Supporting the Neonatal and Pediatric Donor - PowerPoint Presentation

Slide1

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 HospitalSlide2

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.

Objectives:Slide3

What practices can I implement  to improve the pediatric and neonatal donation programs at

my hospital?Questions to Run On:Slide4

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 reportSlide5

Ends and Meansare essential to ethical analysis

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

For example:Slide6

Does your hospital have a brain death committee?

My credentialsGoal: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 intentionsSlide7

I suspect this group already has better than average education about organ donationSlide8

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 editorSlide9

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25% indicated that mechanical ventilation was withdrawn in pts to reduce suffering in persons presumed dead without the issue of donation ever being raised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 2011Slide10

What does this tell us?

Some nurses may have doubts as to whether some people being treated as dead are really deadSome 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 donationSlide11

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? Slide12

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 interestSlide13

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 issueIt 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.Slide14

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

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)

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

Utilitarian

DeontologicalSlide15

Kant’s Supreme

Moral Law

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

Rational agents recognize themselves as “ends-in-themselves” and because they are rational, recognize other rational beings as belonging to the same kingdom and therefore respect them as such

Categorical ImperativeSlide16

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 elseSlide17

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 opposedSlide18

“Full court press”: I pity the fool that makes a decision to withhold care before this pt has a full chance at resuscitation

“Full court press”: this patient could be an organ donor

But how do we justify one choice or another?

“Nothing”: there is no point, this pt will die. Damn it Jim, I am a doctor not a miracle workerSlide19

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)Slide20

Modified Pascal’s Wager

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.

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 1658Slide21

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, patientHe 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 passSlide22

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 ICUSlide23

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 deservedThere is a major communication problem in this unitSlide24

How do we best proceed?

Clear objectives and communication with everyoneThe patient’s best interest is first priorityNever 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.Slide25

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 correctlyPolicies 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 interestSlide26

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 unambiguousWhen caregivers do not discuss donation with families

If we do the right things (means) for the right reasons (ends)Slide27

Thank you

This means the endSlide28

Potential organ donors among newborns undergoing circulatory determination of death

Mudit Mathur, MDAssociate Professor, Pediatrics/Critical Care

Loma Linda University Children’s Hospital

Pediatric Intensivist, Huntington HospitalSlide29

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)Slide30
Slide31

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 yearsNICU DCDD donor Potential is similar to PICU data (5.5-8.7%)

Identifying NICU donors may

Markedly expand the infant donor poolReduce short-term wait-list mortality rates for infants waitlisted for heart transplantationSlide32

The percentage of waitlisted patients needing a kidney is (approximately):

20% 40%

60%

80% 100%Slide33

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 dialysis5,000 kidney waitlist deaths/yearSlide34

Pediatric En Bloc Kidney Transplantation to Adult Recipients: More Than Suboptimal?

Bhayana

et

al. Transplantation 2010; 90 (3): 248-54Slide35

How about pediatric recipients?

Small en bloc kidneys into 8 pediatric recipientsDonors 4-22 kgOne kidney lost to intraoperative thrombosis, other remained viableAll 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 Slide36

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 donationSlide37

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)Slide38

Inclusion Criteria

> 1.8 kgDCD warm ischemia ≤ 120 minsCold ischemia < 48 hoursNo systemic infection, HIV, or tumorAcute kidney injury okay unless donor is

anuricSlide39

Exclusion Criteria

Presence of tumor, systemic infection, or HIVRequirement of

renal

replacement therapy Urine output < 0.5 mL/kg/hCreatinine ≥ 1.5 mg/dL

Death greater than 120 minutes after withdrawalSlide40

Results

Total NICU discharges: 11,201 Deaths: 609Weight ≥ 1.8 kg at the time of death: 359

Mode of Death

Brain deaths: 0Death despite CPR: 55 (15.1%)Withdrawal: 159 (44.3%)DNR: 145 (40.6%)Slide41

Mode of Death (n=359)Slide42

Results

159/359 (44%) patients withdrawn from life support Age: 1 day to 284 daysWeight 1800 to 9845 grams at the time of

deathSlide43

Potential Newborn DCDD

Ventilator withdrawn in all 159, also inotropes in 57, ECMO in 7 patients97 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 babiesSlide44

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 Anomaly-Omphalocele, Gastroschisis

4

4

Inborn Error of Metabolism

1

1Slide45

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)Slide46

Study Summary

No brain deaths 28-38% of newborns ≥ 1.8 kg undergoing withdrawal could be potential DCDD kidney donorsA 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)Slide47

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 Slide48

Conclusions/Action plan

The potential for newborn DCDD donation existsSolid organs-primarily kidneys, potentially heartHepatocytes for researchDiscuss this on your unitConsider any newborn > 2 kg undergoing withdrawal for evaluation as a potential donorSlide49

Acknowledgements

Loma Linda University Children’s HospitalHeather Hanley, MD (PICU fellow)Sunhwa Kim,

MD (Neonatologist)

Erin Willey, MD (NICU fellow)OneLegacyDana Castleberry, RN, CPTC (In-house coordinator)Slide50

What practices can I implement  to improve the pediatric and neonatal donation programs at

my hospital?Questions to Run On:Slide51