Nursing Management of Nursing Management of the Potential Organ and the Potential Organ and

Tissue DonorTissue Donor

Susan Ulit, RN, BS, MSN, CNRNSusan Ulit, RN, BS, MSN, CNRN

Clinical Nurse SpecialistClinical Nurse Specialist

Dina Elias, RN,BSN,CCRNDina Elias, RN,BSN,CCRN

Clinical Nurse Educator Clinical Nurse Educator

ObjectivesObjectives• Understand the role of the critical care nurse in the Understand the role of the critical care nurse in the

referral of potential organ donor patientsreferral of potential organ donor patients• Recognize the importance of the critical care nurse in Recognize the importance of the critical care nurse in

partnering with OPO representativespartnering with OPO representatives• Describe in brief the pathophysiology of brain death and Describe in brief the pathophysiology of brain death and

the management goals for the organ donor patientthe management goals for the organ donor patient• Understand the role of the critical care nurse as a Understand the role of the critical care nurse as a

patient and family advocate during the transition phase patient and family advocate during the transition phase of organ donationof organ donation

• Understand the importance of collaboration of Understand the importance of collaboration of healthcare team members in referral and conversion healthcare team members in referral and conversion rates and outcomesrates and outcomes

Referring the Potential Referring the Potential DonorDonor

• Identify the potential donor in your Identify the potential donor in your unitunit

• Be familiar with the hospital’s Be familiar with the hospital’s criteria for clinical triggerscriteria for clinical triggers

• Refer the potential donor to the Refer the potential donor to the OPO promptlyOPO promptly

• Understand the great influence the Understand the great influence the CCRN has on the process CCRN has on the process

Clinical TriggersClinical Triggers

Partnering with your Partnering with your OPOOPO

• Introduce self to the OPO coordinator Introduce self to the OPO coordinator assigned to the referral assigned to the referral

• Encourage collaboration with the OPO Encourage collaboration with the OPO member, as they are now an integral member, as they are now an integral member of the health care team member of the health care team

• LCSW, Pastoral care, physicians, nursing teamLCSW, Pastoral care, physicians, nursing team

• Ask your OPO member to share Ask your OPO member to share information and resources information and resources

• T-4T-4• Articles in support of donor managementArticles in support of donor management

Educate Yourself / TeamEducate Yourself / Team

• Policy and ProceduresPolicy and Procedures• Become knowledgeable about the different Become knowledgeable about the different

types of donationtypes of donation• Donation after Cardiac Death vs. Brain DeathDonation after Cardiac Death vs. Brain Death

• Become well-informed about organ donation Become well-informed about organ donation and the pathophysiological effects of brain and the pathophysiological effects of brain death death

• Patient management goalsPatient management goals• Realizing the positive impact organ donation Realizing the positive impact organ donation

brings to all those involved – the “U-turn”brings to all those involved – the “U-turn”

Pathophysiology of Pathophysiology of Brain DeathBrain Death

Elevated ICPElevated ICP

Profound catecholamine responseProfound catecholamine response

Sustaining CPPSustaining CPP

Increases afterloadIncreases afterload

LV ischemia/ Myocardial necrosisLV ischemia/ Myocardial necrosis

Decreased LVFDecreased LVF

Pathophysiology of Pathophysiology of Brain DeathBrain Death

Herniation of the brain stemHerniation of the brain stem

Ischemia (sympathetic denervation)Ischemia (sympathetic denervation)

Profound vasodilationProfound vasodilation

Brain Death = Brain Death = cardiac function + cardiac function + vasodilation vasodilation

What are the goals?•Organ Perfusion

•Organ Oxygenation

When does it start?Immediately!

Management goals

Management GoalsManagement Goals• Obtain accurate height and weight if not Obtain accurate height and weight if not

already done (admission) already done (admission)• Line em up!!Line em up!!• Temperature measurementTemperature measurement

• No tympanic temps (will be inaccurate)No tympanic temps (will be inaccurate)

• Initial Labs:Initial Labs:• CMPCMP• CBCCBC• UAUA• CoagsCoags• Type and crossType and cross

Management GoalsManagement Goals• Timely hemodynamic management Timely hemodynamic management

• Cornerstone of successful donor Cornerstone of successful donor managementmanagement

• Management includes:Management includes:• Ensuring adequate intravascular volumeEnsuring adequate intravascular volume• Maintaining appropriate CO with possible use Maintaining appropriate CO with possible use

of vasoactive dripsof vasoactive drips• Initiating T-4 protocol as appropriate Initiating T-4 protocol as appropriate • Early recognition and treatment of DI, SIADH, Early recognition and treatment of DI, SIADH,

HHNSHHNS• Tight glycemic control Tight glycemic control • Coagulopathy correction Coagulopathy correction

Management GoalsManagement Goals

• SBP 90-110 mmHgSBP 90-110 mmHg• U/O 1-3 cc/kgU/O 1-3 cc/kg• HR 60-140 HR 60-140 • PAWP 7-12 mmHgPAWP 7-12 mmHg• Serum electrolytes WNLSerum electrolytes WNL• CBC and coags WNLCBC and coags WNL• SPO2 >95%SPO2 >95%• PaO2 90-110 PaO2 90-110 • pH 7.35-7.5pH 7.35-7.5• PCO2 25-45 PCO2 25-45 • PF ratio >300PF ratio >300

NORMAL PARAMETERS!!NORMAL PARAMETERS!!

Making The “U-Turn”Making The “U-Turn”

When a patient dies, despite best efforts, organ donation When a patient dies, despite best efforts, organ donation becomes a positive outcome to a tragic situation. becomes a positive outcome to a tragic situation.

Hope for Recovery… Hope for Recovery… can become can become… Hope Through Donation… Hope Through Donation

Patient and Family Patient and Family AdvocateAdvocate

• Gate keeperGate keeper• Honor your patients’ and families’ Honor your patients’ and families’

wisheswishes• Uphold a family’s right to be offered Uphold a family’s right to be offered

the opportunity of organ donation the opportunity of organ donation • Do not take that opportunity away by Do not take that opportunity away by

making that decision for them making that decision for them • All health care team membersAll health care team members• Leave your personal opinions to yourselfLeave your personal opinions to yourself

Patient and Family Patient and Family AdvocateAdvocate

• Promote compassionate Promote compassionate communication communication

• Promote collaboration Promote collaboration • Be the bridge that links the health care Be the bridge that links the health care

team to patients and their familiesteam to patients and their families

• Avoid conflict of interestAvoid conflict of interest• DO NOT mention organ donationDO NOT mention organ donation• What is the message we are sending?What is the message we are sending?• What if the family asks about donation?What if the family asks about donation?

TransitionTransition

• Brain Death pronouncementBrain Death pronouncement• Communicate early and often with the Communicate early and often with the

familyfamily• Facilitate communication between Facilitate communication between

physicians and the familyphysicians and the family• Re-iterate prognosis given by Re-iterate prognosis given by

physician to ensure understandingphysician to ensure understanding

• Second Brain Death note is official Second Brain Death note is official TODTOD

Team HuddleTeam Huddle

•Team huddle occurs before Team huddle occurs before discussion of pronouncement discussion of pronouncement with familywith family

•Team huddle members include:Team huddle members include:• OneLegacyOneLegacy• PhysicianPhysician• Bedside RNBedside RN• LCSW’sLCSW’s• Pastoral CarePastoral Care

TransitionTransition

•Brain death discussionBrain death discussion•Patient is DEAD (don’t equivocate)Patient is DEAD (don’t equivocate)

•Transition & decouplingTransition & decoupling•How to respond to “What’s Next?”How to respond to “What’s Next?”

•““A specialist will talk with you about the A specialist will talk with you about the next steps…”next steps…”

•How to introduce OneLegacyHow to introduce OneLegacy•““A member of our healthcare team…”A member of our healthcare team…”

•Donation conversation (OneLegacy)Donation conversation (OneLegacy)

PHASE 1

E.O.L. Family DiscussionE.O.L. Family Discussion

MD informs family of grave prognosisMD informs family of grave prognosis

Family is presented with donation options by trained designated requestor only!

Family must be given time alone to process this new information

DO NOT MENTION DONATION TO FAMILIES

“I will get a dedicated family specialist to speak with you”

PHASE 2

National HRSA Collaborative Best PracticesCMS / Joint Commission Mandate 42. CFR 482.45HUCLA Policy 316, Data accessed Nov. 24, 2009

Collaboration = Higher Consent RateCollaboration = Higher Consent Rate

• Organ donation consent rate highest when Organ donation consent rate highest when hospital staff and OPO approach togetherhospital staff and OPO approach together

Source: “Improving the Request Process to Increase Family Consent for Organ Donation”; Gortmaker, et.al. (Journal of Transplant Coordination 1998; 8:210-

217)

Summary Summary

• Educate!Educate!

• Advocate!Advocate!

• Collaborate!Collaborate!

• What you What you saysay and and dodo can make the can make the difference between a yes and a no.difference between a yes and a no.