Brain Death Approach vs Donation after Cardiac Death Approach

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Brain Death Approach vs Donation after Cardiac
Death Approach
Robert Coppel Family Care Specialist, OneLegacy
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Discussion about End Life
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Determination of Death

• Two types of death
• Biological death
• aka Cardiac death
• Irreversible cessation of circulatory and
  respiration functions
• Neurological death
• aka Brain death
• Irreversible cessation of all functions of the
  entire brain, including the brain stem
  independently confirmed by another licensed
  physician.

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Brain Death and DCD History

• Prior to 1968, all transplanted organs came from
  donors who had suffered Cardiac Death
• 1968Harvard Ad Hoc Committee on Brain Death
  publishes a report addressing irreversible coma
• New diagnosisBrain Death
• Brain Death became the standard for organ
  donation because of improved outcomes
• Beginning 2000s Donation after Cardiac Death
  (DCD) reintroduced

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Ethical Axiom of Organ Donation

• UNOS DCD Consensus Conference
• Adhere to the dead donor rule
• The retrieval of organs for transplantation
  should not cause the death of a donor
• Multiple organs should be removed only after
  death
• (Donation after Cardiac Death Donation after
  Brain Death)
• Donation option should only be presented after
  family made a decision to withdraw
  life-sustaining measures

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Potential DCD Donor

• Patients with severe neurological injury
• Anoxic injury, intracranial hemorrhage, stroke,
  trauma
• Patients without neurological injury
• Degenerative neuromuscular diseases
• End-stage cardiopulmonary diseases
• Do not meet the criteria for brain death
• No chance for survival off the ventilator
• Family elects to withdraw support (DNRs)

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Referral for DCD
VENTILATED

• BEGINNING discussions of
• End-of-Life
• Withdrawal

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Evaluation for DCD

• Medical suitability
• DCD Tool evaluates if death would likely occur
  within 1 hour of withdrawal of care
• Patient may be eligible to donate kidneys, liver,
  lungs, pancreas and all suitable tissue

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Prior to Approach for DCD

• Pt determined to be medically suitable
• AFTER family has decide to withdraw care
• Family Care Specialists huddle with hospital
  team

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Prior to Approach for DCD

• Hospital team set up time for family meeting
• Preparations
• Hospital policy
• Can OR accommodate family members
• Who and how will the OL coordinator will be
  introduced
• The role of the hospital team member in the
  approach

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The Approach for DCD

• Answer questions
• Provide missing information (e.g. coroners case)
• Informed request for DCD
• Possibility of progression to brain death
• Obtain brain death consent as well

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The Approach for DCD

• Explain timeline and DCD logistics
• Preparation time
• OR
• Extubation in the OR
• Family presence in the OR

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The Approach for DCD

• Explain timeline and DCD logistics (continued)
• Comfort measures
• What family may witness / experience
• 60 Minute limit for expiration
• Recovery

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If Family Declines Donation

• Offer support to family as they gather relatives
  and friends to say good-bye
• Provide packet of information
• Offer to help with funeral arrangements, grief
  support, and referrals

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If Family Consents to Donation

• Offer family a Memory Box and Handprints
• Support family friends throughout process
• Provide grief packet
• Information on organ and tissue donation
• Family Services support programs
• Call family after recovery to provide information
  about organs recovered

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Fundamentally

• The family should make the decision to withdraw
  life support independent of and prior to, any
  discussion regarding organ donation.