Organ Donation After Circulatory Determination of Death:
OR Process, by Dr. Sally Vitali.
Please note that in this video, we
will be following the guidelines used
at Boston Children's Hospital.
Some of this information may need
to be modified based on the guidelines and practices
in place in your institution.
This video is part three in a series on the organ
donation after circulatory determination of death,
or DCDD, process at Boston Children's Hospital.
My name is Sally Vitali, and I'm a Pediatric Intensivist here
at Boston Children's.
Broadly, this video will cover the time period
from arrival in the operating room until the patient's death.
We will watch excerpts from a video of a DCDD simulation that
was produced by the Institute for Professionalism and Ethical
Practice here at Boston Children's and our organ
procurement organization, the New England Organ Bank.
The parents in the video are portrayed by actors,
the patient is a mannequin, and the care team
are all members of the Boston Children's and New England
Organ Bank staff.
I will use video clips during this presentation
to cover the arrival in the operating
room with the patient and the family,
the withdrawal of the ventilator, and possibly
cardiac support medications, or ECMO,
the monitoring for hypotension and administration
of heparin at the appropriate time,
monitoring for pulselessness, and if pulselessness occurs
before 60 minutes after the withdrawal
of life-sustaining treatments, the family
will remain in the first operating room,
and the patient will be moved to the second operating room.
Declaration of death will occur there
after five minutes of pulselessness.
If pulselessness does not occur within 60 minutes,
the team will communicate to the family
that organ donation is no longer possible,
and the patient and the family moved back to the ICU
to continue end-of-life care.
As we watch the first video clip,
you will notice that the operating room has
been prepared before arrival by the OR nurses, who
have worked to cover as much of the equipment as possible
with drapes and have brought in chairs and a second bed
for the family.
If the family has other special requests about the environment,
these should be communicated to the OR nurses ahead of time.
On arrival to the OR, it's helpful to have
a team dedicated to getting the patient situated
and a team who will orient the family
and discuss the steps of DCDD, preparing the family as we
would before any withdrawal of the ventilator
and end-of-life care.
How are you holding up?
Alright under the circumstances.
I think you're very impressive.
I think you're doing great.
Well, these folks are just getting
Danielle settled in bed.
I just want to ask you about her monitor.
One of the things that we'll be doing
is watching her monitor in an effort
to be able to judge what's changing after we take out
the breathing tube.
And we expect her oxygen levels to change
and her heart rate to change and her blood pressure.
And that's our job, to look at those monitors.
Now, you've seen those in her room for the past five days.
And so one of the things that I would ask you is
"Do you want to be able to see that monitor to see what we're
seeing, or should we just turn that away and we'll look at it,
but you can focus on Danielle?"
I think I'd like to--
I'd like to watch.
I'd like to know.
I just dont-- I just want to know right away, I think.
Yeah, I feel the same way.
Yes, I think we'd like to have the monitor, then.
So first of all, remember that it's
likely Danielle will take some breathing
efforts, just like when we challenged her
before to see if she would breathe without the ventilator
putting in breaths.
It's likely her body will still try to breathe,
and so that breathing may become noisy,
almost like a snoring sound.
And it is normal as oxygen levels fall
and carbon dioxide levels build up
when someone isn't breathing normally.
It is normal for them to start trying to take deeper breaths.
And those deeper breaths can look disturbing.
They can look like gasps, and they
can cause her body to lift and move
as she takes a deep breath.
OK.
And how otherwise will we know if she's in any kind of pain
at all?
Good question.
We're going to give her some analgesics, some morphine,
and some sedation with midazolam before we take the breathing
tube out, so we can be absolutely certain
that she's not experiencing any discomfort or any pain.
OK.
Good.
Do you want to get in?
Can I come around this side?
Sure.
Hey baby.
Hey Danielle.
I'd like to go ahead and have Tony
give some medications in preparation
for taking out her breathing tube.
OK?
Yeah.
After the ventilator and any cardiac medications or ECMO
have been withdrawn, the team will
continue supporting the family, including
any plans for prayers, music, or other requests
that might have been discussed ahead of time,
monitoring for signs of discomfort in the patient
and treating with the appropriate medications,
monitoring for hypotension, and delivering heparin
according to the DCDD protocol, monitoring
for pulselessness with the arterial line wave form,
or by a cardiologist performing an echocardiogram
to determine whether the heart is injecting blood if there is
no arterial line, and also documenting the exact time
of pulselessness.
If the pulseless arrest occurs within 60 minutes,
the family will say their final goodbyes,
and the patient will be transported to the second OR.
The ICU physician will continue monitoring
for the pulselessness and declare death
in the second operating room when
five minutes have elapsed without a spontaneous return
of pulses.
Organ procurement will commence, and the ICU physician
will communicate to the family that the patient has
been declared dead.
If the patient does not progress to pulseless within 60 minutes
of withdrawal of the ventilator, the ICU team will communicate
to the family that the patient cannot donate organs,
and the patient and family will be moved back to the ICU
to continue end-of-life care.
If the patient becomes an organ donor,
the family may wish to spend more time with the patient's
body after death.
This can be arranged to occur back in the ICU
after the organ recovery surgery.
This concludes part three of the video series on DCDD
at Boston Children's Hospital.
Any questions about this material
can be directed to your unit clinical or nursing director
or to the Organ Donation Oversight Committee
representatives from your unit.
Thank you for taking the time to help improve the quality
of our organ donation process here at Boston Children's.