Palliative Care: Achieving Comfort for those with Limited Treatment Options

Moderator:Thomas Nakagawa, MD, Wake Forest Baptist HealthPresenters:Darren Malinoski, MD, Cedars-Sinai Medical CenterBreakout Session A:Optimizing Donation Outcomes within the Context of End-of-Life Care

1Optimizing Donation Outcomes within the Context of End-of-Life Care2011 OneLegacy Organ Donation and Transplantation Symposium

Darren Malinoski, MDDirector of Surgical Critical CareCedars-Sinai Medical Center

Questions to Run On?What PI initiatives can I employ at my hospital to better support donation best practices?What clinical practices can I implement to improve donation outcomes at my hospital?Goals for this PresentationEmphasize the importance of organ donation for both recipients and donorsIdentify the role of critical care providers in organ donation and discuss how their involvement improves outcomesDiscuss the role of Catastrophic Brain Injury Guidelines (CBIGs) and how to implement themDiscuss the dilemma between DNR and organ donationHospital RequirementsCenters for Medicare/Medicaid Services & American College of SurgeonsNotification processDeclaration of brain deathOrgan procurement organization (OPO) relationshipPerformance Improvement (PI) programPatient/family opportunity to donate

Institutional standards have been developed and must be strictly followed to maintain accreditation status as an organ donor center. The Center for Medicare and Medicaid Services has developed conditions for participation as an organ donation facility. Conditions include timely notification and assurance that every family with the potential to donate lifesaving organs is given the opportunity to donate. The American College of Surgeons developed additional guidelines, namely that the center must have an established relationship with a recognized OPO, that there must be written policies in place for triggering notification of the OPO, that the PI program must review the organ donation rate, and that there must be written protocols for the declaration of brain death. To fulfill these requirements, a multidisciplinary organ donor council was established in 2007 at our institution.5Impact of Timely Referralon Conversion RatesTimely Referral*Eligible DeathsEligible DonorsConversion RateYES20,10914,16770.5%NO3,6192,08057.5%TOTAL23,72816,24768.5%* Based on OPOs definition of timely referralOPTN data January 2008 June 2010Impact of Effective Requeston Conversion RatesEffective Request*Eligible DeathsEligible DonorsConversion RateYES18,94714,33275.7%NO3,9981,87046.8%TOTAL23,72816,24768.5%* Based on OPOs definition of effective requestOPTN data January 2008 June 2010

Brain DeathDIDICArrhythmiasPulmonary EdemaAcidosisHypothermiaHypotensionCardiovascular Collapse

p=0.45 vs. 2007p=0.20 vs. 2007

OTPED = effectiveness of an organ donation programConsiders conversion rate & donor management

11After instituting our DCD policy in 2007, we have had an 11% rate, approaching statistical significance. Organs transplanted per donor trended downward from 2007 to 2008, though its cause is multifactorial, including an increase in the number of ECDs to 38% in 2008. Ultimately, after initiation of our organ donor council, the total number of organs transplanted remained stable despite an overall decrease in national numbers.

Pre-ADM(1995 1998)Post-ADM(1999 2002)Percent Changep-value*Referrals for donation341537+ 57%< 0.001Potential donors214255+ 19%0.01Actual donors57104+ 82%< 0.001Family decline (%)109 (51%)106 (42%)- 9%< 0.05Donors lost to CVS collapse395- 87%< 0.001Medically unsuitable940+ 344%< 0.001Organs recovered217370+ 71%< 0.001The next thing we did was compare how we do to a number of local level I trauma centersone of the best methods for looking at how successful organ donor management is, by tracking the number of donors lost from cardiovascular collapse. Region 5 refers to 9 level 1 trauma centers and the numbers of donors lost since 1996. Significantly better than region 5 and really pre-Roth protocol was atrocious.Bottom line, ADM works..but it is not enough.

12How Can I Adopt this at My Institution?Aggressive Donor ManagementDevastating Brain Injury GuidelinesorCBIGs: Catastrophic Brain Injury Guidelines

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Devastating Brain Injury PathwayBenefit to Patients/FamiliesHemodynamic StabilityApnea test/Confirmatory TestLocate familyTime to grieve/decide on next stepsSome patients clinically improve and survivePreserves option of donation if chosen ***Donors and their families want to donate75% families consent, 42% adults registeredGrieving data

98% would choose donation again92% identified positive aspects to the donation process/experienceMajority agreed that donation was comfortingAssociated with less depression

The Impact of Compliance with the American College of Surgeons Trauma Center Verification Requirements on Organ Donation-Related Outcomes A Survey of the Level 1 and 2 Trauma Centers in Southern California Compliance with ACS 67%5.1 vs. 5.3 donors/1000 trauma admits (p=0.88)Trauma Surgeon on Donor Council 67%6.0 vs. 4.2 donors/1000 trauma admits (p=0.04)21 vs. 11 donors/1000 ICU admits (p=0.03) Catastrophic Brain Injury Guidelines 48%6.3 vs. 4.2 donors/1000 trauma admits (p=0.04)69 vs. 62% conversion rate (p=0.01)- D Malinoski, et al. 2011 PCSABackgroundChecklists have demonstrated utility in several arenasStandardized critical care endpointsDonor Management Goals (DMGs)Checklists have demonstrated utility in both medical and non-medical arenasStandardizing critical care endpoints at the bedside of brain-dead organ donors may help to improve the consistency of donor management and increase the number and quality of organs procured.Toward this end, the organ donation breakthrough collaborative has encouraged the use of donor management goals, or DMGs, by organ procurement organizations

21Critical Care EndpointDMG1. Mean Arterial Pressure (MAP)60 110 mmHg2. Central Venous Pressure (CVP)4 12 mmHg3. Ejection Fraction (EF)> 50%4. Vasopressor use 1 and low dose5. Arterial Blood Gas pH7.3 7.56. PaO2:FiO2 (P:F)> 300 on PEEP = 57. Serum Na0.5 cc/kg/hrRegion 5 Donor Management GoalsThese ten critical care endpoints were selected as Region 5s donor management goals for the purpose of our initial, retrospective analysis.These goals reflect the hemodynamic, acid-base, respiratory, endocrine, hematologic, and renal status of the donor.

22Region 5 Donor Management GoalsDonor Management Goals met at consent improve outcomes90% increase in the chance of achieving 4 organs transplanted per donor50% decrease in the chance of developing recipient renal delayed graft functionBalancing DNR and DonationTiming determine prognosisTiming EOL care planningTiming referral to OneLegacyMaintain standard critical care until the patients prognosis has truly been determined and the intent to donate has been elucidatedSummaryMaking donation a priority improves outcomesAggressive donor management / CBIGs affect the number and quality of organs available for transplantationDonation benefits OUR patients/familiesQuestions to Run On?What PI initiatives can I employ at my hospital to better support donation best practices?What clinical practices can I implement to improve donation outcomes at my hospital?THANK YOU Darren Malinoski, MD malinoskid@cshs.org I would like to thank all of the members of the region 5 DMG workgroup and would be happy to entertain any questions.27GOALTo maintain hemodynamic stability in patients with devastating brain injuries