Organ Donation After Circulatory Determination of Death:
Pre-OR Preparations, by Dr. Sally Vitali.
Please note that in this video, we
will be following the guidelines used
at Boston Children's Hospital.
Some of this information may need
to be modified based on the guidelines and practices
in place in your institution.
This video is part two of a series on the Organ Donation
After Circulatory Determination of Death, or DCDD Process,
at Boston Children's Hospital.
My name is Sally Vitali, and I'm a Pediatric Intensivist here
at Boston Children's.
In this video, I will cover important issues
during the period after consent and before travel
to the operating room before DCDD.
Before discussing the objectives for patient care
during the pre-OR period, I want to clarify the chain of command
for patient management.
Confusion may arise because in donation
after neurologic determination of death, or brain death,
the patient is legally dead and our organ procurement
organization, the New England Organ Bank, or NEOB,
takes over directing all management
of the brain-dead patient after a consent for organ donation
has been signed.
The ICU team provides consultation and assistance
to the NEOB prior to the organ recovery surgery.
In contrast, in DCDD, the ICU team
continues to manage the patient up
until the declaration of death in the operating room,
with the NEOB providing close consultation
throughout this time period.
In this video, I will elaborate on several goals that
are being pursued during the period of time
before travel to the operating room for DCDD, including
pain management, attention to and excellent communication
about illness trajectory and escalations of care,
preparing the family for the OR experience,
commencing end-of-life care, gathering supplies, equipment,
and medications to take to the OR,
and meeting and coordinating efforts with the OR staff.
The patient awaiting DCDD is by definition not brain
dead and therefore, does have the capacity
to experience discomfort.
The level of comfort should be assessed regularly
and pain and sedation medications titrated as needed.
Importantly, these medications should not
be withheld because of any concern
that they might precipitate death
prior to going to the operating room and jeopardize the DCDD.
The patient's comfort should be the top priority.
During this period, the NEOB will
be working to find recipients for the organs
and arranging for the organ recovery
with the goal of traveling to the OR as soon as possible.
Some patients will have clinical stability during this time,
but some will be decompensating at the end of life.
It's important that team members at the bedside
have excellent communication amongst themselves,
with the family, and with the NEOB team regarding
the patient's illness trajectory.
Sustained escalations of care, such as higher ventilator
settings and higher FiO2, increased pressor or volume
requirement, or the need for transfusion,
should be evaluated together by the care team in the family.
The team should consider the risk
that any escalation of care will cause pain and suffering
and how that can be effectively managed.
As best as possible, the team should understand from the NEOB
the timeframe for traveling to the OR
so that they may determine whether escalating care will
contribute to the likelihood of the patient surviving
to a successful DCDD.
The family should weigh in on their perceptions
of the patient's suffering and illness trajectory,
and they should be told that choosing not to escalate care
is a reasonable option.
If the bedside team and the family
decide that escalation is appropriate,
they should revisit the illness trajectory and appropriateness
of continued escalations on an hourly basis
until the DCDD happens.
Importantly, our DCDD protocol does not
permit chest compressions, defibrillation,
or ECMO cannulation in order to get
the patient to a successful DCDD in the operating room.
An important goal during this time period
is preparing the patient's family
for the withdrawal of the ventilator
in the operating room.
Though the consenting discussion has happened,
the family needs time to understand DCDD
and is likely to have many more questions as they consider
the process more thoroughly.
The providers at the bedside will
need to educate the family about the DCDD process.
Providers should review the third video
in the series on the DCDD OR process
in order to have a better understanding of the experience
to more confidently educate families about what to expect.
The New England Organ Bank staff has the most experience
with DCDD and will be a helpful resource to educate families.
They should be included in these discussions.
The family should be informed about the expected order
of events, but also that delays and accelerations in the timing
are very common in the period leading up to DCDD.
They should understand that after the ventilator
and any cardiac medications are stopped,
we will treat any discomfort with pain medication
and monitor for pulselessness.
When the patient has no pulse, the ICU attending and fellow
will take the patient's body into a separate operating
room where the organ recovery surgery will take place.
The family may wait with members of the ICU team in the first OR
until the patient has been transferred
and death has been declared after five minutes
without spontaneous return of pulses.
A member of the ICU team will let them
know that this has happened.
If they want more time with the patient's body after donation,
that can be arranged to occur back in their room in the ICU.
The family should anticipate what
might happen if the patient still
has a pulse after one hour in the operating room
and understand that they and the patient
will come back up to their ICU room
to receive a continuation of end-of-life care.
By talking about this possibility ahead of time,
the team can work to diminish the sense of failure
if it occurs.
The family should be reminded that they may opt out
of DCDD at any time during the process
and that no one on the ICU or any OB staff
will be upset with them about this.
Preparations for the end of life should
follow the same procedure as you would
if the patient was having withdrawal
of life-sustaining treatments in the ICU,
including helping the family decide
about memory-making, prayers or rituals
by spiritual advisers, music, and bringing
a second bed into the operating room for the family
to lay next to the patient.
Consider how you will continue this environment
back up in the ICU if the patient does not
progress to a pulseless arrest within the DCDD timeframe.
In preparation for travel to the OR,
the nurse will gather the appropriate supplies,
medications, and equipment for transport and withdrawal
of life-sustaining treatments.
The patient will need to be transported
on a monitor that displays an arterial line waveform.
The patient will stay on this monitor
throughout the ventilator withdrawal,
assessment of pulselessness, transfer
to the second operating room, and declaration of death
after five minutes without return of a pulse.
If there is no arterial line, the ICU team
will arrange for a cardiologist to be present in the OR
with an echo machine to determine
when the heart stops ejecting blood,
and this point will indicate the pulseless arrest.
Bring a working blood pressure cuff
and a stethoscope to the OR to aid
in the diagnosis of hypotension and declaration of death.
Appropriate medications to treat discomfort
should be discussed with the team
and prepared for the operating room.
If the patient is on vasoactive infusions or antiarrhythmics,
these drips will need to be continued
until they are stopped in the OR,
and an adequate supply of each should be insured.
Plan for resuscitation medications and volume
in case of instability during travel to the OR,
and ensure that the appropriate dose of heparin
is ready to be given according to the DCDD the protocol.
The ICU team should arrange a meeting with the OR team
and everyone who will be going to the OR.
The objectives of this meeting are, number one,
to review roles, and number two, to review
the expected order of events in the operating room.
This might occur hours before going to the OR
or at the last minute, depending on the circumstances.
For a checklist of issues to be addressed
in the pre-OR meeting, please review the Cardiovascular
and Critical Care Manual guideline and the Patient Pare
Protocol on DCDD.
If time and resources permit, it's helpful for the ICU nurse
to go down to the OR to review the travel
path to the OR and the OR set-up with the OR nurses
prior to bringing the patient and family down for DCDD.
The family should be introduced to the OR team
prior to going down to the OR.
Just prior to departure, pause at the bedside
to ensure that the family knows everyone at the bedside
and what their roles will be in the operating room.
Encourage them to ask questions prior to departure
and throughout the process.
This concludes part two of the video series on DCDD
at Boston Children's Hospital.
Any questions about this material
can be directed to your unit clinical or nursing director
or to the Organ Donation Oversight Committee
representatives from your unit.
Thank you for taking the time to help improve the quality
of our organ donation process here at Boston Children's.