Network Event Organ donation: the DH taskforce report and critical - - PDF document
North West London Annex 1 Presentation handouts Network Event Organ donation: the DH taskforce report and critical care A report from the Network Event held on 7 October 2010 Overview of organ donation in the UK - Dr Anthony Gordon ICU
Senior Lecturer / Consultant Clinical Lead for Organ Donation Centre for Peri-operative & Critical Care Medicine Imperial College / Charing Cross Hospital October 2010
500 1000 1500 2000 2500 2003/04 2004/05 2005/06 2006/07 2007/8 2008/9 BSD possible diagnosis Patient confirmed BSD
Audited deaths of patients (n=46 801) Was the patient ever on mechanical ventilation? Yes (n=42 749) No (n=4052) Was brain stem death a likely diagnosis? Yes (n=4166) No (n=38 583) Were brain stem tests performed? Yes (n=2857) No (n=1309) Was brain stem death confirmed? Yes (n=2754) No (n=103) Were there any absolute medical contraindications to heartbeating solid organ donation? Yes (n=42 749) No (n=4052) Was the issue of heartbeating solid organ donation considered? Yes (n=2467) No (n=273) Were the next of kin approached for permission? Yes (n=2320) No (n=147) Was consent given by the next of kin? Yes (n=1379) No (n=941) Were there any absolute medical contraindications to heartbeating solid organ donation? Did donation occur? Yes (n=1244) No (n=135)
Was brain stem death a likely diagnosis? Yes (n=4166) No (n=38 583) Were brain stem tests performed? Yes (n=2857) No (n=1309)
Reasons for not testing (approx 650 / year) 30.4 28.1 14.6 11 8.4 6.1 0.7 0.7 10 20 30 40
cardiovascular instability unknow n residual neurological function family-related problems w ith testing contra-indication to donation (including age) coroner
% total
DOH guidance 2009
3 2
Decision to withdraw cardiorespiratory support Withdrawal Asystole Diagnosis of death Bedside vigil Last offices Decision to withdraw cardiorespiratory support Delayed withdrawal Asystole Expedient diagnosis of death Transfer to theatre Perfusion / retrieval Last offices Check Organ Donor Register Notify DTC Approach family Continue cardiorespiratory support
“Normal” Death DCD
3 4
3 5
3 8
Hea Heartbeating tbeating Non- Non- heart heartbeating eating Donors
611 611 288 288
Ki Kidn dney ey
109 1096 477 477
Pancreas Pancreas
185 185 33 33
Hear Heart
129 129
Lu Lung ng
238 238 23 23
Liver Liver
527 527 80 80
Total organs transplanted Total organs transplanted
217 2175 613 613
Transplant Transplanted organs per ed organs per donor donor
3.6 3.6 2.1 2.1
Organs transplanted from deceased donors in UK, April 08 – March 09
www.ics.ac.uk/intensive_care_professional/standards__safety_and_quality
Shemie SD et al CMAJ 2006 vol. 174 (6) pp. S13-32
anthony.gordon@imperial.ac.uk
Dr Chris Danbury
“Improving organ donation within your hospital”
‘Urgent attention is required to resolve outstanding legal, ethical and professional issues in
unambiguous framework of good practice. Additionally, an independent UK-wide Donation Ethics Group should be established.’
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Recommendation 3 of the Organ Taskforce states:
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There are 5 core legal authorities which govern organ and tissue donation:
* EU Directives apply largely to tissue donation
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Laws which govern Organ Donation primarily focus on removal and use of tissue from deceased persons and end of life care.
Organ Donation Process Addressed by which law Removal of organs and tissues from a deceased person Governed by statute law (Human Tissue Acts) 1) Removal and use of organs and tissue: Organ Donation Process Addressed by which law Law relating to consent to medical treatment Common Law: UK generally Test for decision-making capacity and best interests Mental Capacity Act 2005: England & Wales Adults with Incapacity Act 2000: Scotland Common law: Northern Ireland 2) End of life care:
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For adults
consent to the activity, or a decision of his not to consent to it, was in force immediately before he had died, his consent
consent is required from a nominated representative or a person in a ‘qualifying relationship’ (such as next of kin)
For minors (<18)
death or the minor was not competent to deal with the issue it is the consent of a person with parental responsibility
responsibility it is the consent of a ‘qualifying relative’
As applied in NI, Wales and England 6
The Human Tissue Act provides guidelines on who is able to give consent:
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As applied in NI, Wales and England
Patient Nominated Representatives Qualifying Relatives
Nominated Representatives
witnesses or in writing either: Signed in the presence of at least one witness At his direction and in his presence and in the presence of at least one witness Made in a will
The patient has first rights to consent. Where the patient is not competent, the nominating representatives become the primary stakeholders who can provide consent for a patient
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Traditionally decisions to withdraw care have been made on the grounds of futility, from a physiological, probability and economic perspective Physiology
Body is no longer responding to drugs or any other form of palliative care. Continued treatment would therefore be futile
Probability
Conjecture that the patient will not survive even if treatment is
Economic
Continued care will be too costly with a small chance of success where treatment is continued. Treatment is therefore futile
The concept of futility is nebulous and therefore does not help us, as doctors, to make the most effective, legal and best decisions when it comes to withdrawal of patient care
Airedale NHS Trust v Bland [1993] A.C. 789 ‘In certain circumstances medical treatment can properly be categorised as futile, that is, if it cannot cure or palliate the disease from which the patient is suffering’ 10
Patient competent (Y/N)? Legal authorities with decision making powers Patient has decision making powers England & Wales Scotland Northern Ireland
Welfare Attorney Guardian Intervener Clinician Court of Session High Court Clinician
The chart below shows the decision making process for end-of-life care
YES NO
Decision making powers in end-of-life care vary across countries in the UK
Lasting Power of Attorney Court Appointed by Deputy Court of Protection Clinician or Carer
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The Mental Capacity Act 2005 defines decision-making ‘capacity’ for adults and stipulates various rules governing their medical treatment 1.A person is assumed to possess capacity unless it is established otherwise 2.All practicable steps should be taken to facilitate decision-making capacity 3.All acts done, or decisions made, for a person lacking capacity must be done or made in the person’s best interests
As applied in Wales and England
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When a person no longer has decision-making capacity, decisions must be made in their best interests Best interests embraces the following features:
and in particular the person’s past and present wishes
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The Mental Capacity Act 2005 stipulates that in determining a person’s best interests, the decision-maker must... Consider, as far as is reasonably ascertainable…
The person’s past and present wishes and feelings (and in particular any relevant written statement made when he had capacity) The beliefs and values that would be likely to influence his decision if he had capacity The other factors that he would be likely to consider if he were able to do so
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The judges have previously stated that a person’s best interests must account for the entire range of interests bearing on a person’s welfare
“best interests encompasses medical, emotional and all other welfare issues”
What ‘other interests’ are there?
Emotional Spiritual Psychological Altruistic Welfare
Dame Butler-Sloss in In re A (Medical Treatment: Male Sterilisation) [2000]
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Ahsan v UHL NHS Trust [2007]
spiritual beliefs
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1. Clinicians must consider whether any of the actions taken to facilitate or optimise donation carry with them any risk of harm or distress to the patient 2. Once it is decided that a particular action or actions that will facilitate NHBD are in that person’s best interests, then they may be carried out 3. Some of the actions that are needed to initiate the process of donation fall outside the scope of the MCA and should be carried out as a matter of good practice In MCA Scope
interventions
treatments. Out of MCA Scope
transplant team of a potential donor
the person’s death; and
donation (Data Protection Act must be observed when collecting this information)
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Life-Prolonging Treatments Introduction of new therapies e.g.
Adjustments to existing treatments e.g.
There are 3 key specific scenarios impacted by organ donation law:
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Blood Sampling
interests
transplantation where this is in the patient’s best interests
determining if either of the above was in the individual’s best interests
More Invasive Interventions
the interests of organ donation
heparinisation; resuscitation; femoral cannulation) are unlikely ever to be in a patient’s best interests
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reason for withholding or withdrawing treatment
Oxford University Press, June 2010 ISBN-10: 0199562032 ISBN-13: 978-0199562039
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S
Two aims: The support of donor families The promotion of organ and tissue donation
We aren’ t aliens or heroes We will all react differently We are j ust ordinary, normal people
We don’ t want to ‘ upset them further’ We don’ t want to make ‘ things worse’ They are ‘ too upset’ They’ ve ‘ suffered enough’ Everyone has the right to be asked
T hink about it, T alk about it Do something about it
Nor th West L
Mandy Ve nte rs 7 Oc to be r 2010
the transplant list
days, WL RT C 1,524 days
RT C 500 patie nts o n list in 2009
p to 2008 o nly 20% re c e ive d transplant within 2 ye ars at WL RT C
Dr Gary Wares Consultant in Intensive Care
Massive intra-cerebral haemorrhage.
ICU that further treatment is futile.
emergency cases!!!
Non Heart beating pathway?
Patient Identified as potential donor
and request for organ donation
donation within my area?
– (Conversion not a quality target?)
– Internal guidelines – Quality indicator during monthly M+M
– King’s unique because of MTC – SNOD attends weekly ED meetings – Regular educational sessions for ED nurses
– Independent, so compare!
– Add to quality accounts of Trust
– Early clinical engagement with “-ologists” focussing on EOL quality
– Usual collaborative approach
– No conflict between EOL care and organs
0.5 1 1.5 2 2.5 3 3.5 4 4.5 Oct Nov Dec Jan Febr March April May DBD Converted to DCD DBD Donors DCD Consent DCD Donors
1 2 3 4 5
Number of patients 2 4 6 8 10 12 14
Col 2 Col 3 Col 4 Col 5 Col 6 Col 7 Col 8 Col 9 Aug
Physiol futility Subjecti ve Diagnostic futility Aug 10: 4 10
Medway having been found collapsed in bathroom. GCS dropped from 13 to 9 and then 3. Background ovarian cancer; angina; AF (warfarin). Beriplex. CT: blood in ventricles and patchy periventricular low density. EVD. GCS did not recover. Treatment limited. Died 3.8.10. DC: 1a Hydrocephalus; 1b Spont IVH II AF
injury intra-operatively. Ischaemic left arm. Fem artery repaired. Progression of MOF/bleeding/coagulopathy. Died 11.8.10. Referred to coroner. PM: 1a Haemoperitoneum; 1b mesenteric infarction; 1c AAA with thrombus; II LVH.
hypertension, epilepsy, alcohol abuse and cardiomyopathy. Presented to ED at Sidcup with 3 days of abdo pain and melaena. 22 units of blood, 8 FFP, 2 pools platelets. Transferred for embolisation of a gastric lesion. Very
15.8.10. ?should have been treatment limited?
Unwitnessed fall from ladder. Found face down, unresponsive and not
DCD and family consented. Due to age could not place the kidneys, but donated corneas, skin and bone.
APACHE II 34. known epileptic/GH deficient after previous brain tumour. Out-of hospital cardiac arrest. Hypoxic brain injury confirmed by CT. Critical cerebral swelling with impending tonsillar descent. BSD confirmed. Died 29.8.10. DC: 1a Hypoxic brain injury; 1b Epilepsy; 1c hydrocephalus. II Pilocytic astrocytoma. Family approached and consented. Donated heart, lungs, liver, kidneys and pancreas. All were successfully transplanted.
Oliguric renal failure post CABG. Cardiac arrest 48 hours post CABG on ICU whilst awaiting CVVH. Shocked post
from rupture of giant left middle cerebral artery aneurysm. Arrived with fixed dilated pupils. Repeat CT showed further haemorrhage and midbrain
1a SAH. Family were approached but daughter declined.
Severity was high though.
increase in APACHE II.
effect of delayed discharge (yet) so difficult to report
survive short period, usually out-of-hours. Several admissions were in retrospect inappropriate (epr record)
to Brussels.
rules allowing ‘maximal charging’ are changed the delayed discharge will really cost-surely in current climate this will happen eg with introduction of
recoding –implications for ‘named’ consultant.
– Two CLODS
– Focus on EOL quality
– 100% referral rate: normalises approaching families
– Ongoing analysis to discriminate between poor approach and non-conversion
Paula Aubrey Team Manager London Organ Donation Services
Specialist Nurses – Organ Donation How can SN-ODs assist in the in the donation process ?
Paula Aubrey Team Manager London Organ Donation Services
process
Paula Aubrey Team Manager London Organ Donation Services
‘Saving lives and improving lives’ Aim is to maximise potential for organ donation and transplantation and to ensure 100% referral of potential donors from all critical care areas Hospital wide, ICU and Emergency Departments (ED)
Paula Aubrey Team Manager London Organ Donation Services
Organ Donation Services Team- London
SCOTLAND NORTH NORTH WEST YORKSHIRE MIDLANDS SOUTH WALES EASTERN SOUTH EAST SOUTH CENTRAL SOUTH WEST NORTHERN IRELAND LONDONKey Roles Team Background Assistant Director Anthony Clarkson Regional Manager Jane Griffiths Team Managers Julie Whitney Paula Aubrey Jeanette Foley Team SN-ODs 22 NHS Trusts
Paula Aubrey Team Manager London Organ Donation Services
from Critical Care
Paula Aubrey Team Manager London Organ Donation Services
Planning
Identification and collaboration with key personnel hospital wide
Paula Aubrey Team Manager London Organ Donation Services
Presence Clear visibility of SN-OD
Critical Care & other specialities is key to success
fundamental to raising awareness
help guide clinical staff
Paula Aubrey Team Manager London Organ Donation Services
Role of the SN-OD Sequence of events
& Swan)
Paula Aubrey Team Manager London Organ Donation Services
Role of the SN-OD in supporting the process
support to potential donor families open and honest communication
excellent communication
Support family in their decision
Paula Aubrey Team Manager London Organ Donation Services
Good Communication should never be underestimated!
communication skills as an essential component of end of life care
communication generates more complaints than any other aspect of work performed by health care professionals
Paula Aubrey Team Manager London Organ Donation Services
Recognition of needs of Critical Care Family Members
progress
given to the patient
Mendonca & Warren, Crit Care Nurse Q 1998;21(1):58-67
Paula Aubrey Team Manager London Organ Donation Services
subject raised only at an appropriate time
death
Paula Aubrey Team Manager London Organ Donation Services
potential donor families earlier and on a more extended basis than a traditional ‘Regional Donor Coordinator’
– Early referral / minimal notification criteria – Experience SN-OD & well established Trust of MD Team – Open communication
Paula Aubrey Team Manager London Organ Donation Services
improving lives’
establishment of good ‘team’ working is essential
ensure seamless facilitation of donor process from initial donor referral to last offices