Organ Tissue Donation Policy

Organ and Tissue Donation Policy

Version 2

Name of responsible (ratifying) committee Organ Donation Committee

Date ratified 8th July 2014

Document Manager (job title) Clinical Lead for Organ Donation

Date issued 20th August 2014

Review date 19th August 2016

Electronic location Trust Intranet & NHSBT intranet.

Related Procedural Documents Controlled Non Heart Beating Donation Protocol

Key Words (to aid with searching)

Organ & Tissue Donation, Brainstem death, Donation after circulatory death (DCD). Donation after brainstem death (DBD). Withdrawal of treatment. Liverpool Care Pathway.

Version TrackingVersion Date Ratified Brief Summary of Changes Author

Policy for Organ and Tissue Donation. Version 2. Issued:20th August 2014 (review date 19th August 2016) Page 1 of 19

CONTENTS

QUICK REFERENCE GUIDE................................................................................................................2INTRODUCTION....................................................................................................................................32. PURPOSE.......................................................................................................................................43. SCOPE............................................................................................................................................44. DEFINITIONS.................................................................................................................................45. DUTIES AND RESPONSIBILITIES................................................................................................56. PROCESS Adults & Paediatrics..................................................................................................67. TRAINING REQUIREMENTS.........................................................................................................98. REFERENCES AND ASSOCIATED DOCUMENTATION.............................................................99. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS………………………………………………………………………………………………….1010. EQUALITY IMPACT STATEMENT…………………………………………………………………….10

Appendix Flowchart I - Donation after Brainstem Death (DBD) ………………………………………...12Appendix Flowchart II - Donation after Circulatory Death (DCD) ………………………………………..13Appendix Flowchart III - Tissue Donation ………………………………………………………………….14Appendix IV - National Tissue Services referral guide …………………………………………………...15

QUICK REFERENCE GUIDE

This document helps to support staff in aiming to provide tissue or organ donation as an option to all patients (and their relatives) of Portsmouth Hospitals as part of end of life care; making donation “usual”.

There is detailed background, references and processes laid out in the policy

At the end, there are FLOW DIAGRAMS that aid with the specific scenarios that will occur.


INTRODUCTION1.1.The policy aims to provide guidelines on organ and tissue donation at Queen Alexandra Hospital, supporting recommendations from the DH Organ Donation Taskforce report (Jan 2008), “Taking Organ Transplantation to 2020 (TOT20), a UK strategy” (DoH, July 2013) report, and NICE guidance on organ donation (2011).This policy will ensure that, where suitable, the option of organ and/or tissue donation will be offered to the patient’s next of kin (NOK - where NOK may include relatives, friends and significant others). It also ensures that healthcare professionals are aware of their role in caring for the potential donor and their NOK, and receive adequate support. This policy covers donation in adults and paediatrics.

“Organ donation should become usual and be a normal part of end-of-life care for appropriate patients, involving timely consultation of the NHS Organ Donor Register and appropriate involvement of the Specialist Nurse Organ Donation (SN-OD). Organ and tissue donation should be considered in all areas where end-of-life care is provided.”

1.2. In conjunction, the donation committee aims: To influence policy and practice in order to ensure that organ & tissue donation is

considered in all appropriate situations. To identify and resolve any obstacles to this. To ensure that a discussion about donation features in all end-of-life care, wherever

located and wherever appropriate, recognizing and respecting the wishes of individuals, or the NOK for patients unable to make choices (paediatrics and patients whom have previously lacked mental capacity to make their wishes known).

To maximize the overall number of organs donated, through better support to potential donors and their NOK

To ensure that donation is accepted and viewed as usual, not unusual. To maximize organ donation.

Ensuring: All potential donors are identified. Early contact made with the relevant Specialist Nurse-Organ Donation (SN-OD). Routine checking of the organ donation register in relevant patients. Donation is offered to all NOK where possible. Respect at all times to the decisions and views of the patients and their families. Encouragement to seek the views of all NOK as to the patient’s likely wishes. Provision of quality counselling, comfort and quality end-of-life care to patients and their

NOK. Move towards a culture of considering organ donation as a normal end-of-life process. Provision of embedded in-house SN-OD to support staff and NOK, and to educate with

a view to seeing donation as a normal part of the end-of-life pathway. Provision of sensitive and professional practice when approaching NOK. Follow best practice guidelines. Sensitive feedback and audit collection.


2. PURPOSEThis policy has been written to reflect current legislation and existing codes of practice on organ and tissue donation in the United Kingdom (UK). The policy will ensure that, where appropriate, the positive option of organ and/or tissue donation will be offered to all patients, and where appropriate (in most cases) their NOK, and that the explicit wishes of the patient are identified and respected. It also ensures that healthcare professionals are aware of their role in the identification and management of potential donors and their NOK.

3. SCOPE3.1. This policy applies to healthcare professionals, who will ensure that, where appropriate,

the positive option of organ and / or tissue donation will be offered to all potential donors and their NOK and that their explicit wishes identified and respected as part of end of life care. It also ensures that healthcare professionals are aware of their role in the identification and management of potential donors and their NOK.

3.2. This policy covers donation from both brain stem dead patients and those where the decision has been made for withdrawal of life sustaining therapies. Many steps in the donation process are the same for both donation following brain stem death (DBD) and donation following circulatory death (DCD); explanation is offered throughout this document where differences occur. This includes adults and paediatrics.

3.3. All patients undergoing brain stem death tests to be referred to the appropriate SN-OD at the earliest opportunity for consideration for donation after DBD.

3.4. Where the decision has been made to withdraw life sustaining treatment in the Emergency Department or Critical Care, these patients will be referred to the SN-OD as a potential donor for donation after circulatory death (DCD).

3.5. That brain stem death (BSD) testing should be carried out in all patients where BSD is a likely diagnosis, even if organ donation is an unlikely outcome.

3.6. Consideration of tissue donation in patients following death.3.7. Clinical priorities will take precedence in the situation where activity must be directed

away from organ donation towards life-sustaining actions for other patients being cared for by the relevant clinical staff (eg where acute admissions pathway +/- hospital capacity is overwhelmed by unpredictable workload such as ‘flu pandemics or major incidents).

4. DEFINITIONS Brain stem death (BSD)Irreversible cessation of conscious brain activity together with the loss of the ability to breathe (ACoMRC 2008). This is confirmed by well laid out brain stem death tests performed by experienced medical staff.Brain stem death testsA series of clearly defined tests used to establish whether or not the brain stem still has any function.Clinical Lead for organ donation (CLOD)An appointed clinical lead for the promotion of the potential for organ donation in the organisation, and ensuring any potential donation maximises the transplantation opportunities.Donation after brain stem death (DBD)The donation of an organ or organs after death has been confirmed by neurological criteria, ie BSD.Donation after circulatory death (DCD)The donation of an organ or organs after death has been confirmed following permanent cessation of the heartbeat. This pathway for donation has previously been termed donation after cardiac death, and non-heart beating donation.Donation committeeIs a multi-disciplinary group of individuals committed to organ donation that provides consensus and expertise to improve donation rates through education, policy implementation, awareness and audit.Human Tissue ActsThe Human Tissue Act 2004 applies in England, Wales and Northern Ireland and the Human Tissue Act (Scotland) 2006 applies in Scotland. Both Acts came into force in full in September


2006. The Acts are very similar but not identical, and cover (amongst other issues) the removal, storage and use of organs from dead people for transplants.Human Tissue Authority (HTA)The regulatory authority established under the Human Tissue Acts that, amongst many functions, defines the consent process (authorisation in Scotland) required for organ donation.Mental Capacity Act 2005The Act that describes, amongst many other things, what can and cannot be done to a person or patient who lacks the capacity to give consent themselves.National Blood Service (NBS)An operating division of NHSBT responsible for ensuring that there is a safe and secure supply of blood and most blood products for England and North Wales. It also has responsibility for some, but not all, tissue donation, banking and supply.NHS Blood and Transplant (NHSBT)A Special Health Authority within the NHS, established in 2005, that incorporates both UK Transplant and the National Blood Service, together with Bio Products Laboratory.Organ Donor RegisterThe NHS computer register of those who have recorded their wish to donate their organs and/or tissues after death.Potential Donor Audit (PDA)A UK-wide audit of patients who die in intensive care units. It was established in 2003 and provides information about the number of potential organ donors and whether they became actual donors or not.Specialist Nurse-Organ Donation (SN-OD).The primary role of a SN-OD is to ensure that the choices that individuals make in life are identified and fulfilled at the time of their death. Where an individual has not expressed a wish in life, SN-ODs support families when they make the decision on behalf of their loved one. More strategically, specialist nurses for donation are expected to work with CLODs and donation committees, to identify and overcome local barriers to donation and to make donation ‘usual, not unusual’.

5. DUTIES AND RESPONSIBILITIES5.1. SN-OD.

To support and deliver training in the process of organ and tissue donation, The SN-OD will co-ordinate and support actual donation processes in conjunction with the team caring for the potential donor. The SN-OD has professional accountability to NHSBT and, locally, is responsible to the Modern Matron of Critical Care and the Senior Nurse for the Emergency Department. The SN-OD will collate data for the Potential Donor Audit and present findings to the donation committee and NHSBT.

5.2. Clinical Lead for Organ Donation (CLOD)To provide clinical leadership within the Trust/hospital to raise the profile of organ donation; to maximise the local organ retrieval rates and to ensure the Trust implements the recommendations of the Organ Donation Task Force (ODTF) and TOT20 reports across the whole Trust, focussing particularly on Critical Care and the Emergency Department.

5.3. Critical Care and Emergency Department staff.To support the training of all health care professionals in end-of-life care. To ensure that, where appropriate, the positive option of organ and / or tissue donation will be offered to all potential donors and their NOK and that their explicit wishes identified and respected as part of end of life care.

5.4. Donation Committee. Leading on policy and practice in order to ensure that organ and or tissue donation

is considered in all appropriate situations. Ensuring that a discussion about donation features in all end-of-life care, wherever

located and wherever appropriate, recognising and respecting the wishes of individuals.

Maximising the overall number of organs donated, through better support to potential donors and their families.


Ensuring that organ and tissue donation adheres to best practice guidelines, along with national and local policies and procedures.

Ensuring that the Organisation complies with the Report of the Organ Donation Taskforce published in January 2008, and its 14 recommendations which, amongst others called specifically for the appointment of Trust Clinical Donation Champions (now termed CLODs) and the formation of Trust Donation Committees chaired by a non-clinical Donation Champion (Recommendation 4)

Ensuring the organization works towards the taking organ transplantation to 2020 strategy (DoH July 2013), especially Outcome 2. In particular, the donation committee will look to engage the local community about organ donation and transplantation, including making the most of all publicity opportunities.

5.5. All Healthcare Professionals have responsibility to:Provide all next of kin/significant of potential donors, the opportunity to consider organ and tissue donation as part of end-of-life care.Where possible to use a collaborative approach to achieve a consistent and effective research based approach to donation. Ensure consideration is given to tissue donation in patients that die in any clinical area.Inform relatives of potential donors about the support services provided for example: Chaplaincy and Bereavement.

6. PROCESS Adults & Paediatrics (See flow charts for DBD & DCD: Appendix I, & II)If the donation process includes paediatrics then it is recommended that extra advice is sought from a Paediatrician where appropriate. 6.1. The referral. Donation after brain stem death. (DBD)6.1.1. Outside of office hours, contact can be made with the on call SN-OD (pager

07659183499). 6.1.2.When brain death is suspected, certification of death by brain stem tests should be

performed (as set out by the Academy of the Medical Royal Colleges 2008). This should be done regardless of the question of organ donation and allows staff and relatives to be confident that further therapy is of no benefit.

6.1.3.Normal homeostasis is maintained with fluids and vasoactive drugs as indicated.6.1.4.The clinician or nurse will refer all patients who are potentially going to undergo brain

stem tests to the embedded SN-OD as soon as the sedation/analgesia have been discontinued or immediately if the patient was never on medication. If the patient is not due to be tested imminently due to sedation, the SN-OD should still be contacted so that they can negotiate with the consultant an appropriate time to be available at the hospital.

6.1.5.The SN-OD, clinician or nurse will check the ODR to see if the patient is registered. The regional SN-OD’s are available at all times to assist and support families though the decision making process.

6.1.6.The referring staff will have clinical information available for discussion with the SN-OD to ascertain the potential suitability for donation.

Donation after circulatory death. (DCD)6.1.7.When the decision is made to withdraw life sustaining treatment, it must be based on a

multi-disciplinary consensus on the futility of continued organ support. Where possible, this should involve senior medical and nursing staff and key family members. A decision to withdraw must be transparently independent from any discussion about organ donation.

6.1.8.The criteria for organ donors after circulatory death are as follows: A decision to withdraw life sustaining treatment has been made. Patients are on advanced respiratory support. (Non invasive ventilation is not a total

exclusion to referral). The patient has been clear of any malignancy (excluding primary brain tumours) for 3

years and does not have HIV disease (not HIV infection) or suspected CJD. Relative contraindications for all organs should be discussed with transplant teams via

the SN-OD e.g. high oxygen requirements, blood pressure, BMI, diabetes mellitus etc.


6.1.9.If a patient meets these criteria, then the nurse or clinician should contact the SN-OD for patient assessment.

6.1.10. The SN-OD, clinician or nurse will check the ODR to see if the patient is registered.6.1.11. The referring staff will have clinical information available for discussion with the SN-

OD to ascertain the potential suitability for donation.6.2. The approach for donation (DBD & DCD)6.2.1.A planned approach should be made. A collaborative approach has been shown to

increase consent rates.6.2.2.The approach to the NOK should be made at an appropriate time, normally once the

NOK understand that brain stem death has been confirmed or that treatment will be withdrawn and the patient is likely to die. The NOK should be given time and privacy to consider events and the information about organ donation.

6.2.3.The option of organ donation should NOT be given to the NOK in the same discussion as the decision to withdraw treatment (unless the NOK raises the issue) and the NOK should be given the time to accept this decision.

6.2.4.The approach to the NOK would usually be carried out by the SN-OD so that there was no perceived conflict of interest.

6.2.5.Whatever the NOK’s decision, this will be respected and continued care and support be given as appropriate. The outcome of discussions must be documented in the patient notes and if the NOK decline to proceed with donation, the reason should be documented.

6.3. Donation process (DBD & DCD)If the patient is on the Organ Donor Register, which is now recognised as lawful consent (HTA 2004), the SN-OD will inform the NOK of the patient’s wishes regarding donation. The SN-OD will discuss the organ donation procedure and answer any questions. Consent documentation will be completed, along with a medical and social history assessment obtained from the NOK. If the NOK disagree with the patient’s wishes, this would require further investigation and exploration. (There are clearly some circumstances when the NOKs’ wishes should be taken into account and therefore donation should not occur. These should be assessed on an individual basis).

If the patient has not made their wishes known during their lifetime, the SN-OD will make reasonable enquiries to determine if the patient has nominated a representative during their lifetime to act on their behalf after their death. If no representative is identified, then the relative ranking highest within the hierarchy (as per the Mental Capacity Act 2005) will be approached to discuss the possibility of organ donation.

If the NOK happens to raise the possibility of organ donation with local staff without being formally asked for donation, the duty consultant should be informed and a referral to the SN-OD should be made. The SN-OD will advise staff on how to proceed, and will discuss donation with the family and facilitate the organ donation process.

The SN-OD will provide information for the NOK on organ donation and the processes involved. The NOK will be encouraged to ask questions which will be addressed. Where requested the NOK should be left to discuss donation privately, ensuring appropriate support is available should they require it. If the NOK give their consent for organ donation to proceed, The SN-OD will discuss donation with the NOK and obtain formal documented consent along with a medical and relevant social history assessment.

The SN-OD/doctors will discuss potential donors with HM Coroner where indicated (as is the case in almost all cases); if further investigations into the cause of death are required, this will be discussed with the coroner’s officer on an individual basis. Occasionally HM Coroner may place some restrictions on the donation dependant upon the circumstances of the patient’s death.


Donation after circulatory death (DCD)

The SN-OD will facilitate the donation process; once consent is obtained Critical Care staff will be asked to perform several investigations, which include the collecting of blood specimens for tissue typing and virology testing.

Withdrawal of treatment takes place in the Critical Care or other agreed area (i.e. recovery or anaesthetic room), at a time negotiated and agreed by the NOK, SN-OD (in collaboration with the organ retrieval teams) and hospital staff. A member of the Critical Care, Emergency Department or anaesthetic staff performs the withdrawal of supportive therapies. Family may wish to be present during this time; medical and nursing staff are also present during this stage. The patient is closely monitored following withdrawal.

After five minutes of the absence of cardiac output the Doctor declares the patient dead using current standard criteria (Academy of Medical Royal Collages 2008). Written confirmation of death by circulatory criteria must be entered in the hospital notes, and be in accompaniment with the patient. Following the confirmation of death, the patient is moved into the operating theatre and the retrieval operation can begin. The surgical team will be on site and on standby within the theatre complex prior to withdrawal of treatment.

In all cases the organ retrieval process will be coordinated by the SN-OD who will support all staff involved in the patient’s care throughout. Care of the deceased patient’s body is performed by the hospital staff and assisted by the SN-OD in accordance with the hospital policy. Respect and dignity for the patient is maintained at all times.

Donation after brain stem death (DBD)The SN-OD will facilitate the donation process. Critical Care staff will be asked to perform several investigations which include the collecting of blood specimens, ECG, chest X-ray, echocardiogram, and the administration of methylprednisolone, T3 and Pitressin. An organ donation reference folder is available, providing detailed information on donor management and the rationale for investigations. The SN-OD will be present for advice and guidance as to the management of the organ donor. A care bundle has been developed by NHSBT for the management to these patients and will be given to the care team by the SN-OD after consent has been given.

6.4. DocumentationThe SN-OD and the medical staff involved with the patient’s care will record a clear and precise record of all events in the hospital medical notes.

Brain stem death should be recorded as indicated in the Code of Practice for the Diagnosis of Brain Stem Death and attached to the medical notes.

If the patient proceeds to organ donation, a copy of the consent and the patient assessment forms should be filed in the medical notes. The retrieval teams will record the surgery in the patient’s notes.

6.5. Tissue Donation – See Flowchart on the Process for Tissue Donation (Appendix III)

Approach for tissue donation 6.5.1.In the event of all deaths within the Trust, a member of staff who is knowledgeable and

confident should ascertain whether the patient had expressed a wish to donate after his/her death. NOK should be offered information regarding tissue donation options. The SN-OD can offer support and guidance to the healthcare professionals involved with approaching the NOK at this time.

6.5.2.At the time of renewing this policy the ICU and ED departments have become part of the Alliance Site project (National Blood Service) to increase tissue donation by a mandatory referral system. All deaths in ICU and ED that are under 80yrs old and do not have


absolute contra-indications to tissue donation are to be referred using the referral form at appendix IV

6.5.3.This system does not require nursing or medical staff to discuss tissue donation with the bereaved as they will be given a tissue donation booklet along with the standard bereavement care booklet. The staff are to then make the referral using the referral form and NBS Tissue services will contact the bereaved to offer tissue donation if it is appropriate.

6.5.4.The national tissue referral centre can also advise on tissue donation and will take referrals to consent for tissue donation (National Blood Service (NBS) Tissue Coordinator: 0800 432 0559) by email or fax, see appendix IV.

Tissue Donation process 6.5.5.If the NOK give their consent for organ donation to proceed, the SN-OD will discuss

tissue donation with the relatives and obtain formal documented or recorded consent along with a medical and social history assessment, as per NHS Blood and Transplant policy & Human Tissue Act 2004 on obtaining consent for donation.

6.5.6.If consent is given for Tissue donation and further investigations into the cause of death are required the patient should be discussed with HM Coroner. Occasionally HM Coroner may place some restrictions on the donation dependant upon the circumstances of the patient’s death.

6.5.7.NBS tissue services or the SN-OD will organise the tissue retrieval process with assistance from relevant tissue banks. This process is carried out in the mortuary and does not delay movement of the patient from the ward area. The hospital staff, in accordance with the hospital policy, performs standard care of the deceased. Respect and dignity for the patient is maintained at all times.

6.5.8.The patient is required to be in the mortuary within 6 hours of confirmation of circulatory death to donate tissues. If this is likely to be longer, then please check with tissue services on potential for tissue retrieval.

7. TRAINING REQUIREMENTSAll staff should be trained in end-of-life care, understanding which patients would be suitable for organ and tissue donation.Staff should be trained in how and when to make tissue referals to NBS tissue services. Staff are still very much supported to talk to the bereaved about tissue donation if they feel they have the appropriate skills and knowledge to approach next of kin for tissue donation.Staff will understand the flow processes to donation.Training will be facilitated by members of the Donation Committee for the relevant Departments and Trust staff, and attendance recorded at a local level.

8. REFERENCES AND ASSOCIATED DOCUMENTATIONAcademy of the Medical Royal Colleges (2008) A code of practice for the diagnosis and confirmation of deathHuman tissue act (2004)Mental Capacity Act 2005

Links to other key Strategies & PoliciesDepartment of Health (2008) Organs for Transplants: A report from theOrgan donation taskforce.

UK NHSBT (2004) Donor Family Care Policy.

Human Tissue Authority. Code of Practice – Donation of organs.

Human Tissue Act 2004. www.hta.gov.uk.

Intensive care society (2005) Organ and tissue donation guidelines.


http://www.hta.gov.uk/

Legal issues relevant to non-heartbeating organ donation2009 Department of Health http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_108825

Map of medicine: http://www.mapofmedicine.com

Organ donation: http://www.organdonation.nhs.uk

Organs for Transplants – A Report from the Organ Donation Taskforce. DOH January 2008. www.dh.gov.uk

Saving Lives, Valuing Donors: A Transplant Framework for England. DOH July 2003. www.dh.gov.uk

United Kingdom Hospital Policy for Organ and Tissue Donation – UK Transplant 2003

Tissue and cells for transplantation. Code 2 July 2006. www.hta.gov.uk.

Withholding and withdrawing - guidance for doctors, 2010 General Medical Councilhttp://www.gmc-uk.org/guidance/ethical_guidance/6858.asp

Taking organ transplantation to 2020. A UK strategy 2013 DoH

Organ donation: implementing NICE guidelines Nov 2011 DoH

9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS

Embedded SN-OD to audit all deaths occurring within Critical Care/ED Units – Potential Donor Audit. This audit will demonstrate rates of potential donor identification, referral, and approach to the NOK and consent to donation.

Embedded SN-OD to continue to collect data on all potential tissue donor referrals – proceeding to donation and non–proceeding.

This document will be reviewed after one year or sooner if new evidence, legislation or change in best practice occurs. All of the above information will be taken into account along with details of adverse events in assessing the effectiveness of the Policy

If through ongoing compliance monitoring the policy is found to not be delivering the expected results, the SN-OD and Donation Committee will review the results and amend the Policy accordingly.

10. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

All policies must include this standard equality impact statement. However, when sending for ratification and publication, this must be accompanied by the full equality screening assessment tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy Documentation


http://www.gmc-uk.org/guidance/ethical_guidance/6858.asp

http://www.hta.gov.uk/

http://www.dh.gov.uk/

http://www.organdonation.nhs.uk/

http://www.mapofmedicine.com/

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_108825

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_108825

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:Respect and dignityQuality of careWorking togetherNo waste

This policy should be read and implemented with the Trust Values in mind at all times.


Donation after Brain-stem Death (DBD) Appendix I


Brain stem death (BSD) is suspected.

Patient has a confirmeddiagnosis of BSD Patient DOES NOT

have a diagnosis of BSD.

Discuss the case with the coroner. Record any coroner’s restrictions to

donation

Patient is not BSD Consider DCD pathway

Notification of potentialdonor to Specialist

Nurse Organ Donation(SN-OD).

Pager: 07659183499

Check Organ Donor Register: Duty Office at the Directorate of

Organ Donation and Transplantation in Bristol on 0117

9757580 or 0117 9757581

Assessment of patient for donation by the SN-OD & clinician

Discussions with NOK ensuring understanding of

BSD

Patient potentiallysuitable for organ

donation?

Planned approach for donation to include SN-OD,

clinician & nurse.

Family object to donation

End of life care pathway

Family agree or consent to donation

Obtain blood samples for tissue typing and

virology

SN-OD will co-ordinate organ offering, theatre, retrieval teams & family

follow up

Patient NOTpotentially suitable for organ

donation


Consider tissue donation pathway

Formal consent and patient assessment

completed by SN-OD

NOK / clinicians / nurses will be kept

informed of the process

Maintain therapy andphysiological stability

- use NHSBT donor care bundle


Maintain therapy and physiological stability

: (Perform BSD Testing)

Patient will require the following tests: CXR, ECG, FBC, U&E’s, LFT’s (including

GGT, & amylase), Clotting studies, Blood group.

ECHO (if cardiothoracic organs considered)

The patient remains physiologically supported and ventilated until post cross clamp in theatre. The hospital will provide an anaesthetist. The SNOD attends theatre with the patient.

The SN-OD will arrange for staff and NOK to receive information following the donation process.

Donation after circulatory death (DCD). Appendix flowchart II


Decision made thatto continue treatment

would not be of overallbenefit to the patient

Discuss the case with the coroner. Record any coroner’s restrictions to

donation.

Notification of potentialdonor to Specialist

Nurse Organ Donation(SN-OD).

Pager: 07659183499

Check Organ Donor Register: Duty Office at the Directorate of

Organ Donation and Transplantation in Bristol on 0117

9757580 or 0117 9757581

Assessment of patient for donation by the SN-OD & clinician

Discussions with NOK ensuring understanding of

futility.

Patient potentiallysuitable for organ

donation?

Planned approach for donation to include SN-OD,

clinician & nurse.

Family object to donation


Family agree or consent to donation

Obtain blood samples for tissue typing and virology

SN-OD will co-ordinate organ

offering, theatre, retrieval teams & family follow up

Patient NOTpotentially suitable for organ

donation


Consider tissue donation pathway

Formal consent and patient assessment

completed by SN-OD

Family / clinicians / nurses will be kept

informed of the process.


Maintain therapy andphysiological stability.

Maintain therapy and physiological stability

Patient will require the following tests: CXR, ECG, FBC, U&E’s,LFT’s (including GGT,& amylase),

Clotting studies, Blood group.

The patient is taken to theatre immediately following certification of circulatory death. The SNOD attends theatre with the patient.

The SN-OD will arrange for staff and NOK to receive information following donation.

Planned withdrawal of life sustaining measures

Policy for Organ and Tissue Donation. Version 1. Issued: August 2014 (review date August 2016) Page 14 of 19

Page 14 of 19

Has the patient died? No

In all other cases:Give unit bereavement booklet and tissue donation leaflet and E-Mail the NBS referral form to

[email protected] sure you have the contact details of bereavedShould you have any questions before making a referral please call NBS tissue services on 0800 432 0559

Absolute contraindications to ORGAN donation -Over 85yrs of agePrimary intra cerebral lymphomaAll secondary intracerebral tumorsActive CA with evidence of spread CJD and variantsactive and untreated TB.West Nile virusAnd HIV (active)

Contact Specialist Nurse–Organ Donation before withdrawal, they will assess if suitable for Organ Donation

07659 183499 – 24hrs. Leave your name & full contact details you will receive a reply

within 20mins.

Tissues for donation can include:Skin TendonsHeart valves LigamentsBone Blood vesselsCorneas Age limits apply for some tissues. Tissue Services or a SN-OD can advise on this.

Yes

Is there is a plan to withdraw treatment and the patient is receiving advanced respiratory +/- circulatory

support?

Consultant must be involved in this decision & aware of potential for

donation.

YES

If the deceased is over 85 and had any of the follow. No further action is required regarding Tissue donationAlzheimer’s disease and other neurological degenerative diseases (All dementias and Parkinsonism) Diseases of unknown aetiologyLeukaemia and LymphomaHIV, Hep B, Hep CCJDViral Encephalitis or Encephalitis or unknown origin, Viral Meningitis

Give bereaved unit bereavement booklet and Tissue donation leaflet

Make referral using the form at Appendix Discuss / offer potential tissue donation with NOK. Inform of ODR check and any restrictions.They do not need to make a decision right away and can wait to consider once they get home. (Tissue donation can occur up to 24hrs after death and up to 48 hrs. for some tissues)Ask if they would like more information and if they do a specialist nurse will contact them. Warn them they will be asked some personal questions to ensure donation is a suitable option.

If the

End of life care.Organ and Tissue Donation

To check the Organ Donor Register (ODR) Tel: 01179 757580 (24hrs) you will need patients name, date of birth & address.

(Not being registered does NOT exclude donation)

Appendix flowchart III

mailto:[email protected]

Appendix IVTissue referral to National Referral Centre (NRC)

All deceased patients who are:

A Not absolutely contra-indicated to tissue donationB under 85years of age

Are to be referred to National Referral Centre (NRC) using the Tissue donation referral form and E-Mailing to [email protected] for consideration of potential tissue donation, and if appropriate they will be offered the option of tissue donation by the NRC.

Absolute contra-indications to tissue donation at August 2014 are:

HIVHepatitis B or CDementia and any other neurological degenerative diseaseDisease of unknown etiologyLeukemia or lymphomaActive tuberculosis

General information about proceeding tissue donation

The deceased’s body must go to the mortuary with 6hrs of death.Blood samples will be taken to support any tissue donation.The deceased GP will be contacted to check past medical history You (or the doctor) may be asked for more information of the patients past medical historyAll retrieval of tissues is preformed like any surgical operation and the body is closed with sutures where necessary and covered with dressings. For eye donation the normal shape of the eye is restored with the eyelids closed. For Skin donation the areas are covered with appropriate dressings.

Tissue donation will not affect any funeral arrangements.All tissue retrieval will be done in this hospital mortuaryThe body can be viewed pre and post donation

Process.During the discussion with the family and relatives it is normal practice to give a bereavement booklet. In addition to this booklet you must include a tissue donation leaflet. You must also fill in the tissue donation referral form and e-mail it to [email protected]. Instructions on how to do this are attached.

Please note faxing must only be done as a last resort and a call to the NCR made pre and post faxing to make sure that the fax has arrived at it intended destination.

The referral will be assessed for potential to donate and if tissue donation is possible the NRC will make a call to the relatives at home to offer the option of tissue donation in line with Portsmouth hospitals end of life care policy.

Q&A

1Q Do I mention or offer tissue donation to the family?




1A their is no need for you to offer the option of tissue donation. Whilst there is no reason why you shouldn’t offer tissue donation, the criteria for tissues is ever changing. So it is better to either; find out what is possible or refer to the specialist in that area.

2Q What if the family see the tissue donation leaflet and make it clear that the deceased would not want tissue donation?

2A Document in the notes and DO NOT make a referral

3Q what if the deceased has an absolute contra indication to tissue donation?

3A Document in the notes and DO NOT make a referral. You can tell the family that you have considered tissue donation but that in this case it is not possible due to an absolute contra-indication.

4Q what do you do if the family ask what can they donate?

4A Refer to the leaflet but say that a specialist nurse in that field will call them when they get home to identify what is possible and what they would like.

5Q should I check the Organ Donor Register?

5A it is good practise to check the organ donor register as this will give you more information. It may help answer questions if asked about tissue donation. However it is not necessary to do so because the national referral centre will check the organ donation register before they make a formal approach for tissue donation.

6Q what should I do if I don’t know the answers to questions about tissue donation?

6A Tell them that this is not your specialist area, and that you will get a specialist to call them to discuss tissue donation when they are at home.

7Q how quickly must tissue donation happen, how long does the family have to make a decision?

7A Tissue donation must be done within 24 hrs for corneal donation and 48hrs for all other tissues. The decision does not need to be made immediately but allow for the organisation of retrieval. No decision needs to be made during the initial bereavement discussion they will receive a call from tissue services to discuss fully in due course.

8Q should I inform the coroner?

8A the coroner must be informed if the patient is reportable to the coroner under normal circumstances. Otherwise the national referral centre will discuss with the coroner if required.

9Q what should I do if I need more information now?

9A Call the NRC and ask for advice on 0800 234 0559 or If Mick Willcox or Helen McManus the specialist nurses for Organ donation are in the hospital ask them for help.




11. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assurance compliance.

Minimum requirement to be monitored

Lead Tool Frequency of Report of Compliance

Reporting arrangements Lead(s) for acting on Recommendations

Referrals to SN-OD SN-OD NHSBT Potential Donor Audit

Annual Policy audit report to: Donation Committee, NHSBT

CLOD, SN-OD

Neurological testing SN-OD NHSBT Potential Donor Audit


CLOD, SN-OD

Consent SN-OD NHSBT Potential Donor Audit


CLOD, SN-OD

The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.

The details of the monitoring to be considered include:

The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs); The lead for ensuring the audit is undertaken The tool to be used for monitoring e.g. spot checks, observation audit, data collection; Frequency of the monitoring e.g. quarterly, annually; The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required.

In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on the Trust Intranet Trust Intranet -> Policies -> Policy Documentation

The lead(s) for acting on any recommendations necessary.


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