A Clinical Balancing Act:
Honoring the DNR Decision While
Preserving the Option of Donation
Brian J. Kimbrell, MD, FACS
Trauma / Surgical Critical Care Director
St. John’s Regional Medical Center
Oxnard, CA
“How To Be”
• Being in Action!
• The Answers Are In the Room
• “Report out” on Questions to Run-on:
– Scribe
– Spokesperson
• All Teach / All Learn
Question to Run-On
What ideas would most help you
in your work with patients and families
facing end-of-life decisions?
A Clinical Balancing Act:
Honoring the DNR Decision While
Preserving the Option of Donation
Brian J. Kimbrell, MD, FACS
Trauma / Surgical Critical Care Director
St. John’s Regional Medical Center
Oxnard, CA
DNR Decision
What does the DNR decision mean to the family?
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No Chest Compressions?
No Shock?
No Medications?
No Labs?
No Fluids?
“Do not harm?” or “Do not treat?”
DNR Decision
What does the DNR decision mean to the healthcare team?
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Routine decision in the Critical Care Unit
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Interpreting DNR decision varies by hospital, unit,
physician, nurse
Donation Decision
Understanding the donation option clinically:
• Maintaining blood pressure
• Normalizing electrolytes
• Managing oxygenation and organ perfusion
• Balancing Intake and Output
• Assessing brain death accurately
How can a family give the gift of life when the organs
are not preserved for transplantation?
Balancing DNR and Donation
Devastating Traumatic Brain Injury (TBI)
+ Overall Clinical Deterioration
+ DNR Decision by Next-of-Kin
+ Fatal Diagnosis (Brain Death?)
“Step Down” in clinical management?
- or -
Maintain clinical management and prevent
secondary injury to organs?
Case Study
Patient: 41 y/o Male s/p MVC with blunt head trauma (ICH)
Admitting GCS = 8
Data: post-craniectomy, GCS=6, BP=140/80,
H/H=14/38, UO=200mL/hr, pH=7.4, Na=135,
Cr=0.8/BUN=10, ICP=15
Management: IV fluids, Mannitol, no pressors,
sedation, Neurosurgery on case
Case Study
2 days post-admission:
Data: GCS=5, BP=100/60, H/H=10/30, UO=200mL/hr,
pH=7.35, Na=155, Cr=1.1/BUN=20, ICP=45
Family conference with Physician
Physician Progress Note: “Discussed DNR with family.
No Heroic Measures.”
Management: IV fluids, Mannitol, no pressors, sedation,
RN calls OneLegacy
Case Study
4 days post-admission:
Data: GCS=3, BP=90/50, H/H=8/25, UO=200mL/hr,
pH=7.30, Na=170, Cr=1.3/BUN=22, ICP=60
Physician Progress Note: “Pt. appears brain dead.
Discussed grave prognosis with family. Neurosurgery
to evaluate.”
Management: IV fluids, sedation
Family Conference with Physician
Case Study
5 days post-admission:
Data: GCS=3, BP=90/50, H/H=8/25, UO=300mL/hr,
pH=7.28, Na=180, Cr=2.0/BUN=30, ICP=60
Brain Death Note #1
Neurosurgery Progress Note: “Attempted apnea test. Pt did
not breathe for 2 minutes but became unstable. Apnea test
aborted. PT is brain dead, based on clinical exam. Discussed
with family. Will require brain death confirmatory test. Second
brain death note to follow.”
Management: IV fluids, sedation, high dose
Levophed and Neosynephrine
Assessing the Balancing Act
Admission:
Data: post-craniectomy, GCS=6, BP=140/80, H/H=14/38,
UO=200mL/hr, pH=7.4, Na=135, Cr=0.8/BUN=10, ICP=15
5 Days Post-Admission:
Data: GCS=3, BP=90/50, H/H=8/25, UO=300mL/hr,
pH=7.28, Na=180, Cr=2.0/BUN=30, ICP=60
Does our patient data reflect preservation of the
family’s donation option?
Assessing the Balancing Act
Devastating TBI
+ Overall Clinical Deterioration
+ DNR Decision
+ Fatal Diagnosis (Brain Death)
Maintain clinical management and
prevent secondary injury to organs.
Pathophysiology of
Traumatic Brain Injury
Physiologic collapse frequently accompanies TBI:
Hypotension
Endocrine Dysfunction
Pulmonary Dysfunction
Hematologic Dysfunction
Pathophysiology of
Traumatic Brain Injury
Hypotension:
• “Autonomic storms”
• Systemic and pulmonary vasoconstriction
• Associated with herniation
• Can recur unpredictably
• Smooth muscle ATP depleted = vasomotor hypotension
• Diuretics
Pathophysiology of
Traumatic Brain Injury
Hypotension:
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Closely monitor Intake and Output – DI?
Anticipate BP spike followed by BP drop
Consider Fluid Resuscitation
Titrate Vasopressors
Consider Hormone replacement – T4
Pathophysiology of
Traumatic Brain Injury
Endocrine Dysfunction:
• Hypothalamic injury -> pituitary dysfunction
• Thyroid dysfunction
– T4 Infusion
• Glycemic control disrupted
– Insulin infusion
Pathophysiology of
Traumatic Brain Injury
Endocrine Dysfunction:
• Relative deficiency of corticosteroids
– Solumedrol Infusion
• Reduction of Antidiuretic Hormone / Diabetes Insipidous
– ADH, Vasopressin Infusion
Pathophysiology of
Traumatic Brain Injury
Pulmonary Dysfunction:
• Neurogenic pulmonary edema
– Multifactorial
– Systemic hypertension + LV dysfunction
• Primary pneumatocyte dysfunction
Pathophysiology of
Traumatic Brain Injury
Pulmonary Dysfunction:
• Iatrogenic injury due to aggressive resuscitation
• Exacerbated by intubation, aspiration, atelectasis
• Concurrent blunt lung injury common
– Parenchymal injury problematic in immunosuppressed
recipients
Pathophysiology of
Traumatic Brain Injury
Hematologic Dysfunction:
• Thrombocytopenia
– Platelets as needed
• Coagulopathy/DIC
– FFP / Cryo as needed
• Hypothermia
– Keep them warm!
What Are Traumatic
Brain Injury Guidelines?
Hospital approved guidelines
for treating patients with
Traumatic Brain Injury
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What Are Traumatic
Brain Injury Guidelines?
Prevent secondary injury, even with grave prognosis
• Secondary injury includes other organs, as well as the
brain
Maintain Organ Perfusion
• Volume Load
• Monitor & Maintain adequate CVP, MAP
• Oxygenation
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What Are Traumatic
Brain Injury Guidelines?
Continuous fluid resuscitation
• Correct electrolyte abnormalities
Rule of 100’s:
• SBP >100mm Hg
• U/O >100ml/hr
• PaO2 >100
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Why Implement
TBI Guidelines?
• Ensure consistent management of the critically ill patient
• Maintain homeostasis for accurate brain death
assessment
• Prevent “secondary injury” to organs, even with grave
prognosis
• Provide a clinical bridge between determination of brain
death and family’s decision on donation
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Aggressive Organ Donor Management Significantly
Increases the Number of Organs Available for
Transplantation
(Salim et al. J Trauma 2005; 58: 991-994)
• LAC + USC Standardized organ donor management
protocol
• Before-after study (January 1998) of ADM institution
– January 1995-December 2002
LAC+USC Study
(Salim et al. J Trauma 2005; 58: 991-994)
• Vasopressors if MAP <70.
– Dopamine
– Levophed
– Vasopressin
• Hormones for maximal vasopressors.
– Insulin
– Solumedrol
– T4
LAC+USC Study
(Salim et al. J Trauma 2005; 58: 991-994)
Results
• 878 patients referred, 460 (53.4%) patients potential organ
donors and 161 (34.3%) actual donors.
• # patients referred increased 57%
• # of potential donors increased 19%
• # of actual donors increased 82%
• # of patients lost to cardiovascular collapse decreased 87%
• # of organs recovered increased 71%
How to Implement TBI
Guidelines in Your Hospital?
Clinical Educator
Critical Practice Committee
Critical Care Leadership
Critical Care Physicians or Medical Director
Sample Guidelines available at:
www.onelegacy.org
DNR Decision
What does the DNR decision mean to the family?
•
•
•
•
•
No Chest Compressions?
No Shock?
No Medications?
No Labs?
No Fluids?
“Do not harm?” or “Do not treat?”
Summary
• Critical care teams can honor the DNR decision while
preserving the option of donation.
• Pathophysiology of TBI can be anticipated and treated.
• TBI Guidelines can be implemented to prevent “step
down” in clinical management, and preserve the family’s
donation option.
Question to Run On
What ideas would most help you
in your work with patients and families
facing end-of-life decisions?
Transition to
Breakout Session #2
Next Breakout Session starts at 11:30am
Please see agenda for specific room locations
Enjoy the Learning!
Transition to Lunch
Lunch is from 12:30 – 1:30
Crystal Ballroom, main level
Open seating
Bon Appétit!