Supporting the Neonatal and
Pediatric Donor
Breakout Session A
Presenters:
Jeffrey Johnson, MD, LAC + USC Medical Center
Mudit Mather, MD, Loma Linda University Medical Center
Moderator:
Marcia Penido, LCSW, MPH, Huntington Hospital
Objectives:
• Discuss the means by which ICU staff preserve
the opportunity for donation
• Review the ethics of donation and pre-donor
management
• Understand how to identify patients that meet
criteria for DCD referral.
• Discuss the true donation potential for pediatric
DCD donors.
Questions to Run On:
What practices can I implement to
improve the pediatric and neonatal
donation programs at my hospital?
Preserving the option for
donation: Making sure the
means justify the end
Jeffrey L. Johnson, MD, MA, FAAP
Associate Chief of Pediatrics
Director of Pediatric Inpatient and
Critical Care Services LAC+USC Medical Center
Assistant Professor of Clinical Pediatrics Keck USC
I have no financial conflicts of interest to report
Ends and Means
are essential to ethical analysis
For example:
• A good end is desired, eg.
providing for his family before
he dies.
• But the way the end is
achieved, the means he
chooses to make money, is the
basis for all the mayhem the
show delivers
Does your hospital have a brain
death committee?
• My credentials
• Goal:
In this talk I want to
focus on the means by
which we in ICUs
preserve the opportunity
for donation, by focusing
on objective actions and
intentions
I suspect this group already has
better than average education
about organ donation
Wednesday, September 25, 2013
“For me personally, human life requires the ability of the person
to intellectually connect to, and interact with, the environment.”
Medscape editor
ICU nurses’ attitudes:
Barriers to donation?
• 702 ICU nurses responded to a survey in
Sweden
• <50% trusted that the clinical dx of brain
death was accurate w/o a confirmatory
study
• 25% indicated that mechanical ventilation
was withdrawn in pts to reduce suffering in
persons presumed dead without the issue
of donation ever being raised
Floden et al, J Clinical Nursing, Nov 2011
What does this tell us?
• Some nurses may have doubts as to
whether some people being treated as
dead are really dead
• Some nurses may feel that there is a
conflict of interest between being a pt
advocate and being an organ donation
advocate
• So I am going to tell you how I think this
relates to ends and means
and barriers to donation
Do I have biases?
• I am an advocate for critically ill and
injured children.
• I am an advocate for the families of my
patients
• I am an advocate for Organ donation
Are there potential
conflicts of interest
in these statements?
Some are obvious
• For example: Why do Hospitals have policies
that prohibit the primary care team from being
involved in the removal of organs and decisions
for donation?
“Neither the physician making the determination
of brain death nor the physician making the
independent confirmation may participate in
procedures for the removal or transplanting of
organs after death”
ASA 106: LAC+USC Policy on determination of death
That policy’s fundamental purpose is
to minimize conflict of interest
Some people are afraid that they will be “used”
(ie treated as a means to some other end)
• Medical history is full of examples in which great abuses
were justified by utilitarian calculations.
• A Google search will uncover dozens of bloggers
commenting on this issue
• It is frequently sited as a major reason why people, even
those that may favor donation, do not have “red dots” on
their drivers’ license.
• Therefore, traditional ethics of transplant medicine as it
applies to the individual has been much more
deontological in emphasis.
Utilitarian vs Deontological
– Mr. Spock when asked why he sacrificed himself to save his
crew
• “The needs of the many outweighed the needs of the one” (a
“logical” calculation of utility)
– MAXIMUM pleasure or happiness (J Bentham), monistic
– Human flourishing (JS Mill), can also be rule based
Utilitarian
– Capt Kirk when asked why the crew risked their lives to save
Spock
• “The need of the one outweighed the needs of the many”
(an “irrational” expression of duty)
Deontological
– Virtue based ethics (Aristotle, Divine law) we are obligated by rules
or “right-making” characteristics
– Categorical Imperative (Kant), technical reformulation of the
Golden Rule, Do unto others as you would have them do unto you
Kant’s Supreme Moral Law
Rational agents recognize themselves as “ends-inthemselves” and because they are rational, recognize other
rational beings as belonging to the same kingdom and
therefore respect them as such
Categorical Imperative
1.
2.
3.
Act only on a maxim that at the same time you
would will that it should become a universal law
Act as if one were a king creating universal
laws for a kingdom of ends-in–themselves
No person should be treated as a means to
an end
I think this is essential to the
success of organ transplant as a
societal enterprise
• Individuals, families, communities must be
certain that they are not viewed as just a
means to an end by the medical
profession, that is
Their loved ones are not going
to be treated as just sources
of organs for someone else
What does that mean in practice?
• Lets say we have a catastrophically brain injured pt
in an ER
• GCS is 3, pupils are fixed, no resp effort
• FS Glu 418, pulse 130, pt hypotensive.
• In the ED resuscitative efforts are started
• CT shows a non-operable subdural bleed and
edema
• HOW SHOULD CARE CONTINUE?
• 3 choices
– Full court resuscitation
– Comfort care only approach
– Something in between
Diametrically opposed
“Full court
press”: I pity
the fool that
makes a
decision to
withhold care
before this pt
has a full
chance at
resuscitation
“Nothing”:
there is no
point, this pt
will die.
Damn it Jim,
I am a doctor
not a miracle
worker
“Full court
press”: this
patient could
be an organ
donor
But how do we justify one choice or another?
How good are we at predicting
the future in Medicine?
• Pretty good but far from perfect
• We are better when we create self-fulfilling
prophesy. (If I don’t resuscitate a critical pt
that pt will die)
Modified Pascal’s Wager
If God does not exist, one will lose nothing
by believing in him, while if he does exist,
one will lose everything by not believing.
Blaise Pascal (1623-1662)
Pensees 1658
• If one doesn’t aggressively resuscitate this
pt one will lose everything by not trying,
but if one does aggressively resuscitate he
may survive and if not the family may still
retain the option of donation.
Is it ethically possible/appropriate to
hold to hold two views about the
injured person?
• He or she is a catastrophically injured, but
still living, patient
• He or she is a potential organ donor.
I believe it is because focusing on
optimizing the care of the injured person will avoid the
temptation to view the injured as only a means
to another end while also
optimizing the conditions needed to
maximize donations should that choice come to pass
Let’s go one step further.
Consider this nurse’s feelings…
• “Its hard to explain but I felt like I was doing
something dishonest almost. All the hard work
the family thought was for their loved one was
actually all for someone else, some person
who might eventually receive organs. No one
had talked to the family yet about outcome or
that we were hoping they would donate, they
didn’t know why we were doing what we were
doing. It was all standard care, but I still felt
wrong.”
» RN describing feelings in caring for a man
with a non-survivable brain injury in the
ICU
What’s going on?
• This nurse thought this pt was being used
as a means to an end and was not being
treated with the respect he deserved
• There is a major communication problem
in this unit
How do we best proceed?
• Clear objectives and communication with
everyone
• The patient’s best interest is first priority
» Never treat a living pt like a dead patient
• I can maximize my ability to help the patient and
to prognosticate accurately when I am
aggressive in my resuscitation and care of a
severely injured pt.
Our “modified wager” works
in favor of any end
• Even if the family wishes to withdraw care?
– I can agree prognostically because I have done everything and it
hasn’t helped ( and this still might permit the best outcome in
DCDD)
• When death is declared it must be done with the utmost
care and consistency.
– Be empowered to guard that it is done correctly
– Policies and best practices should be strictly followed (“almost”
doesn’t cut it)
• In no case should the medical care givers discuss
donation, that would be left to the OPO after care
decisions had been made
• No conflict of interest
When are OneLegacy reps
most succesful?
• When families are certain that everything
possible was done for their loved one
• When there has been communication between
caregivers and families (honest, clear, timely)
• When families understand death and the
process for determining it has been
unambiguous
• When caregivers do not discuss donation with
families
• If we do the right things (means) for the right
reasons (ends)
Thank you
This means the end
Potential organ donors among
newborns undergoing circulatory
determination of death
Mudit Mathur, MD
Associate Professor, Pediatrics/Critical Care
Loma Linda University Children’s Hospital
Pediatric Intensivist, Huntington Hospital
Why is brain death rare in NICU?
• Mechanisms-non trauma, focal bleeds-maybe
less edema?
• Open fontanelle, non-fused sutures: lower ICP?
• Withdrawal before progression?
• Brain death criteria limitations-not any more
– 2011 update (Nakagawa et al, Crit Care Med 2011)
– Defines gestational age (>37 weeks)
– Defines inter-examination interval (24 hours)-may be
shortened if ancillary study consistent with BD
– Clarifies ancillary study preferred (CBF)
NICU DCDD potential-Heart donors
• Potential donors can be readily identified among
NICU patients undergoing withdrawal of life support
(5 infants, 4.3% of all deaths) over 5 years
• NICU DCDD donor Potential is similar to PICU data
(5.5-8.7%)
• Identifying NICU donors may
– Markedly expand the infant donor pool
– Reduce short-term wait-list mortality rates for infants
waitlisted for heart transplantation
The percentage of waitlisted patients
needing a kidney is (approximately):
A.
B.
C.
D.
E.
20%
40%
60%
80%
100%
Can’t we just continue dialysis?
• Over 95,000 wait-listed for kidney
transplant
• 35,000 added to the list annually (about
17,000 cadaveric and living donor
transplants per year)
• 5% mortality for each year on dialysis
• 5,000 kidney waitlist deaths/year
Pediatric En Bloc Kidney Transplantation to
Adult Recipients: More Than Suboptimal?
Bhayana et al. Transplantation 2010; 90 (3): 248-54
How about pediatric recipients?
• Small en bloc kidneys into 8 pediatric
recipients
• Donors 4-22 kg
• One kidney lost to intraoperative thrombosis,
other remained viable
• All grafts increased in size
• Median eGFR was 130 mL/min/1.73 m2 size
Butani et al. Outcomes of children receiving en bloc renal transplants from small
pediatric donors. Pediatr Transpl 2013; 17: 55-58
Our study
• Discharges from our 84 bed NICU over 10
years (November 2002-October 2012)
• All deaths categorized into four modes:
Brain death, Death despite CPR, Death with
DNR order in place, Withdrawal of life support
• Examined patients undergoing withdrawal for
cause of death and criteria for kidney donation
Current Literature on Donor
Selection Criteria
Shore et al. Potential for Liver and Kidney Donation After Circulatory Death in Infants and
Children. Pediatrics 2011; 128 (3)
Inclusion Criteria
•
•
•
•
•
> 1.8 kg
DCD warm ischemia ≤ 120 mins
Cold ischemia < 48 hours
No systemic infection, HIV, or tumor
Acute kidney injury okay unless donor is
anuric
Exclusion Criteria
•
•
•
•
•
Presence of tumor, systemic infection, or HIV
Requirement of renal replacement therapy
Urine output < 0.5 mL/kg/h
Creatinine ≥ 1.5 mg/dL
Death greater than 120 minutes after
withdrawal
Results
•
•
•
•
Total NICU discharges: 11,201
Deaths: 609
Weight ≥ 1.8 kg at the time of death: 359
Mode of Death
– Brain deaths: 0
– Death despite CPR: 55 (15.1%)
– Withdrawal: 159 (44.3%)
– DNR: 145 (40.6%)
Mode of Death (n=359)
Brain Death
0%
CPR
15%
Withdrawal
Withdrawal
44%
DNR
CPR
DNR
41%
Brain Death
Results
• 159/359 (44%) patients withdrawn from life
support
• Age: 1 day to 284 days
• Weight 1800 to 9845 grams at the time of
death
Potential Newborn DCDD
• Ventilator withdrawn in all 159, also inotropes
in 57, ECMO in 7 patients
• 97 patients had at least one exclusion criteria,
time of withdrawal not recorded in 2 patients
leaving 60 eligibles
• WIT <60 min in 45 babies
• WIT < 120 min in 60 babies
Cause of Death
Warm ischemic time <60
minutes (n= 45)
Warm ischemic time
<120 minutes (n= 60)
Complex Congenital Heart
Disease
11
16
Neurological Anomaly, Disorder
or Injury
11
15
Respiratory Failure due to
Diaphragmatic Hernia or Lung
hypoplasia
8
9
Genetic Disorder, Multiple
Congenital Anomalies
5
9
Prematurity
5
6
Congenital AnomalyOmphalocele, Gastroschisis
4
4
Inborn Error of Metabolism
1
1
Warm Ischemic Time <60
minutes (n=45)
(median)
Warm Ischemic Time <120
minutes (n= 60)
(median)
Age Range (days)
1 to 214 (13.5)
1 to 284 (12.5)
Weight Range (kilograms)
1.8 to 9.8 (3.3)
1.8 to 9.8 (3.2)
Males
20
29
Females
25
31
Urine Output Range (ml/kg/hr)
0.6 to 7.4 (2.8)
0.6 to 7.4 (3)
Serum Creatinine Range
(mg/dL)
0.1 to 1.2 (0.3)
0.1 to 1.2 (0.4)
Warm Ischemic Time Range
(minutes)
1 to 57 (29.5)
1 to 115 (37.5)
Study Summary
• No brain deaths
• 28-38% of newborns ≥ 1.8 kg undergoing
withdrawal could be potential DCDD kidney
donors
• A NICU DCDD donor program at our center
would provide about 3-4 additional paired
kidneys per year for transplantation
(based on 68% PICU brain death consent rate over
the study period)
The true potential-DCDD
• Brain death is rare in NICU-very few donors now,
in the future??
• In California alone there are 89 Level IIIB and C
NICUs with a total of 2726 NICU beds: 97-120
additional paired DCDD kidneys available for
transplant each year
• Nationally: 677 Level III B and C NICUs with
24,043 beds: 859 to 1145 paired donor kidneys
Conclusions/Action plan
• The potential for newborn DCDD donation
exists
– Solid organs-primarily kidneys, potentially heart
– Hepatocytes for research
• Discuss this on your unit
• Consider any newborn > 2 kg undergoing
withdrawal for evaluation as a potential donor
Acknowledgements
• Loma Linda University Children’s Hospital
– Heather Hanley, MD (PICU fellow)
– Sunhwa Kim, MD (Neonatologist)
– Erin Willey, MD (NICU fellow)
• OneLegacy
– Dana Castleberry, RN, CPTC (In-house coordinator)
Questions to Run On:
What practices can I implement to
improve the pediatric and neonatal
donation programs at my hospital?