate
Authorising Organ & Tissue DonationThe DO process to verify that appropriate consent/authorisation has been obtained is complex, and is outlined in Table 1. The key factor is that the deceased person had not during their lifetime ‘expressed an objection’ to the removal of tissue from his or her body. If an objection is determined the donation process ceases.
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The DO may make their own enquiries or rely on information obtained by others, such as the DSNC.
Once satisfied that death and consent/authorisation have occurred, the DO completes the ‘Authorisation by Designated Officer to Remove Tissue after Death’ form.
Designator Officer Appointment RequirementsAn appointment as a Designated Officer is done via formal appointment with the ACT Chief Health Officer.
Appointment requires the following: A combination of face to face and eLearning (via Capabiliti) Initial training on the role of a DO, the process of authorising organ and/or tissue
donation, and appointment requirements As required, ongoing support primarily by the DL ACT clinical staff who hold the DO and
Education portfolios Annual communication seeking confirmation of ongoing commitment to the role,
offering update training, and seeking feedback.
DOs will be updated with information in relation to changes of practice and/or legislation as required via an email distribution list.
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Section 3 – ICU Admission 3.
3.1. General InformationPatients considered or requesting organ donation (OD) as part of end of life care will have a timely and coordinated Intensive Care Unit (ICU) admission ensuring the patient and their family is given time to come to terms with the patient’s prognosis. This practice is in line with ‘Best Practice Guideline for Offering Organ and Tissue Donation in Australia’ and the ANZICS ‘Statement on Care and Decision-Making at the End of Life for the Critically Ill’.
Admission to ICU for organ donation as part of EOLC generally refers to patients who are between neonates (>3Kg) and adults (< 90yrs of age). However, the extension of age limits for organ donation suitability does occur depending on organ function and demand.
There are 2 possible pathways for admission to ICU – via ED or the ward. Regardless of pathway, the admission criteria is the same (discussed in detail below): Commencement of End of Life Care Referral to DonateLife ACT via switch Determination of the patient’s wishes regarding organ and tissue donation by DonateLife
ACT accessing the AODR.
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Assessment of preliminary medical suitability for donation conducted by the DSNC and DSM
Consultation with ED, ICU/NICU, the patient’s treating team and DonateLife ACT DSNC and DSM
Admission via EDNeither consent nor authorisation needs to have occurred for admission to ICU via ED.Patients who fit the criteria for consideration of organ donation may be admitted to the adult or neonatal ICU.
Admission via the WardWhen organ donation is raised by the patient/ family in ward setting: Prior to the patient/ family being approached by DonateLife ACT, the Home Team
Consultant along with an independent Medical Practitioner (>5yrs Post Graduate) must both agree in writing that prognosis is poor and death is considered imminent (within the next 7 days)
The patient/ family will be fully informed of the steps and all known interventions required to fulfil an organ donation wish – including the admission to ICU
A plan will be developed which consists of when and how the patient will be transferred to ICU to fulfil that wish
At any time the wish can be revoked by the patient or the family
3.2. Admission CriteriaEnd of Life Care (EOLC) Discussions Section 1: Notification of Death and End of Life Care mandates that all patients who are
commencing EOLC discussions in Critical Care Areas are notified to DL ACT.
Australian Organ Donor Register (AODR) Status Section 2.2: The AODR will be checked prior to request for admission to ICU. For intent/
consent or not found, the patient should be considered for admission to ICU. In the event there is a ‘refusal’ on the AODR, discussions will be held with the DL ACT Donation Specialist Medical (DSM) prior to requesting admission to ICU.
EOLC with initial medical suitability Initial medical suitability is reviewed and determined by the DSNC and the DSM, the
following factors will be reviewed (but not limited to):o Age of donoro Disease process/ mechanism of injuryo Donation Pathwayo Suitability of organs dependent upon age and pathwayo Medical history available at the time
3.3. Consultation and Admission ProcessThe following criteria determine whether a patient is appropriate for admission to ICU for consideration of EOLC options:
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EOLC discussions have been considered or commenced The patient meets initial medical suitability criteria for organ donation, see Section 3.2
If these criteria are met, admission to ICU is required. Timely admission to ICU is crucial for ongoing management and also ensures that family discussions about organ donation occur at the appropriate times and in the most appropriate environment.
Decision to Admit to ICUThe decision to admit a patient to ICU for the EOLC options is made in consultation with the DSNC, DSM and the relevant Medical Specialist and Nursing Manager from the ward area e.g ED, ICU, NICU, Paediatrics and/or Access Unit/AHHM
Process of Admission Patient is notified to DSNC DSNC and DSM determine admission criteria have been met (as per 1. Admission Criteria
to ICU for End of Life Care Options) DSNC liaises with ED & ICU Medical staff confirming admission criteria have been met. Admission to ICU as per usual process
Access BlockIn the event that ICU is experiencing “access block”, the normal procedure for resolution is adopted, as per the CHHS Capacity Escalation Procedure.
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Section 4 – Organ Donation4.
4.1. General InformationThis document relates to patients that are of Term Gestation and under 85 years of age however, the extension of age limits for organs does occur depending on demand. For this reason, any EOLC discussions in Critical Care Areas should be discussed with Donation Specialist Nurse Coordinator (DSNC). As per Section 1.2
4.2. Determination of Medical SuitabilityMedical Information CollectionMedical information is obtained via Patient notes Treating Team Medical Records – hard copy Clinical Information System (CIS) Clinical Records Information System (CRIS) MetaVision Clinical Portal Other Hospitals Records General Practitioner (After consent/ authorisation)
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Any other potential source of medical information
Initial Medical SuitabilityMedical suitability is guided by the Transplant Society of Australia and New Zealand (TSANZ) Clinical guidelines for organ transplantation from deceased donors – Version 1.0 – April 2016 The patient is brain dead or likely to progress to brain death – Brain Death (BD) The patient is not brain dead and is unlikely to progress to brain death – Donation
following Circulatory Death (DCD) The patient is supportable for up to 48 hours The treating ICU/ED consultant predicts that the patient will die within 90 minutes,
following Withdrawal of CardioRespiratory Support (WRCS) The patient has no absolute contraindication to donation Current active malignancy as primary admission diagnosis (excluding primary brain
tumours of grades 3 or less
This is a guide only and where there is a query as to the medical suitability of a patient or the potential for extended criteria organ donation, the DSNC will contact the DL ACT Donation Specialist Medical (DSM) to discuss further.
4.3. Family MeetingsFamily Donation Conversation (FDC)A family meeting will be held with the DSNC, ICU consultant or delegate, and may also include but not be limited to the Bedside Nurse, Social Worker and Aboriginal Liaison Officer. It is important to ensure that staff do not out number family members for these conversations. All information required to obtain a consent/ authorisation for organ and tissue donation will be conveyed to the family or potential donor. Essential information must be given to ensure an informed decision and valid consent/ authorisation is obtained.
The family meetings may take place over a number of meetings and hours, depending on the family’s needs and situation.
A family meeting should include the following, explaining and defining as required: Provision of basic needs such as privacy, all relevant family present and that family
members have had sufficient food and drink Offer and organise immediate and relevant spiritual support (religion/belief/family based
support person) Gain understanding of family structure/names/dynamics Ascertain the family’s understanding of the patient’s situation Reiterate BD or unsurvivable injury if required Explanation of BD testing/imaging with ICU Doctor if required If BD still to be confirmed then explain time of death after BD testing Discuss organ and tissue donation with the family Inform Family of AODR status (if listed) Explain why consent/ authorisation is required Identify the family’s SANoK
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Explain which organs and tissues can be retrieved if consent/ authorisation is given Explain the role of the Designated Officer Provide information to the family for Coroner’s cases (if not explained already by ICU
Medical Team) Time frames for donation Including Withdrawal of CardioRespiratory Support (WCRS) and rapid transfer to theatre
for DCD cases Required pathology testing and potential medical imaging prior to donation Explain the need for increased activity around donor: blood tests, x-rays, physio, ECG etc Theatre time Reasons why donation may not proceed Post donation viewing Post donation family follow up Family given ample opportunity to ask questions
The amount of information needs to be tailored to the family needs (ensure they have enough information to make an informed decision).
4.4. Communication PathwayWhen organ donation is planned to progress the DSNC will advise the following team members, to allow preparation for staffing and additional resources (if required): ICU staff Treating team consultant Theatre DL ACT DSM DL ACT Manager DL ACT State Medical Director (SMD) DL ACT DSNCs (as needed for staffing)
4.5. Donation Specialist Nurse Coordinator ActivitiesBloods A set of bloods will be taken at commencement of the donation process, these bloods
are then sent to Sydney for tissue typing, serology and Nucleic Acid Testing (NAT) DSNC will request, via the Intensivist or delegate, regular blood tests to be sent to ACT
pathology and arterial blood gases (ABGs) to be attended at the same time (as required)
Donor Medical Social Questionnaire A Donor Medical Social Questionnaire (DMSQ) is carried out to determine medical
suitability and risk assessment of the patient The DMSQ is undertaken with the Senior Available Next of Kin (SANoK) and any other
relevant family and friends Additionally, another DMSQ is undertaken with the General Practitioner (GP)
Physical Assessment
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The physical assessment requires a head to toe and back to front examination, using the techniques of observation/ inspection, palpation, percussion and auscultation
The physical assessment is to observe for any abnormalities and to match physical assessment with DMSQ
Will be attended by the DSNCs before referral to the transplantation teams
Selection of Donor Quilt DL ACT offer handmade quilts to families, which are placed with the patient during the
donation journey The quilt is kept by the family and taken home The DSNC will assist the family in the selection and placement of the quilt
Handprints/ Hairlocks Families are offered the opportunity to take handprints and locks of hair from their loved
one The DSNC/ bedside nurse will assist the family with this process
Data Collection/ Interpretation and Entry DSNCs will be collecting data and patient information, as per Section 2.4 Medical
Suitability All information will be entered onto the Electronic Donor Record (EDR) by the DSNC During the consent/ authorisation process, the SANoK is requested to give permission to
share data via the EDR, as required to relevant health professionals
4.6. Donor ManagementAcceptable Physiological ParametersDonor management is the maintenance of optimal organ perfusion and ultimately aims to maximise organ viability for transplantation.
Patient management shifts to donor management when the ICU treating team agree it is appropriate (in collaboration with the DSNC). This shift of priority can also require that treatment is recognised by the family as futile (in the DCD setting) or brain death is confirmed and consent/authorisation for donation has been obtained.
All potential donors are under the management of the ICU Intensivist or delegate with guidance from the DSNC and Donation Specialist Medical (DSM) on donation specific requirements. The ICU Intensivist will allocate a Registrar to liaise with the DSNC in facilitating investigations and clinical management of each potential donor. All potential donors must have a central line, an arterial line and an indwelling urinary catheter.
AnteMortem InterventionsAntemortem interventions are interventions that are required to facilitate donation PRIOR to death (in DCD cases). Antemortem interventions may be requested by the Transplant Teams, these will be discussed with the DSM and the ICU Intensivist before being
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commenced. These interventions should not be commenced if they will cause harm to the potential donor.
Examples of interventions that may be requested include (but not limited to): Antibiotics Steroids Heparin (except in cases of bleeding) Medication to optimise organ function can also be requested by the transplant teams Bronchoscopy Coronary angiography CT with or without contrast
Palliation in Organ DonationPatients, who are donating via the ‘DCD’ pathways, should ALWAYS have the same palliation pathway as any patient entering end of life care. Some clinicians have ethical issues and concerns when palliating patients going down the DCD pathway; they do not wish to be seen to be hastening death. According to the ANZICS ‘Statement on Care and Decision-Making at the End of Life for the Critically Ill’, Principle 3 states in general that “The use of medication for patient symptom control in this setting is ethically and legally appropriate, even though this may shorten life (Pg 10).” Organ donation should not influence ‘normal’ end of life care practices, the clinicians should follow their normal palliation regimes, with the ultimate goal to have a peaceful death.
In order to allay concerns a clinician may have in terms of palliation for DCD patients, they are strongly encourage to clearly outline their palliation plan PRIOR to withdrawal of treatment, which is in line with their normal palliation regime for any patient. This is further supported by ANZIC who provide a template for planning palliation in general – see Attachment 1 for ICU Palliation Care Plan – which outlines the medication to be used for sedation and pain relief– including doses, boluses and commencement time (if required).
The ANZIC Statement (above) along with the Australian Commission on Safety and Quality in Health Care (ACSQHC) – ‘National Consensus Statement on Essential Elements for Safe and High-Quality End-of Life Care’, both support the general palliation principles that: The patient and family should be the centre of the decisions made Palliation should be aligned the values, needs and wishes of the individual, including the
circumstances, environment and place in which they die
The ACSQHC Statement also empowers any person (staff or family) involved with the patient to voice concerns if they believe that end of life care needs are not being met.
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4.7. Theatre Preparations When the potential donor is assessed as suitable, the OT team leader needs to be
informed of donation activity for theatre such as :o Advise estimated time for retrievalo Organs that may be retrieved o Advise the OT team leader of updates to retrieval team estimated time of arrival
(ETA)
The retrieval teams provide: NSW DSC Transplant surgeon/s Assistant surgeon/s Anaesthetist Perfusionist/s
Equipment required: Ice (DSNC to organise) Laparotomy set up Bronchoscopy tray may be requested by retrieval teams
Pre-OT MeetingThe DSNC instigates and manages the OT team meeting that takes place prior to surgery. The “huddle” may be part of an ICU meeting or independent.
Meeting objectives: OT staff are introduced to the retrieval teams, names written on OT whiteboard Role clarification Confirm consent/ authorisation with all team members Confirm organs to be retrieved Confirm timeframes. The OT team must be scrubbed and set up prior to patient
transport Touch base with individual team members assigned to retrieval surgery Answer any questions Ensure all staff are comfortable to proceed Involvement of non relevant staff (e.g.: student nurses, doctors, physiotherapists etc) is
at discretion of the DSNC and Senior OT staff
4.8. DCD Withdrawal of CardioRespiratory SupportAll potential organ donors are palliated as per intensive care guidelines. Withdrawal of CardioRespiratory Support (WRCS) will not occur until the retrieval teams are setup and ready in OT.
Collaboration on time WRCS will be negotiated with family, OT and retrieval teams
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Intensivist and or delegate will be informed of when retrieval teams are available for retrieval
Family will be informed of WCRS time by the DSNC
Pre-WCRS Meeting Brief meeting with ICU treating Medical Officers, DO, wardsperson, bedside nurse and
other relevant staff will occur prior to the WCRS. DSNC will discuss WCRS, DCD and transport procedures with staff. In some instances, WCRS will occur in the OT as opposed to ICU
Palliative Care and WCRS Preparation All potential organ donors are given palliative care as per intensive care guidelines
Preparation for WCRS and OT transport:Preparations for DCD include (but are not limited to): Family will be with patient as per their wishes Pre-WCRS Meeting (as above) Theatre or ICU wardsperson to be on standby for transfer to theatre (preferably they are
present in the unit) Disconnect all monitoring except arterial pressure and oxygen saturations
o Ensure monitor is in palliation modeo Turn central screen away from familyo Silence all alarms o Reiterate to staff that monitor is not to be touched during WCRS as arterial pressure
trace must be visible to DSNC 1 at central station Remove all surplus equipment (pumps, IV stands, trolleys, chairs) Ensure all power cords are disconnected Place air mattress on transport mode & disconnect Donors arms are out of hospital gown Donor torso is shaved as required The location of ID bands are documented on the OT ‘Pre OR’ form and visible Ensure whole of ICU is prepared for transfer to theatre and route to theatre is clear and
other patients’ curtains/doors are drawn or closed Ward Clerk is aware not to admit visitors to the ICU between WCRS until after transfer to
OT Liaise with Team leader/ CNC to request if it is possible to restrict visitors access to ICU
during withdrawal of treatment and transfer to OT Ensure retrieval teams are ready ICU doctor declaring death (>5 years as medical practitioner) to be at a position where
they can see arterial pressure tracing (inside or outside of the room). This ensures doctor is aware of cardiac standstill; doctor can time the two minute hands off period and then declare death immediately.
Confirmation of DeathOnce cardiac standstill occurs:
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A two (2) minute “hands off” period commences After the 2 minute hands off, the ICU/ED doctor declares death. The ICU doctor then completes:
o A Death Certificate (for NON Coroner’s cases) and/ or o A “Determination of Death for Organ Donation After Circulatory Death” form
DO authorises organ donation
Patient Did Not Die in Timeframe for Organ DonationDCD only continues if a potential donor dies within the ischaemic time limits for specific organs (maximum of 90 minutes). If WCRS to cardiac standstill is more than 90 minutes then the organ donation ceases.
If WCRS took place in OT and the patient did not die in the timeframe, the patient should be transferred back to ICU: Donation process ends Theatre and Retrieval teams will be advised ICU ordered Palliation plan will continue for patient Family are able to remain with patient
Tissue donation is still possible (if this was consented/authorised) and will be facilitated by the DSNC within acceptable timeframes.
4.9. Donation SurgeryTime OutProcess upon arrival when the donor arrives in OT: ID bands checked by DSNC, OT staff, and surgeon Clarify time of death Paperwork shown to theatre staff
o Consent paperwork – SANoK and Coroner (where necessary)o “Death on a Ventilator” form for BD o “Clinical/ non Clinical – Determination of Death for Organ Donation After Circulatory
Death” form for DCDo DO authorisation for organ and tissue donationo Blood group sighted and signed by surgeon
Re-Intubation for a DCD Lung Donor by Visiting Anaesthetist, will be attended prior to transfer to OT table
Throughout surgeryAs per any surgery: Sedation or analgesia is not required but may be administered to prevent spinal
reflexes* Long acting muscle relaxant administered Anaesthetist role is to maintain ventilation/oxygenation and haemodynamic stability
until aortic cross clamp DSNC assists as required
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Note: Spinal reflexes such as tachycardia, diaphoresis and muscle movements can occur at time of incision.
Completion of surgeryAt completion of retrieval surgery: Retrieval team closes surgical incision and dress suture line All medical lines, cannula, CVC, IDC, ETT etc can be removed if not a coroner’s case. If the
patient is a coroner’s case, coroner’s advice will be obtained as to what can/cannot be removed (often permission is given to remove ETT so the family are better able to view their loved one)
DSNC washes the patient with OT staff assistance DSNC advises OT staff that debriefing will occur, if required
Transfer of Patient post-surgeryFamily ViewingIf the family wishes, they can see their loved one post-retrieval surgery in a familiar, private and appropriate setting. The preferred post-operative viewing area is their pre-operative ICU room, but this is at the discretion of the unit. Prior to end of retrieval surgery, the DSNC advises ICU approximate time for patient to
return and will double check bedspace availability If ICU have no bedspace then the DSNC will check with the OT patient flow leader about
using the Recovery isolation room as a viewing area (privacy is paramount) If none of the above areas are available then the family will be advised that viewing will
take place in the mortuary viewing room
4.10. Tissue Donation Will be attended in the mortuary after retrieval surgery, if it had not already occurred in
OT (See Section 5 for further details)
4.11. Follow Up SupportFamily The Family Support Coordinator (FSC) is responsible for bereavement support of donor
families and staff after donation occurs. The DSNC will phone the family post-donation at a pre-arranged time.
Staff All staff involved in organ and tissue donation will be informed and supported through
the process All staff will have opportunity to ask questions DSNC will visit ICU, theatre and ED (if appropriate) and provide outcome information and
receive staff feedback DSNC will liaise with senior staff and arrange a formal debrief by DL ACT, if required The DSNC will also offer all staff involved in organ and tissue donation (as needed)
contact details for the Employee Assistance Program.
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Section 5 – Tissue Donation5.
5.1. General InformationThis section describes the procedure for obtaining cadaveric tissue for transplantation and scientific purposes. Current medical suitability criteria for tissues are determined by the Tissue Banks that DL ACT utilise. The tissue retrieval process is coordinated by DL ACT clinical staff.
Logistical IssuesFor tissue donation to be completed within the 24 hour timeframe a Death Certificate is required before the DSNC can approach the family for authorisation to tissue donation. The Death Certificate needs to be completed at the time of death by the doctor that certifies death.
There may be a need for the potential donor to be transported to the CHHS Mortuary for the purpose of attending to tissue retrieval. If the patient is being transferred to CHHS after hours, the Afterhours Clinical Nurse Consultant will be required to sign the patient into the mortuary and to place an identification label onto the patient. The donor’s details will also be entered into the DonateLife Mortuary admission book located next to the mortuary entrance on the shelf (Black/Red A4 book).
5.2. Medical SuitabilityAll deaths are assessed to determine medical suitability for tissue donation. This check is fundamental in ensuring tissue donation is offered only to medically suitable donors. As part of the medical suitability prior to tissue retrieval commencing; a physical examination will be performed as part of the medical suitability (as per Section 4.5 Donor Medical Social Questionnaire and Physical Assessment).
5.3. Retrieval ProcessTissue retrieval, except eye tissue, will only be completed in the CH mortuary. Eye tissue retrieval can be undertaken within the following areas: Mortuary Theatre Ward areas Funeral Homes
5.4. Afterhours Tissue StorageWhen retrieved eye tissue is unable to be booked onto last flight of the day to the receiving Tissue Bank, the eye tissue will be stored in Pathology Level 2, back room specimens fridge. DSNC will complete the ‘ACT Pathology Request – DL ACT Tissue Storage’ form Pathology staff will log the tissue
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Collection will occur by courier to meet first flight the following day
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Section 6 – Donor Family and Staff Support6.
6.1. General InformationBereavement and aftercare is part of care for the family of every organ and tissue donor, unless refused by family. Aftercare in the initial stages is attended by the DSNCs and will then be followed with contact from the Family Support Coordinator (FSC). This follow up is done through face–to–face, phonecall, letter and email correspondence.
6.2. Staff Debriefs DSNC will visit ICU, OT and ED (if appropriate) and provide outcome information and
receive staff feedback DSNC will liaise with senior staff and arrange a formal debrief by DL ACT DSNC and DFSC DSNC will also offer all staff involved in organ and tissue donation (as needed) contact
details for the Employee Assistance Program
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Section 7 – Media, Legal and Ethical Issues7.
7.1. Media IssuesIf media have requested information around organ and tissue donation, the following will occur: Contact the DSNC oncall via CHHS switchboard 62442222 – 24hrs/ day DSNC will email request to [email protected] and cc DL ACT Agency Manager
7.2. Legal or Ethical IssuesIf legal or ethical issues arise as a result of a donation, the following should occur: Contact the DSM oncall via CHHS switchboard 6244 2222 – 24hrs/ day The DSM will assist with any issues and escalate to State Medical Director (SMD) if
required If the staff member, following consultation with DSM/ SMD still has issues, they should
escalate to the Executive oncall via Afterhours Hospital Managers
All donation activity is legislated and the DL ACT staff work within the boundaries of the following legislations: Coroners Act 1997 Human Rights Act 2004 Health Act 1993 Transplantation and Anatomy Act 1978 Health Records (Privacy and Access) Act 1997
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Director Generals Alert Senior Executive meetings Email to Senior Critical Staff
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Related Policies, Procedures, Guidelines and Legislation
CHHS Policies/CPs Framework for the Management of Coronial Business in the ACT Health Management of the Deceased Person Policy Privacy & Confidentiality Policy Public Interest Disclosure Policy Standards of Practice for ACT Allied Health Services ICU Palliation guidelines
Legislation Coroners Act 1997 Human Rights Act 2004 Health Act 1993 Transplantation and Anatomy Act 1978 Health Records (Privacy and Access) Act 1997 Information Privacy Act 2014
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References
1. Australian and New Zealand Intensive Care Society (ANZICS), ‘Statement on Care and Decision-Making at the End of Life for the Critically Ill’, Edition 1.0, 2014:
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2. Australian and New Zealand Intensive Care Society (ANZICS) Statement on Death and Organ Donation, Edition 3.2, 2013: http://www.anzics.com.au/Downloads/ANZICS%20Statement%20on%20%20Death%20and%20Organ%20Donation%20Edition%203.2.pdf
3. Australian Commission on Safety and Quality in Health Care, ‘National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care’, Version 1, 2015, https://www.safetyandquality.gov.au/wp-content/uploads/2015/05/National-Consensus-Statement-Essential-Elements-forsafe-high-quality-end-of-life-care.pdf
4. Australasian Transplant Coordinators Association Incorporated 5. DonateLife (2015), The Australian Organ and Tissue Donation and Transplantation
Authority, viewed April 2017, www.donatelife.gov.au 6. National Clinical Taskforce on Organ and Tissue Donation (2008) National Clinical
Taskforce on Organ and Tissue Donation Final Report: Think Nationally, Act Locally. Commonwealth of Australia.
7. Organ and Tissue Authority, ‘Best Practice Guideline for Offering Organ and Tissue Donation in Australia’, Version 1.0, June 2017 http://www.donatelife.gov.au/sites/default/files/Best%20practice%20guideline%20for%20offering%20organ%20and%20tissue%20donation%20June%202017.pdf
8. The National Health and Medical Research Council (NHMRC) – ‘Clinical Guidelines for Organ Transplantation from Deceased Donors’, Version 1.0 – April 2016, http://www.donatelife.gov.au/sites/default/files/TSANZ%20Clinical%20Guidelines%20for%20Organ%20Transplantation%20from%20Deceased%20Donors_Version%201.0_April%202016.pdf
9. The Transplantation Society of Australia and New Zealand (TSANZ) – ‘Ethical Guidelines for Organ Transplantation from Deceased Donors’ 2016, http://www.donatelife.gov.au/sites/default/files/NHMRC%20Ethical%20Guidelines%20for%20Organ%20Transplantation%20from%20Deceased%20Donors.pdf
10. The Transplantation Society of Australia and New Zealand (TSANZ) – ‘Organ Transplantation from Deceased Donors: Consensus Statement on Eligibility Criteria and Allocation Protocols’, Version 1.2,2012, https://www.tsanz.com.au/downloads/16thMayTSANZConsensusStatementVs1.2_000.pdf
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Donation, DonateLife ACT, End of Life Care, Designated Officer, Organ Donation, Tissue Donation
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Attachments
Attachment 1 – ICU Palliative Care Plan
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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Date Amended Section Amended Approved BySept 2017 All Sections CHHS Policy Committee
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Attachment 1 – ICU Palliative Care Plan
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