Maintaining the Option to Donate
Pre-Donor Management and Brain Death
Declaration
Michael Haley, MD
Medical Director - LifeShare of the Carolinas
Disclosure Statement
No Financial or Commercial Interest to Declare
Serve as Medical Director for LifeShare of the Carolinas
Objectives
• Brief Overview of Donation
– Recipient, Donor, and Regulatory Compliance
• Pathophysiology Associated with Brain
Injury
• Declaration of Death by Neurologic Criteria
• Review the Pathway to Organ Donation
and Identify Potential Areas in Which the
Option to Donate may be Loss
Making the Case for
Preserving the Option to Donate
• Recipient’s Need
• Donor’s Desire
• Regulatory-Compliance
The Growing “Organ Gap”
Recipient Needs
~18 people die
each day due to
the lack of a
suitable organs
for transplant
(~6500 lives/yr)
Organ Procedure and Transplant Network and the Scientific Registry of
Transplant Recipients from 1989-2009
This circle
represents the
United States ~310
million people
.
This dot represents the 8,126
deceased donor in 2011
Over 100 million
registered
donors in the
USA
USA Deaths 2011 - 2,515,458
8,126 represents 0.3% of all deaths
Psychological Effects of Donation
on Families
• 98% Would choose donation again
• 92% Identified positive aspects to the
donation process/experience
– Donation was comforting
– Associated with less depression
Clinical Transplantation. Vol 22 (3); 341–347, 2008
Hospital Compliance
Hospital Requirements
(Centers for Medicare/Medicaid Services)
– OPO- Organ Procurement Organization
Functions within their designated service area:
1) increasing the number of registered donors
2) coordinating the donation process
•
•
•
•
Notification process
Declaration of brain death
Patient/family opportunity to donate
Performance Improvement (PI) program
LifeShare of the Carolinas
Federally designated OPO for 40
hospitals in a 22 county area
ASPE.hhs.gov
The Pathway to Organ Donation
Severe Brain
Injury
Vulnerable Period
Irrecoverable
loss of brain
function
Hours to Days in Length
Physiological Changes Associated with Brain Injury
Physiology Associated with
Severe Brain Injury
Brain Injury
Elevated ICP
Compensatory HTN
“Catecholamine Surge”
•
•
•
•
•
•
•
Peripheral vasoconstriction
Tachycardia - Arrhythmias
Central redistribution of blood
• Pulmonary edema
Myocardial dysfunction
Endothelial dysfunction
Platelet activation-micro thrombi-DIC
Cytokine – Inflammatory activation
(SIRS)
Experimental studies demonstrate circulating epinephrine concentrations increase
on the order of 200 to 1000-fold in association with increase in ICP
Pre-Donor Management
• “Just Good Critical Care”
– Catastrophic Brain Injury Guidelines
• Maintain MAP> 65 (IVF resuscitation
vasopressor support)
• Maintain oxygenation (Sat>90%)
• Monitor and correct electrolyte abnormalities
• “What is good for the patient is good for the donor”
The Pathway to Organ Donation
Severe Brain
Injury
Vulnerable Period
Irrecoverable
loss of brain
function
Healthcare providers often recognize poor outcome early on….
Healthcare providers can feel conflicted……
Ongoing Support vs. DNR-DNI or Limitation of Care
The Pathway to Organ Donation
Severe Brain
Injury
Vulnerable Period
Irrecoverable
loss of brain
function
Death by
Neurologic
Criteria
Vulnerable
Period
Withdraw of
Care
Physiologic Changes
with Brain Death
Decline in Organ Function after Brain Death
Physiologic Changes
Hemodynamic Instability
Inflammatory response
• Capillary leak
• Coagulopathy
Volume depletion
Hypothermia
Hormonal Abnormalities
Pre-existing Co-morbidities
&
Associated Injury (trauma)
Organ Dysfunction
(Loss of Opportunity to Donate)
Treatments
• Mannitol
• Steroids
• Volume Resuscitation
Outcomes are better with organs obtained from
live donors compared to organs from brain-dead
donors as these physiologic insults are avoided
The Pathway to Organ Donation
Severe Brain
Injury
Vulnerable Period
Irrecoverable
loss of brain
function
Death by
Neurologic
Criteria
Withdraw of
Care
Death by Neurologic Criteria
• <1% of all deaths in the US per year
– Estimated 15k/yr; ~2.5million deaths in US/yr
•
•
•
Historically---“Death”- permanent cessation of heart & breathing
1950’s Invention of artificial respirator
– Breathing supported even when people were in a deep coma.
– Invention forced doctors to rethink their definition of “death”
1968 Ad Hoc Committee of the Harvard Med School
– “A Definition of Irreversible Coma” (JAMA 1968;205:337–340)
• 1981 – The Uniform Death Determination Act
– “An individual who has sustained either (1) irreversible cessation of
circulatory and respiratory functions, or (2) irreversible cessation of
all functions of the entire brain, including the brain stem, is dead.”
Process of Brain Death Declaration
1. Clinical Prerequisites
– Must evaluate for these confounding
variables prior to consideration of brain
death
2. Neurological exam
Clinical Prerequisites
Prior to Brain Death Consideration
1st - Irreversible Cause • Must have a proximate cause for the “brain death”
– TBI, ICH, SAH, CVA with associated edema, hypoxic-ischemic, etc.
– Often demonstrated by neuro-imaging
Normal
SAH
TBI
ICH
2nd - Exclude Potentially Reversible Conditions
• Drug intoxication/poisons; electrolyte/acid-base disturbance;
endocrine disturbance
3rd - Exclude Hypothermia (>32C)
Brain Death Neurological Exam
Coma---Absent Brain Stem Reflexes---Apnea
• Coma:
– No spontaneous movements, posturing, or localizationwithdraw to stimulus
• Assess brainstem:
– Midbrain- CN 3- pupil response
– Pons- CN 4,5,6- corneal, occulocephalic, cold caloric testing
– Medulla- CN 9,10- gag/cough and spontaneous respirations
*Atropine test
• Apnea Test:
Sound Easy…..
So Why Can Problems Arise With Brain
Death Declarations?
Brain Dead Patients Move…
• Movements present in 40% of heart-beating cadavers
• Interpreting motor responses can be challengingsome demonstrate abnormal motor activity when
stimulated due to spinal reflexes
– Movements occur when a sensory stimulus arises from receptors in the
muscle, joints, and skin, resulting in a motor response that is entirely
contained within the spinal cord.
• Spinal reflexes include:
–
–
–
–
–
–
–
Finger jerks/oscillations
Plantar flexion in one or both lower extremities
Head turning with stimulation
Triple flexion response to plantar stimulation
Stereotypic flexion of one or more limbs
Facial myokymia
Lazarus sign
Video of Movements
Confounding Variables May be Present
• Drug intoxication/poison; electrolyte/acidbase disturbance; endocrine disturbance
• Sedative Metabolism
– Varies amongst individuals
– Hypothermia slow drug metabolism
• Confirmatory Testing
Brain Perfusion Scan
Technetium 99 Isotope
Cerebral
Angiogram
EEG
TCDs
Why is the Formal Declaration
of Brain Death Important
• Provides family with a diagnosis of finality
(no decision about “stopping” necessary)
• Allows “de-coupling” period from death and
donation
• Simultaneous “approach” at the time of brain
death notification is associated with a decreased
donation rate by ~30% (Niles & Mattice, 1996)
The Pathway to Organ Donation
Severe Brain
Injury
Vulnerable Period
Irrecoverable
loss of brain
function
Death by
Neurologic
Criteria
Withdraw of
Care
Donation after
Brain Death
LifeShare of the Carolinas
2011
2012
2013
Referrals
10080
9984
9490
# Donors
83
87
84
Donor Mtg Time (hr)
19
25
21
Organs Recovered
322
340
338
Transplanted
274
271
259
Research
11
9
46
CaroMont Regional Medical Center
2011
2012
2013
Referrals
1051
968
836
# Donors
7
4
6
Donor Mtg Time (hr)
17
30
25
Heart
2
0
2
Lung
6
0
1
Kidney
10
7
6
Liver
5
3
6
Pancreas
0
0
1
Intestine
0
0
1
Organs Recovered
23
10
17
Transplanted
22
10
11
Research
1
0
6
The Pathway to Organ Donation
Severe Brain
Injury
Vulnerable Period
Irrecoverable
loss of brain
function
Death by
Neurologic
Criteria
Withdraw of
Care
Donation after
Brain Death
Donation after
Cardiac Death
(DCD)
Donation After Cardiac Death
• Prior to brain death laws, DCD was the way in which
all organs were recovered for transplant from
deceased donors (standard practice prior to the 1980s)
• 3 Separate reviews by the Institute of Medicine (IOM)
– “ethically acceptable practice of end-of-life care, capable of
increasing the number of deceased-donor organs available for
transplantation”
DCD Process
• Withdraw of Care is decided upon prior to any
discussions about donation (DNR order entered)
• DCD is a patient/family driven process
– Life Support removal- typically in operating room
• Cardiac Death
– Time from the onset of insufficient cardiac activity to generate a pulse
or blood flow (not necessarily the absence of all EKG activity) — to
the declaration of death is 5 minutes
– Data suggest that circulation does not spontaneously return after it
has stopped for 2 minutes (auto-resuscitation)
• If death does not occur (typically within 60min) then recovery of
organs does not occur, end-of-life care continues (up to 20% of cases)
National Trends in DCD
100
80
LifeShare of Carolinas
60
2011-’13 – DCD- n-36 (14%)
40
20
0
‘02
‘05
‘08
Years
‘11
2002- n- 189 (3%)
2006- n- 644 (8%)
2011- n- 1055 (13%)
Changing Paradigm in Critical Care
Hope for Recovery
Hope through Donation
Aggressive
Care
End of Life
Discussions…
Life Saving
Donation
Deteriorating
Condition
Donor
Management
Preparing Family“Grave Prognosis”
DNR-DNI
Limitation of Care
Preserving the
option to donate
Declaration of Death
Family Support
Donation after Cardiac Death (DCD)
Goals of Care Discussions are being addressed earlier – if the patient has
the ability to donate and is thought to be dead by neurological criteria then
brain death testing should be pursued
Conclusions
• Need for organs continues to outpace the availability
• Medical management of potential donors can be time
consuming and requiring advanced critical care
• Brain death declaration can be complex but is an essential
component to donation
• National donor data shows an increase trend in DCD
donations
• All healthcare providers need to be aware of the potential
vulnerable periods during the path to donation