Organ Donation After Cardiac Death DCD Checklist by liaoqinmei

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									                                                   Mercy St. Vincent Medical Center
                               Organ Donation After Cardiac Death (DCD) Checklist
                                                                     PC-029

Patient Name ______________________________________MR #_______________ Unit ________________
Date/Time__________________________ Referral Number ___________________UNOS # ______________
Attending Physician_________________________________________________________________________
Consulting/Designated Physician on Withdrawal_________________________________________________
Primary RN________________________________Chaplain_________________________________________
Clinical RN Manager/Charge RN_____________________________RT_______________________________
Palliative Care Nurse __________________________________ LCO Coordinator ______________________

 Step   Procedure                                                                                                          Date/Time
                                                                                                                           Completed/
                                                                                                                           Initials
  1     Patient referred to donor referral line according to clinical triggers/imminent death criteria                     ______
  2     Decision for withdrawal of support made by treating physician/family, grave prognosis is                           ______
        verbalized to patient’s family.
        Decisions concerning treatment of patient made separately from and prior to discussion about                       Date/Time:
        organ donation                                                                                                     __________
        **Palliative Care consult made by calling 251-4510/Peds Palliative 251-8008**
        (This consult can be made by MD, resident, RN, chaplain, etc.)
  3     End of life orders put in place. DNRCC order written, documented in physician’s progress                           Date/Time:
        notes, and may also be placed in EHR. A copy of the order MUST be placed in the chart.                             __________
        *LCO updated on code status change*
  4     LCO coordinator performs on-site DCD evaluation                                                                    Date/Time:
        ____Devastating neurological illness/injury with hopeless prognosis requiring ventilator support                   __________
        ____Patient, family, or other authorized party has chosen to discontinue life support and formal
        DNRCC order is in patient’s chart
        ____Health care team discusses whether patient is expected to die within 60 minutes after
        termination of ventilator support
  5     Medical suitability for DCD determined by LCO (determination involves review of patient records,                   ______
        discussions with physicians, and consultation with transplant physicians.
  6     If case falls under the jurisdiction of Coroner/Medical Examiner, LCO coordinator contacts appropriate             Date/Time:
        person(s) to obtain permission for organ/tissue recovery. CORONER/ME________________________                       __________
  7     Patient is NOT a Candidate:____
                Palliative Care and chaplaincy support are continued.                                                      ______
                Plan for withdrawal of support is developed with family.
            **Stop and Do Not Proceed Any Further**
        Patient is a Candidate:____                                                                                        ______
                Palliative Care and chaplaincy support are continued.
                Attending physician/designee and hospital team consults with LCO on plan for
                approaching family and maintains medical management until death pronounced
                Comfort measures follow hospital protocols/ administered by hospital staff.
  8     TEAM HUDDLE                                                                                                        Date/Time:
        Includes Primary RN, Charge RN, Clinical Nurse Manager (if applicable), Physician, Palliative Care RN, Chaplain,   __________
        LCO coordinator/IHC
        Review of Staff Concerns
                Chaplain or coordinator inquires of staff as to ethical concerns, DCD process reviewed
  9     Family approached by LCO coordinator/appropriate hospital team members. The
        following items are discussed:                                                                                     Date/Time:
                  Options for organ/tissue donation                                                                        __________
                  Any procedures related to DCD (placement of lines, etc.)
                  Explanation of the DCD Evaluation tool
                  Extended waiting times for required screening/recovery
                  Potential that screening may disallow donation
                  Routine information about organ recovery/placement
                  Plan of care if DCD is not successful
              Assurance that donation does not add additional costs
              Assurance of continued care of patient without regard to donation
              Thorough medical/social history
              Transportation to operating room
     *The family will be offered the opportunity to be present at the patient’s bedside during the 60-
     minute waiting period for cessation of cardiac activity.
     *The family will be given the responsibility of designating family members to be present during
     this time.
10   Family Does NOT Consent to DCD:____                                                                                     Date/Time:
            Palliative Care and chaplaincy support are continued.                                                            __________
            Plan for withdrawal of support is continued.
     ***STOP AND DO NOT PROCEED ANY FURTHER***
     Family Consents to DCD:____
            Palliative Care and chaplaincy are continued.
            LCO coordinator completes routine organ and tissue consent process (includes                                     Date/Time:
            additional testing/screening)                                                                                    __________
11   TEAM HUDDLE
     Includes: Includes Primary RN, Charge RN, Clinical Nurse Manager (if applicable), Physician, Palliative Care RN,
     Chaplain, LCO coordinator/IHC
            Notify Clinical Nurse Manager/Charge RN of DCD case
            Name/Date/Time:____________________________________________________
            Notify Nursing Administrator On-Call (Call Operator and ask for Nursing Admin On
            Call) Name/Date/Time:________________________________________________
            Notify Nursing Supervisor of case/arrange for Palliative RN (419-539-0564)________
            Notify OR (1-4711) of potential DCD case Name/Date/Time:____________________
            Notify Attending Physician/arrange for MD for declaration process
            (Trauma, CC, DO surgery, surgery residents on-call**have 2cd MD for backup**)
            Note: If Pediatric case, an Attending Physician (NO residents) must declare death
            _________________________________________________________________
            Notify Care Coordination Center (1-4160), determine where withdrawal to take place
            and reserve Palliative bed or PICU bed (if Peds case) Room #_____________
            Notify Palliative Care/Leigh Moore (1-4067) or Donna Ruedisueli (1-3068) if Peds
            case. Date/Time: ______________________
     Family Care Plan Developed:
            Family needs, who responsible for which aspects of family support
            DCD process reviewed with hospital staff by LCO coordinator
            Chaplain and Palliative RN available to provide spiritual/emotional support
12   Charges for Patient Care:
              All charges related to the donation process will be the responsibility of LCO
              These patients will NOT be discharged and readmitted as in brain death donation, therefore; the LCO
              coordinator will be responsible to ensure all charges incurred as part of the donation process will be LCO’s
              responsibility.
13   Patient Care Management During Screening and Placement:
             Any orders prior to death remain the responsibility of the attending physician or
             designee.
             LCO coordinator requests orders for consultations, studies
             Verify DNRCC order is complete, orders are written for comfort care medication                                  ______
             No medications or procedures to sustain the patient’s organs for donation will
             be given prior to declaration of cardiac death
             Primary RN remains responsible for the care of the patient
             Palliative Care RN introduced to family and discusses withdrawal of care, extubation,
             what to expect, and questions answered
             Chaplain provides care for the family
     COMFORT MEASURES ARE TO REMAIN THE PRIORITY
14   Re-Evaluation (LCO coordinator):
             Potential OR space is identified___________
             Potential DCD team members are identified (bedside RN/Palliative RN)
             Physician for declaration___________________/Backup Physician_______________
             Area for withdrawal is determined_______________
             Palliative or PICU bed____________
15   OR is informed by LCO coordinator that DCD will proceed. OR:
             Designates an area for the transplant recovery team to stay (this team MAY NOT be
             involved in or in the patient’s room during withdrawal or declaration of
             death)_________
             Arranges surgical team to support the process
             LCO coordinator reviews DCD process with OR staff
16   Transplant recovery team arrives at SVMMC and reviews time line for DCD. LCO coordinator
     orients recovery team/OR staff to case.                                                                     ______
17          Team Huddle prior to transport to determine any last minute concerns and to review
            the plan for transport, process/staff roles, extubation, DC of NG tubes/vasopressors                 ______
            All meds/supplies for comfort care are available, care plan discussed.
            Patient is transported to withdrawal area fully supported and accompanied by
            primary RN, palliative care RN, respiratory therapist, and chaplain (if not attending
            to the family’s needs). LCO coordinator may be present for recording events
            The primary RN/chaplain/palliative RN orient family to area of withdrawal
            Chaplain provides support for the family (ensure adequate seating)
18   Withdrawal of Support
            Primary RN continues to provide care of the patient, administers comfort measures                    Date/
            Palliative Care RN is at bedside supporting family, explains process, what family can                Time
            expect, acts as consult/support to primary RN.                                                       vent dc’d:
            Physician is present to declare death                                                                __________
            Vent is disconnected in accordance with hospital protocol/vasopressors discontinued
            Surgery team is kept informed of patient’s status
            Continue monitoring for heart tones and pulse to monitor for asystole (cessation of
            cardiac activity) or pulselessness by continuous EKG, and if appropriate, arterial pulse
            pressure monitoring
            Family members must leave the bedside as soon as pulselessness occurs
            OR notified of cardiac death and immediate transport.
            Team transports patient to OR
19   Declaration of Death:
            No steps taken for purpose of hastening the patient’s death.
            Palliative care is continued.
            Declaration of death can in NO way involve members of the organ and tissue
            recovery team
            Attending physician or designated physician present at the time of withdrawal remains
            at bedside to declare death
            Patient meets criteria for cardiopulmonary death, run EKG strip if possible
            Given the above, any ONE of the following EKG criteria will be sufficient for
            determination of death:                                                                              Date/
                                                                                                                 Time 5
         1. 5 minutes of ventricular fibrillation                                                                minute
         2. 5 minutes of electrical asystole (i.e. no complexes, agonal baseline drift)                          start:
         3. 5 minutes of pulseless electrical activity                                                           ________

              The organ recovery process will NOT be initiated until patient exhibits this 5 minute              Date/
              period of breathlessness and pulselessness.                                                        Time 5
                                                                                                                 minute
              Death is declared by the attending physician or designated physician following the
                                                                                                                 stop:
              above criteria and documented in the progress notes
     Physicians pronounce death based on the laws and codes in the state of Ohio. The RN documents vital signs   ________
     and the physician documents in the physician progress notes.                                                *This is
     **Notify the originating floor and Palliative Care Unit/PICU or unit where bed has been                     DATE/TIME
     reserved) that DCD has been successful**                                                                    of DEATH*
             Pronouncement progress note including date and time of death must be written
             IMMEDIATELY and remain with the patient in the OR room
             Primary RN to complete death packet                                                                 _______
     Reporting to the family is the responsibility of LCO coordinator, palliative RN and the
20   chaplain. They will:
             Locate family in a conference room/quiet area                                                       ______
             Inform family when patient has died and organ/tissue recovery begins.
     Cases in which DCD is Not Successful:
21   (If patient does not expire within 60 minutes of withdrawal of support, the patient will no longer be a candidate for   Date/Time:
     organ donation)
               The primary RN calls the Palliative Care Unit (1-4510) or PICU (1-4630) in the                                ______
               event the DCD is not successful. (OR contact Care Coordination Center at 1-
               4160)
               Physician gives orders for transfer to the floor/continuance of care                                          ______
               Includes routine and palliative care orders (EHR order set)
               Chaplain, Palliative RN and LCO coordinator inform family. Chaplain informs the family
               that the patient is to be moved to the room reserved for this scenario.
               Chaplain/Palliative RN moves the family to the room/waiting room on this unit.
               Patient admitted to the room-palliative/pastoral care continued.
               Death packet completed by RN caring for patient at time of death.                                             ______
               NOTIFY THE ATTENDING PHYSICIAN, if not already in attendance
     **Charges for patient care revert to the responsible party of the patient at the point the patient is admitted to
     the unit**
22   Completion of Donation through DCD:                                                                                     Date/Time:
             Floor informed (Or Care Coord Center 1-4160) DCD successful- patient will NOT be                                ______
             transferred (LCO Coordinator)
             Chaplain and LCO coordinator provide brief report to family/answer questions
             If family requests, the chaplain/LCO coordinator arranges with the OR for the family to                         ______
             view the body following donation.
             Placement of the body in the morgue and release of body follows normal hospital
             procedure.                                                                                                      ______
             Primary RN is to ensure the death packet is completed
             If and when the patient does die, Primary RN is responsible for contacting the
             Coroner/Medical Examiner of the event, if appropriate.
23   Families Who Leave the Hospital:
             Chaplain/LCO coordinator documents location/ phone number for family                                            ______
             Chaplain and/or LCO coordinator provides updates and support throughout
             Chaplain, Palliative RN and LCO coordinator inform family if DCD is not successful
             and the location/phone# of unit patient will be moved to
             Chaplain and Palliative RN provide supportive care should the family decide to return
             Pronouncement of death and communication to the family should take place in a
             manner consistent with hospital policy.
     Reporting to a Family Outside the Hospital Contact Information:
     Next of Kin Name:_______________________________
     Location:_______________________________________
     Phone(s):______________________________________
     Other Information:


     ***Completed worksheet should remain with LCO Coordinator and a copy made and kept with
     patient chart until case completion, at this time, return to LCO/St. Vs In-House Coordinator to be
     submitted for Quality Review***
     An interdisciplinary committee will conduct a quality review of each clinical use of this protocol.

     Update on OR time:
     ____OR
     ____Declaring MD
     ____Backup Declaring MD
     ____Palliative Unit/PICU
     ____Pastoral Care

     Color Key: Green=LCO Coordinator
                Blue=Hospital staff/RN
                Black=LCO and hospital staff/RN

     10-13-09 KAZ Page 4

								
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