Physician Champions: Role in the Organ Donation Process

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Physician Champions Role in the Organ
Donation Process

• GIFT OF LIFE MICHIGAN
• CME PRESENTATION
• APRIL 15, 2009
• MICHAEL JAGGI, DO, FACEP, FACP
• Vice President and Chief Medical Officer
• Chairman, Department of Emergency Medicine
• Hurley Medical Center
• Flint, Michigan

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Faculty Disclosure

• Physician Champion
• Gift of Life Michigan
• No disclosure

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Focus Group Feedback(17 critical care physicians)

• Improve collaboration and communication with Gift
  of Life donation coordinators
• Participate in the donation discussion with
  families
• Contribute their clinical expertise to improve
  donation outcomes
• Understand the donation coordinators
  qualifications and expertise
• Define the physician and donation coordinators
  roles and expectations.
• Understand current reimbursement practices for
  their services during the donation process
• Based on Feedback from
• Focus Group Research Summary Report by
• Advantage Research Services, Inc. (Oct 08)

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Waiting List vs Organ Donors(National)
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Statistics

• In 2008, 27,958 lives were saved and improved
  because of organ transplants
• 6,801 people died in 2008 while waiting for an
  organ transplant
• 19 deaths each day on the waiting list

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Michigans Big House
Capacity 107,501
101,203 people on the Waiting List for organ
transplants (as of 3/24/09)
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Michigan Patients on Waiting List (as of
March 1, 2009)

• Kidney 2491
• Liver 293 Lung
  50
• Kidney/Pancreas 50
• Heart 77
• Pancreas 25
• Kidney/Liver 17
• Kidney/Heart 1
• TOTAL 3004
• In 2008, Michigan hospitals facilitated recovery
  of
• 922 organs for transplant.

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• Engaging
• Physician Champions

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Physician Champion

• What role can a physician champion
• play in your hospitals organ donation
• process?

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Physician Champions Role

• Advocate for organ donation
• Liaison between Gift of Life and your hospital

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Physician Champions Role

• Participate as an active member of the hospitals
  Donation Committee
• Assist in identifying other key individuals to
  serve on Donation Committee
• Promote Organ Donation Outcome Measures in both
  clinical practice and policy development.
• Evaluate CMS compliance issues
• Provide follow-up on issues with physicians
• Participate in Trauma Committee, if appropriate

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Role in Medical Education

• Advocate Donation Best Practices internally and
  to other hospitals and physician groups
• Discuss organ donation practice guidelines at
  professional organization meetings
• Assist Gift of Life in identifying physician
  audiences needing CME
• Teach physicians to collaborate with Gift of Life
  for optimal outcomes for all

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Physician Champion as Educator

• Target residents and medical students our
  future donation champions
• Set the bar high for Residents regarding
  interactions during donation processes
• Take an active role in teaching Residents and
  Medical Students
• Model effective family communications
• Teach the importance of collaboration with Gift
  of Life in the donation process

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Engaging in Donor Management

• Donor Management
• Support patient overnight to allow time for
  family to accept grave prognosis
• (Catastrophic Brain Injury Guidelines)
• Facilitate line insertions and evaluative
  procedures (arterial line, lab tests, bronchs,
  echos)
• Consult PRN (infectious disease, brain tumor
  evaluation)

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Physician Champions Qualities

• Respected among their peers
• Firm belief in the benefit of organ donation
• Leadership, decision making position within the
  institution or department
• Enthusiasm, understanding, model behavior a
  team player
• Willingness and availability to resolve barriers
  to organ donation

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Physician Leadership Voice

• Physician Champions include
• Medical Directors, Chiefs of Medical Staff
• Department chiefs (surgery, trauma, etc.)
• Intensivists, Trauma Surgeons, Pulmonologists
• Emergency Medicine Physicians, Hospitalists
• Neurosurgeons, Neurologists
• Clinical specialty not as important as ones
  willingness to pursue each donation opportunity.
• Donation Champions also include nurses, social
  workers, chaplains, etc.

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Building a Culture of Success

• Hospitals with identified Physician Champions
  have a more collaborative internal process
• Physician Champions have a pivotal role in the
  hospitals organ donation process!

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• CASE STUDY
• Physician Champions Role
• in an Effective Approach Process
• Evidence-Based Physician Best Practices for Organ
  and Tissue Donation

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Case Study 1

• Upon Admission
• 20 yom w/GSW to head non-operable
• Pupils NR, Corneals, Cough, posturing
• Not breathing over vent, no pressors or
  paralytics
• PMH
• Marijuana (2 joints/day x 6yrs)
• Cigarettes (1 ppd x 6yrs)
• Whiskey (Fifth 2x/wk x 5 years)

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Case Study 1

• Day 1
• 2200 Patient presented w/ GCS 3
• met clinical triggers in ER
• Day 2
• 0030 Pt admitted to Neuro-Trauma ICU
• 0035 RN called referral to Gift of Life
• CMS requires hospitals to notify Gift of Life
  within one
• hour of any patient meeting clinical triggers
  for
• donation. Referral should have been made from
  the ER by
• 2300 on Day 1.
  Center for
  Medicare and Medicaid Services

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Typical Clinical Triggers

• Neuro injured, vented patient with a GCS 5
• Vented patient being evaluated for brain death
• Vented patient being considered for withdrawal of
  vent support
• Vented patient being considered for a change in
  resuscitation status
• Age, medical condition, or Medical Examiner
• involvement does not preclude organ donation.

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Case Study 1

• Day 2 at 0830
• Gift of Life Coordinator arrived on site to
  evaluate pts donation potential establish plan
  with pts care team.
• Coordinator, physician and PA huddled to discuss
  brain death declaration process -- huddles incl
  physicians, Coordinator, nurses, social workers
  and chaplains.
• Patient on vent w/ positive reflexes, purposeful
  movements in upper extremities. GCS now 6,
• ICPs in the 40s.
• Hospital to call Gift of Life prior to brain
  death testing and/or if family mentions
  deceleration of treatment.

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Case Study 1

• Day 2 _at_ 1600 Pt to OR for Crani
• Days 3 4
• Stable and sedated Pt was being aggressively
  treated
• Trauma Services met with family family was not
  ready to make end-of life decisions
• Grave prognosis delivered Coordinator was
  present. Patient remained full code, received
  full treatment.
• Patients grave prognosis was discussed many
  times throughout the hospitalization to prepare
  the family.

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Case Study 1

• Day 4
• 1130 Cerebral blood flow
• 1445 Pt declared brain dead
• 1815 Coordinator called Medical Examiner to let
  her know patient may be a donor ME
• would perform autopsy after recovery
• Purpose of Kyle Ray Horning Law is to ensure
  that all Medical Examiner cases are not
  precluded from being organ donor cases.

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Donor Registry/UAGL

• This patient was not on the Donor Registry
• Patients who are registered on the Donor Registry
  are considered First Person Consent
• UAGL also requires hospitals to treat every
  patient as a potential organ donor until Gift of
  Life can assess for medical suitability,
  including blood draws for tissue typing and
  testing.

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Case Study 1

• Day 4 (continued)
• During second huddle, Pts Care Team reviewed
  brain death studies and made a plan to approach
  the family
• All agreed the physician, Coordinator, nurses and
  spiritual care would be present for brain death
  conversation w/ the family -- consent rates
  increase when Gift of Life is included.
• If the family was ready, physician would
  introduce Coordinator so he/she could explain
  donation process.
• If the family was not ready, it was agreed the
  donation conversation would wait separating the
  brain death discussion from the organ donation
  discussion (decoupling) has proven to increase
  consent rates.

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The Approach Process

• Attending physician took his time with the
  family
• They moved to a private, quiet setting.
• He explained brain death from a medical
  standpoint.
• Physician spent time and listened to the family.
• He took time to answer the familys question,
• What is the next step?

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The Approach Process

• The physician introduced the Gift of Life
• Coordinator
• Doug is here to discuss the opportunity
  of saving lives through donation. He will
  support your family during this time, and help
  answer any questions you might have about your
  husbands end-of-life decisions.
• Together they explained that withdrawing
• treatment was an option, but not the best
• opportunity in this situation.
• Physician told the family that some good can come
• from their loss.

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Collaborative Approach

• Physician stood up and invited the Coordinator to
  sit down with the family
• Physician did not leave the room -- his presence
  reassured the family and encouraged them to
  listen to the Coordinator

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Collaborative Approach

• Coordinator explained the opportunity to donate
• Expected timeline for organ recovery
• Directed Donation (opportunity to donate to
  someone they know on the waiting list)
• Hospital costs related to the donation covered by
  
• Gift of Life
• Their loved one could have an open casket funeral
• According to CMS Guidelines, a Gift of Life
• Coordinator must be present when
• Informing the family about their opportunity for
  donation and
• Making the actual request for donation.

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Successful Outcome

• After a lengthy discussion, the family consented.
• Due to the collaborative efforts of the
  physician, the medical staff and the Coordinator,
  this patient gave the gift of life to six (6)
  people
• Heart (1)
• Kidneys (2)
• Split Liver (2)
• Pancreas (1)

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What made this case so successful?

• Early recognition of clinical triggers and
  referral to Gift of Life
• Frequent huddles helped prepare everyone for
  their role in the approach process
• Physician and Gift of Life Coordinator approached
  the family together each using their expertise
  to help the family understand that their
  end-of-life decisions included the opportunity to
  donate.

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this case so successful?

• Medical staff was transparent and honest with the
  family about the grave prognosis
• Medical staff supported the family throughout the
  entire process and included the Coordinator in
  discussions
• Physicians presence gave the family the gift of
  time they needed with the doctor they had grown
  to trust.

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Conflict of Interest?

• Was there a conflict of interest when the
  patients physician approached the family about
  organ donation?

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No Conflict of Interest

• Whats good for the patient is good for the
  donor!
• Treat all patients like theyre survivable
• The Collaborative Approach gave the physician
  the opportunity to step aside while the
  Coordinator discussed the donation process
• Every family of potential donors must be given
  the opportunity to donate.

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Collaborative Approaches vs Non-Collaborative
Approaches in Michigan
Number of Approaches
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(No Transcript)
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Conclusions

• Become a Physician Champion at your hospital!
• Know the clinical triggers and make timely
  referral calls to Gift of Life Michigan.
• Continue to treat patient until patient can be
  assessed by Gift of Life.
• Huddle to ensure a Collaborative Approach.
• Multidisciplinary donor management.

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Thank you for joining us!

• For more information,
• contact Gift of Life Michigan at
• 800.482.4881.