DCD

Identification and notification requirements of a potential DCD donor to the OPO

Fact-Finding Questions Hospital Leadership Should Ask

1. What is our hospital’s policy and process for identification and notification of potential organ donors to the OPO; and how are we complying with the timeliness of these notifications?
2. Does our hospital patient care team have access to identification and notification resources and tools?
3. Do we have a process in place that ensures the staff in the Emergency Department (ED) are identifying potential donors and notifying the OPO?
4. Has our hospital investigated the opportunity to set-up automated OPO-notifications of potential donors from our electronic health record (EHR) system?
5. Are we ensuring that the potential organ donor is medically maintained in order to allow for the donation potential to be preserved?
6. What is our process for reviewing missed notification opportunities and developing a plan to remediate future misses?
7. What is our process for evaluating ventilated patients for donor potential before they are assessed and moved to inpatient hospice?

Key Points Hospital Leadership Should Remember

• Hospitals must have a written agreement with the OPO that includes mutually agreed upon definitions for imminent death and timely notification of potential organ donors to the OPO.
• The definition of imminent death should be broad enough to ensure timely notification of potential donors after circulatory death.
• Life-sustaining treatment should not be withdrawn until the OPO confirms organ donation suitability and the donation conversation has occurred.
• Processes for identifying potential donors and maintaining life-sustaining treatment should be in place in the ED to avoid missed donation opportunities.
• Patients should be evaluated for donation potential prior to discharge to inpatient hospice for withdrawal of life-sustaining treatment (WLST).
• Automated OPO notifications from hospital EHR systems have the advantage of expediting the notification process, reducing staff time in manual transfer of information, and eliminating the potential for human error.

Model Elements for Identification of DCD Potential

According to Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoP), hospitals must notify OPOs in a timely manner of all patients who have died or whose death is imminent (see Essential 1 for further details).^1,2,3

A DCD potential is a patient who has suffered devastating and irreversible illness or brain injury and may be near death or death is expected but the patient does not meet brain death or death by neurologic criteria (BD/DNC). In these cases, the family has decided to pursue WLST, allowing death to occur. In some rare instances, the patient may make their own decision to refuse continued medical treatment.

Common types of injury or illness observed in DCD potentials:

• Severe brain injury/trauma (gunshot wounds, motor vehicle collisions, etc.)
• Cerebrovascular insult
• Infection (overwhelming sepsis)
• Severe anoxic injury (drowning, post-cardiac or respiratory arrest, hanging, etc.)
• Assist device dependant (ECMO)
• Amyotrophic lateral sclerosis (ALS), High spinal cord injuries

The hospital patient care team is responsible for the identification of patients who meet the definition of imminent death and notifying the OPO in a timely manner. Every hospital should have an established written agreement with the designated OPO for the definition of imminent death and timely notification (see Essential 1).^1,2,3 These definitions should also be clearly outlined in the hospital’s donation policy for easy reference by the hospital patient care team. OPOs establish clinical triggers for the hospital patient care team to serve as reference points for identifying potential donors and determining when and how to initiate contact with the OPO.

The process of identifying potential donors and notifying the OPO should be a hardwired process for the hospital patient care team.⁴ Early notifications are important to allow the OPO adequate time to determine donation potential before any deceleration of treatment or WLST occurs. It also allows the hospital patient care team and the OPO coordinators to work collaboratively together to support the family during the donation conversation. To eliminate the potential for human error and reduce the burden on hospital patient care team members, some hospitals have implemented automated notification processes between the hospital electronic health record (EHR) and OPO’s electronic donor medical record interfaces.

Areas where donor potential is often missed and can be lost are in the ED^5,6 and to inpatient hospice.⁷ It is important for hospitals to evaluate their practices to ensure patients who meet the clinical triggers in the ED are identified and the OPO is notified prior to any implementation of WLST. If considerations are being made to transfer any ventilated inpatient to inpatient hospice for comfort care and possible WLST, the OPO should be notified for a donation evaluation and to ensure families are aware of all of their end of life (EOL) care options.

Clinical Triggers (“Clinical Cues”)

Clinical triggers (or “clinical cues”) is a reference tool that aids the hospital patient care team in the identification of a potential donor who meets the definition of “imminent death” as agreed upon by the hospital and the OPO. These clinical triggers could be provided as badge buddies, reference cards, mouse pads, screensavers, etc.

Examples of clinical triggers include, but are not limited, to any of the following:

• “Imminent Death” might include a patient with severe, acute brain injury or pulmonary/neuromuscular disease process who:³
• Requires mechanical ventilation; AND
  • Exhibits clinical findings consistent with a Glasgow Coma Score8 that is less than or equal to a mutually-agreed-upon threshold; or
  • Loss of a mutually-agreed-upon number of brainstem reflexes; or
  • MD/DOs are evaluating a diagnosis of BD/DNC; or
  • An MD/DO has ordered that life-sustaining therapies be withdrawn, pursuant to the family’s decision; or
  • A family who is beginning discussions of withdrawal of life-sustaining treatments (WLST); or
  • A family who initiates a conversation about donation.
• All cardiac deaths (for tissue and eye donation evaluation)

Patients who are potential DCD donors may not exhibit traditional clinical triggers such as a loss of brainstem reflexes or a minimal Glasgow Coma Score. In many situations, the only indication may be the decision by the family for WLST with the expectation of the patient’s death following WLST. This presents a challenge for the hospital patient care team and OPO coordinators to manage, as most families want WLST to occur within minutes to hours of their decision.

Incorporating “family readiness cues” that a family may be thinking about WLST into the clinical trigger tool can help hospital patient care teams notify the OPO earlier. Examples of cues to incorporate into a clinical trigger tool may be the family talking about the patient in the past tense, gathering friends and family at the bedside, or having conversations centering on funeral arrangements or after the death.

Timely Notification of A Potential DCD Donor

The intent of timely notification to the OPO is to allow the deployment of necessary resources to support the hospital patient care team and family. It allows the OPO time to conduct a donation suitability evaluation and plan the donation pathway. The more time the OPO has to gather all of the details and to be well prepared prior to initiating a donation conversation, the better the family is served.

A “timely” notification is as soon as possible once the clinical triggers are identified and prior to any deceleration of treatment or WLST.^1,2,3 The hospital and OPO must mutually agree upon the definition of timeliness and incorporate it into their written agreement.^1,2,3

It is important to appreciate that timely notification of the OPO when a patient meets clinical triggers has no impact on the hospital care teams treatment of the patient. Many patients who meet the clinical triggers and are referred to the OPO will improve and are successfully discharged to home. Additionally, the misconception that notification of the OPO by the hospital will lead to an OPO/family conversation about organ donation exists but is incorrect. This is not the purpose of the OPO notification process. The timely notification of the OPO, commonly referred to by the OPO as “a referral,” allows the OPO to partner with the hospital patient care team to better prepare for the family and ensure that in situations where the patient may not survive, the opportunity for donation is preserved.

Automated Notification Process

One method to facilitate timely notifications to the OPO is to institute automated donor referrals (notifications) through an interface engine between the hospital EHR and the OPO. Through automated processes, a potential donor is identified and the OPO is notified, in real-time, via an electronic “organ donation order” where pertinent information is sent to the OPO’s donor management system.⁹ The system, in turn, sends back a notification confirming that the OPO has received the information.⁹ The majority of OPO donor management systems in the US as well as the majority of hospital EMRs have the capability to integrate these interfaces. Automated donor notifications increase cost-effectiveness by reducing hospital staff time with manual telephone notification and call backs by the OPO; reduce the potential of human errors in missing patients that meet clinical triggers; may reduce length of time an intensive care bed is needed for a donation case; and may increase staff satisfaction by freeing their time to allow them to focus on their patients.¹⁰

Advantages of Timely Notifications

A successful deceased donation program has a fundamental reliance on the identification and notification of all potential donors.

The advantages of timely notifications of potential donors include:¹¹

• Adequate time for the OPO to evaluate for the medical suitability of the potential donor prior to initiating any donation conversation with the family.
• Adequate time for the OPO to collaborate with the hospital patient care team on the timing of the donation conversation, including assessment of family dynamics and grief support.
• Early collaboration between the hospital patient care team and the OPO coordinators in identifying the next steps in the donation process.
• Resource identification for the determination of BD/DNC, should it become necessary.
• Prompt initiation of the donor management protocols following donation authorization.

According to a study,¹¹ too often, families decline DCD donation because the timing of the donation conversation is too late in the decision-making process for the family, at which point the idea of waiting additional hours to days for WLST seems insurmountable.¹⁰ This supports anecdotal experience from OPO and hospital patient care teams. “Had we known earlier,” is a phrase too often heard from families when they decline donation. By establishing a hard-wired process for potential donor identification and timely notification to the OPO, hospitals can ensure that all potential donors and their families are afforded donation opportunities, through a timely and well-prepared conversation.