BB Mallory Dionne, single ventricle, central shunt, transthoracic VA ecmo x 6days, April 2010
Karelle Galaise Seguin, 16 yo acute myocarditis with complete arrest of cardiac function-asystole and not electrical function for 3 days.
Comment by Dr. Liben, former intensivist, re: organ donation. – what he meant was- it is a big hassle to take care of dead patients, as opposed to the acceptable hassle of taking care of living patients.
When you designate people, define roles and responsibilities, collaborate interprofessionally and provide funding, things work better
Principles of the Canada Health Act: Public administration, comprehensiveness, universality portability and accessibility The Canada Health Act establishes the criteria and conditions related to insured health care services - the national standards - that the provinces and territories must meet in order to receive the full federal cash transfer contribution. (Government of Canada, 2007, www.hc-sc.gc.ca) The provinces of Canada are constitutionally responsible for the administration and delivery of health care services. The administration and delivery of health care services is the responsibility of each province or territory, guided by the provisions of the Canada Health Act. The provinces and territories fund these services with assistance from the federal government in the form of fiscal transfers. Health care services include insured primary health care (such as the services of physicians and other health professionals) and care in hospitals, which account for the majority of provincial and territorial health expenditures.
10 provinces, 3 territories Fragmented system
Fragmented system but progress varies In-hospital donor coordinators Local OD committees and quality assurance process Donation registries- ON, BC, NS, NB Gradual advancement of DCD Collaboration and Collaboratives High school curriculum Hospital accreditation standards in OTDT Shortly after receiving the mandate, we convened over 100 members of the Canadian OTDT community for a facilitated, three day national consultation We learned a great deal about the community and we knew we needed to shape the planning process based on the realities of that community Some of the things we learned: Common ground on many topics Gaps in understanding of the current state Many ideas on resolving challenges Divergent perspectives on what a national system should look like This led us to declare some “process principles” for ourselves as we developed the planning process To be consultative and transparent: we’ve implemented a Committee Structure. Public Affairs Plan, Electronic Forum Consultations To acknowledge successful elements and previous work: Previous CCDT work and National Consultation To be evidence-based: Extensive current-state analysis to be clear about the most critical challenges To be respectful of people’s time: Bulk of preparatory work and support performed by Canadian Blood Services To complete the process in a reasonable time: Target a one-year timeline What we did not want to do was create another report and recommendations without implementation – need alignment from the community on this opportunity for improvement
ODT Stats 2006 Canada - 27 hospitals performing transplants -2160 transplants- 56% kidneys -3500 patients waiting -76% are kidneys -wait list is underestimated due to insufficient resources to list all patients in need of kidneys -243 died on list -417 removed from list for becoming too ill
Limit 3 KMs per slide 11/28/11
Message One: Canadian Blood Services delivered Call to Action to governments in April 2011. Message Two: We have been working with governments since—helping them interpret the recommendations, understand the impacts to their jurisdictions etc. Message Three: Having been asked by governments to produce this strategic plan, it is theirs—they have chosen to embargo it until they are ready to make a decision. We hope to be able to make public this fall—it has been challenging to not be able to keep up the level of engagement with stakeholders that was used during the plan’s development. 11/28/11
Confounding conditions include thiopentone for refractory ICP, within first 24 hours post cardiac arrest.
Intensive Care Med. 2005 Jun;31(6):823-31. Epub 2005 Apr 27. End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom. Wunsch H, Harrison DA, Harvey S, Rowan K. Fig. 2 By individual ICU, the percentage of ICU deaths that occurred following the decision to withdraw active treatment There was considerable variation across units in the percentage of patients in whom a decision to withdraw all active treatment was made (range 0.6–31.8%). Across units, between 1.7% and 96.1% of ICU deaths occurred after a decision to withdraw active treatment; units were evenly distributed between these two extremes (Fig. 2 ). Median time to death following the decision to withdraw active treatment was 2.4 h. However, a quarter of patients survived longer than 7 h and 8% survived longer than 24 h (Fig. 3 ). Median time from admission to ICU to the decision to withdraw active treatment was 2.0 days (interquartile range 0.7–6.3 days; range 0–103 days). This median time varied by ICU (range 0.9–8.5 days) Abstract Objective To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences. Design and setting Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001. Patients 118,199 adult admissions to ICUs. Measurements and results The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7–96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions. Conclusions Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.
Table 2. Frequencies of Patient End-of-Life Categories by Region (N = 4248)* End-of-Life Practices in European Intensive Care Units The Ethicus Study Charles L. Sprung, MD; Simon L. Cohen, MD; Peter Sjokvist, MD; Mario Baras, PhD; Hans-Henrik Bulow, MD; Seppo Hovilehto, MD; Didier Ledoux, MD; Anne Lippert, MD; Paulo Maia, MD; Dermot Phelan, MD; Wolfgang Schobersberger, MD; Elisabet Wennberg, MD, PhD; Tom Woodcock, MB, BS; for the Ethicus Study Group JAMA. 2003;290:790-797. ABSTRACT Context While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt with in diverse ways between different countries and cultures. Objectives To determine the frequency and types of actual end-of-life practices in European intensive care units (ICUs) and to analyze the similarities and differences. Design and Setting A prospective, observational study of European ICUs. Participants Consecutive patients who died or had any limitation of therapy. Intervention Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied from January 1, 1999, to June 30, 2000. Main Outcome Measures Comparison and analysis of the frequencies and patterns of end-of-life care by geographic regions and different patients and professionals. Results Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range, 0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range, 0%-19%). Shortening of the dying process was reported in 7 countries. Doses of opioids and benzodiazepines reported for shortening of the dying process were in the same range as those used for symptom relief in previous studies. Limitation of therapy vs continuation of life-sustaining therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and religion ( P <.001). Conclusion The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.
Healthcare Quarterly, 10(4) 2007: 32-40 Frequency, Determinants and Impact of Overcrowding in Emergency Departments in Canada: A National Survey Abstract : Several reports have documented the prevalence and severity of emergency department (ED) overcrowding at specific hospitals or cities in Canada; however, no study has examined the issue at a national level. A 54-item, self-administered, postal and web-based questionnaire was distributed to 243 ED directors in Canada to collect data on the frequency, impact and factors associated with ED overcrowding. The survey was completed by 158 (65% response rate) ED directors, 62% of whom reported overcrowding as a major or severe problem during the past year. Directors attributed overcrowding to a variety of issues including a lack of admitting beds (85%), lack of acute care beds (74%) and the increased length of stay of admitted patients in the ED (63%). They perceived ED overcrowding to have a major impact on increasing stress among nurses (82%), ED wait times (79%) and the boarding of admitted patients in the ED while waiting for beds (67%). Overcrowding is not limited to large urban centres; nor is it limited to academic and teaching hospitals. The perspective of ED directors reinforces the need for further examination of effective policies and interventions to reduce ED overcrowding.
PRELIMINARY RESULTS - ED SURVEY Method : Retrospective chart review of patients transferred as&quot;Direct to Neurosurgery“ in 8/11 adult neurosurgical centers in Ontario Time period: April 1, 1998 to March 31, 1999. Potential donor definition: Brain death in the ED (GCS=3, no BS reflexes, catastrophic CT), or; GCS <6 with pathology and CT consistent with catastrophic outcome Results : 3447 patients referred 141 patients met criteria for potential donation [above] 96 admitted- 86 died,14 donors, 10 survived to rehab hosp one = cornea donor 34 transferred back to referral hosp. (17 BD, 17 likelyBD)- no donors (assumed) 11 died in ED (2 donors)
In addition to OD coordinator: 6 staff critical care physicians with on call availability and no other clinical commitments Provides 24/7 service, liason with ICU teams, BD certification/examination, DCD, family support, donor resuscitation management, diagnostic testing eg bronchoscopy, end of life care.
Intensive Care Professionals and their role in Organ Donation
Intensive Care Professionals and Deceased Organ Donation National Symposium on Organ Donation and Transplantation 2011 Oslo, Norway November 18 2011 Sam D. Shemie MD Division of Critical Care, Montreal Children’s Hospital Medical Director, Extracorporeal Life Support Program McGill University Health Centre Montreal Children’s Hospital/MUHC Research Institute Professor of Pediatrics, McGill University The Bertram Loeb Chair in Organ and Tissue Donation Faculty of Arts, University of Ottawa Medical Director, Donation, Canadian Blood Services
Norway and Canada: Cultures dominated by Winter Midas winter tires, advertisement
Most people think the strongest will in humans is the will to survive. It’s not. It’s the will to keep things familiar. Dag Sorensen, Stockholm, 2010
Source: International, IRODat as of December 2010; Canada, CORR International Comparison of Deceased Donor rates (NDD + DCD) per million population 2009
Complete and Irreversible Arrest of Heart Function
All vital organs: Heart, Lung, Liver and Kidney, can be supported by technology or replaced by transplantation.
Brain Function and Blood Flow as the Basis of Life
<ul><li>Accepted medical practice has been clearly defined. </li></ul><ul><ul><ul><li>Clinical criteria based on absent brainstem function- it is a clinical diagnosis </li></ul></ul></ul><ul><ul><ul><li>2. Ancillary demonstration of absent brain blood flow </li></ul></ul></ul><ul><ul><ul><ul><ul><li>CT angiography, nuclear perfusion scan, MR angiography </li></ul></ul></ul></ul></ul>The Neurological Determination of Death in Canada Shemie (FRG) et al, CMAJ, 2006 Shemie et al, CJNS, 2008
www.blood.ca <ul><li>http://video.bloodservices.ca/Streaming/nddvideo/ </li></ul>Brain Death Instructional Video
Dialysis: $70,000/patient/year Renal Transplant: $15,000/patient/year (45K year one) ECMO or VAD: $10-15,000/patient per day Cost Comparisons Bridge versus Transplant
Lifetime probability of receiving a transplant for individuals on the waiting list, by age* and gender *Based on age added on the waiting list Canadians have a 30-40% probability of never receiving an organ transplant. Shemie et al, Am J Transplant, 2011
If this patient dies on the waiting list, what will the heart transplant surgeon say to the family? “ We tried our best, but unfortunately, a donor did not arrive in time” Is this true?
Intensive Care Transplantation Protecting Lives
“ It’s just a big aggravation for physicians” Canadian ICU Doctor’s comments re: organ donation (anonymous) 2005
HSC Toronto Impact of an ICU Based Organ Donation Team Retrospective: 1990-1997, informal commitment. Prospective: 1998-2002, formal team. 24x7 service, ICU physician, nurse coordinator chaplaincy, social work * p = 0.006 ** p = 0.003 * **
Lessons from Spain Unless you define the job and fund people to do the job the job does not get done very well.
Its not just about ‘getting organs’. Organ donation is not something you do to people, its something you offer people. It is a standard part of end-of-life care. It is the responsibility of the Critical Care and Neurocritical care professionals to provide these services
Canadian Blood Services www.blood.ca National Health Policy for ICU Organ Donation <ul><li>Severe Brain Injury to </li></ul><ul><li>Neurological Determination of Death (Brain Death) </li></ul><ul><li>April 2003 Shemie (FRG) et al, CMAJ, 2006 </li></ul>2. NDD to Organ Procurement: (Donor Management ) Feb 2004 Shemie (FRG) et al, CMAJ, 2006 3. Donation after Cardiocirculatory Death (DCD/NHBD) Feb 2005 Shemie (FRG) et al, CMAJ, 2006 <ul><li>Brain Blood Flow (Brain Death) </li></ul><ul><li>Nov 2006 Shemie (FRG) et al, CJNS, 2008 </li></ul><ul><li>Donation Physician Specialists in a National System </li></ul><ul><ul><ul><li>Feb 2011 </li></ul></ul></ul>
Health System in Canada Canada Health Act Principles but Provincial Delivery of Services <ul><li>Principles </li></ul><ul><li>Public administration </li></ul><ul><li>Comprehensiveness </li></ul><ul><li>Universality </li></ul><ul><li>Portability </li></ul><ul><li>Accessibility </li></ul><ul><li>The Provinces/Territories of Canada are responsible for the funding, administration and delivery of health care services. </li></ul><ul><li>ICU’s are almost exclusively ‘closed’ units </li></ul>
TRANSPLANT PROGRAMS <ul><li>2010 Statistics * </li></ul><ul><li>2153 organs transplanted </li></ul><ul><ul><li>1234 kidneys </li></ul></ul><ul><ul><li>443 livers </li></ul></ul><ul><ul><li>167 hearts </li></ul></ul><ul><ul><li>178 lungs </li></ul></ul><ul><li>3171 on waitlists(active) </li></ul><ul><ul><li>511 withdrew from lists </li></ul></ul><ul><ul><li>247 died while waiting </li></ul></ul><ul><li>468 deceased organ donors </li></ul><ul><li>*CORR e-statistics </li></ul>
The need for a multi-stakeholder planning process Canadian Donation Performance Need for Redesign Volpe Report DM Report/ ACHS CCDT merges with CBS CCDT established National Coordinating Committee Alberta Framework for Action Citizens Panel (ON) CDM Report/ CCDT QC Minister/ CEST
What are the Principle Goals of an Organ Donation and Transplant System? 1. Serve the needs of potential transplant recipients = ‘underserviced population’ = perform as many transplants as possible 2. Do so in an ethical, legal, safe and equitable manner 3. Provide the opportunity to donate without compromising the duty of care to the dying patient or living donor
The journey towards self-sufficiency Designing a system to improve OTDT performance in Canada
FINAL RECOMMENDATIONS <ul><li>25 recommendations in total—13 for TDT and 12 for ODT </li></ul><ul><li>Completed and sent to Federal, Provincial and Territorial Deputy Ministers of Health in April 2011 </li></ul><ul><li>Presentation at June 2011 Conference of Ministers </li></ul>
<ul><li># people who die and are eligible </li></ul><ul><li>Identification of eligible deaths </li></ul><ul><li>ED to ICU triage </li></ul><ul><li>Referral and consenting </li></ul><ul><li>Organ donor management </li></ul><ul><li>Organ utilization </li></ul><ul><li>DCD programs </li></ul>Variables Impacting on Deceased Organ Donation
<ul><li>Mechanical ventilation </li></ul><ul><li>Unresponsive coma (GCS 3-5) </li></ul><ul><li>Fixed and dilated pupils </li></ul>What Does “Appear to be Brain Dead” Mean? = Clinical Trigger
Withdrawal of All Active Treatment Wide Variation in United Kingdom ICU’s Wunsch et al, Int Care Med, 2005
European Variation in End-of-Life Care 37 ICU`s, prospective, (n=4248) Adapted from Sprung et al, Ethicus Study, JAMA, 2003 %
Evolving Brain Protective Therapies Direct ventricular drainage (Brain Trauma Foundation J Neurotrauma, 2000) Hypothermia Head Injury (Hutchison et al) Cardiac Arrest (Bernard et al NEJM, 2002) (HCASG et al NEJM, 2002) Decompression Craniectomy (Schneider et al Acta Neurochir Suppl 2002)
Perceived Causes of Emergency Room Overcrowding in Canada Bond et al, Healthcare Quarterly, 2007 85% = Lack of Admitting Beds
Ontario Emergency-to-ICU Triage April 98-March 99 8/11 adult neurosurgical centers in Ontario 3447 ER patients with severe brain injury referred as direct admissions to neurosurgical ICU. 45/141 patients meeting criteria for potential donation were refused admission. - died in ED or returned to sending facility. Tenn-Lyn et al, Can J Anaesth. 2006
Shemie’s Unproven Theory Time from brain injury to death ICU Capacity
International Donation after Cardiac Death Donor Rates 2009 pmp Source: International, IRODat as of December 2010; Canada, CORR
Physician Disinterest Low Volume Exposure <ul><li>1-2% of all deaths are eligible for donation </li></ul><ul><ul><li>approx. 10% of ICU deaths are brain death </li></ul></ul><ul><li>For an ICU with 1000 admissions per year: </li></ul><ul><ul><li>3% pediatric ICU mortality </li></ul></ul><ul><ul><ul><li>= 3 donors per year </li></ul></ul></ul><ul><ul><li>12% adult ICU mortality </li></ul></ul><ul><ul><ul><li>= 12 donors per year </li></ul></ul></ul>
No intrinsic reason for physicians caring for ICU patients to develop skill or commitment to donation, or research interest except ‘it’s the right thing to do’ Bigger challenge in ‘open units’
Donation Physician Consultation Participants Feb 2011 <ul><li>International Experts </li></ul><ul><li>Dr. Xavier Guasch, Spain </li></ul><ul><li>Dr. Dale Gardiner, UK </li></ul><ul><li>Dr. Raghaven Murugan, Pittsburgh </li></ul><ul><li>Dr. Gerry O’Callaghan, Australia </li></ul><ul><li>Canadian Critical Care Society </li></ul><ul><li>Dr. Chip Doig, Calgary </li></ul><ul><li>Dr. Alison Fox Robichaud, Hamilton </li></ul><ul><li>Dr. John Drover, Kingston </li></ul><ul><li>Dr. Brendan McCarthy, Winnipeg </li></ul><ul><li>Dr. John Granton, Toronto </li></ul><ul><li>Dr. Robert Fowler, Toronto </li></ul><ul><li>Dr. Giuseppe Pagliarello, Ottawa </li></ul><ul><li>Ethicists </li></ul><ul><li>Dr. Franco Carnevale, Montreal, Qc </li></ul><ul><li>Dr. Bashir Jiwani, Surrey, BC </li></ul><ul><li>ICU based OPO Medical Directors </li></ul><ul><li>Dr. Sonny Dhanani, TGLN, Ottawa, </li></ul><ul><li>Dr. Greg Grant, BC Transplant, Vancouver </li></ul><ul><li>Dr. Jim Kutsogiannis, Northern Alberta </li></ul><ul><li>Dr. Andeas Kramer, Southern Alberta </li></ul><ul><li>Dr. Steve Beed, Halifax </li></ul><ul><li>Dr. Jean-Francois Lize, Quebec Transplant </li></ul>Intensivists Dr. Ian Ball, Kingston, ON Dr. Tony Best, Grand Prairie, AB Dr. Mark James, Saskatoon, SK Dr. Brian Kavanagh, Toronto, ON Dr. Stephan Langevin, Quebec City, QC Dr. Sharon Peters, St. John’s, NL Dr. Jag Rao, Regina, SK Dr. Mike Sharpe, London Dr. Shavaun MacDonald, Saskatoon Canadian Neurosurgical Society Dr. Brian Toyota,Vancouver, BC Canadian Assoc Emergency Physicians Dr. John Tallon, Halifax OPO Mr. Louis Beaulieau, Quebec Transplant Ms. Janet MacLean, TLGN Dr. Frank Markel, TGLN Mr. Laszlo Kalmar, BC Transplant, CBS Kimberly Young Sherri Kashuba Mathias Haun
Donation Physicians: Why? <ul><li>OTD is a medical, economic and socially critical issue </li></ul><ul><li>International successes </li></ul><ul><li>Intensivists are the gatekeepers of most aspects of the donation process- pivotal and undeniable role </li></ul><ul><li>Benefit for families </li></ul><ul><li>A physician’s position on these matters influences other professionals and the hospital culture </li></ul><ul><li>A lot of us can do this, but there are people who can do it better </li></ul><ul><li>eg. palliative care model, ECMO model, neurocritical care, cardiac critical care </li></ul>Greg Grant, Steve Beed Emily Macvean, with thanks
The Evolving Future of Deceased Donation <ul><li>The “professionalization of donation services” </li></ul><ul><li>Organ donation as a subspecialty of ICU services lead by funded ICU physicians supported by donor coordinators </li></ul><ul><ul><li>24x7 multi-hospital clinical service for all forms of deceased donation </li></ul></ul><ul><ul><li>Quality assurance </li></ul></ul><ul><ul><li>Performance metrics and accountability </li></ul></ul><ul><ul><li>Clinical training and academic development </li></ul></ul><ul><ul><li>Clinical trials, research and innovation </li></ul></ul>
Intensivist Lead Donation Management Service University of Pittsburgh Medical Center Increases Organ Utilization in Brain Dead Donors Singbartl et al, SCCM 2010