Week 10- Advanced care planning, organ donation Flashcards
the most important element of advanced care planning
open, honest and informed discussions that occur between the person and his/her substitute decision-maker and family
what is ACP
- tell people what matters to you
- future health care wishes
- so they can speak to you if you cant
3 examples of ACP
organ donor
life measures
MOST
MOST
M1= comfort
M2= care within your location
M3= transferring to higher acuity bed
C2= full code
according to Ipsos- Reid poll
- 82% of Canadians believe that recording their wishes would ________
- 77% of Canadians agree that having an advance care plan makes them feel ______. Only ___ of the general population have an advanced care plan.
- People with disabilities are
- _____of Canadians think the best time to plan for their future health and personal care needs is when
- ___% of Canadians say ______ made them think or talk more abut their wishes for their health and personal care.
- ______think one should start planning under the age of 50.
- help take the pressure off their loved ones.
- relieved, 17%
- more likely to think about their future health and personal care (81%) and many talk about it with others (76%).
- 43%, they are healthy
- 60, COVID-19
- almost half
barriers to ACP
- emotional responses to thinking about death
- stigma around death
- assume people know what they would want
- dont know how or to get advice
- cost of lawyer
- lack o access to resources
- young and healthy so dont need
Why ACP
- If wishes are expressed in advance, a person is more likely to have end of life wishes known and followed.
- Family members will have less stress and anxiety – because they know the person’s wishes.
- The person is more satisfied with care (as is the family).
- The person will have a better QOL and death.
- People hope that they will be able to communicate until the very end, but most death does not occur this way.
ACP now
- process is
- our
- linked to
- part of a continuum of decisions people make about medical treatment
- ethical and legal obligation
- informed consent
ACP historically
- part of
- process of
- good palliative and end-of-life care.
- looking forward to preferences for care with the aim of supporting “good” decision making that enables “good” death.
ACP can answer
- Who will
- what
- would
- what
- make health care decisions for an individual?
- health care treatment(s)are acceptable or unacceptable?- can be specific for each situation
- the individual accept or refuse life support and life-prolonging medical interventions for certain conditions?
- preferences an individual has with respects to his/her/their care?
ACP basics
- makes
- provides
- eases
- ones wishes and instructions for future health care known – written record;
- the health care team with information to guide them in one’s care
- the burden for ‘loved ones’ at a difficult time.
ACP
- conversations about
- appointment of
- Development of
- values, wishes, preferences
- substitute decision maker
- AC plans and instructional directive
3 components for care consistent with patients values and goals
ACP
Documentation
Decisions about GofC or consent for treatment
Representation agreements
A legal document made to appoint a representative
Enhanced (section 9) agreement
- made by
- the adult can use this agreement to
- this agreement does not
- an adult who can understand what the agreement is about, and what it allows their representative to do.
- name someone to make health care and personal care decisions on their behalf.
- This includes refusal of life-supporting care and treatments.
- Personal care refers to ADLs, living arrangements, diet, clothing, hygiene, exercise and safety.
- include legal or financial decisions
standard (section 7) agreement
- allows
- does not
- can be created
- people involved
- an individual to name a person to make and/or help make health care, personal care, legal, and routine financial decisions
- include decisions to refuse life supporting treatments.
- without a lawyer or notary.
- One or more people can be appointed as representatives. Unless specified in the agreement, the representatives must act unanimously on all decisions.
Advanced directive=
- used if
- a representative must
- A legal document that contains an individual’s instructions to accept or refuse specific health care treatments.
- an individual is not capable of providing consent.
- consider the instructions in the advance directive when making the decision(s).
TSDM list
1) Spouse (married, common-law, same sex)
2) Son/daughter (age 19+, and birth order)
3) Parent (either, includes adoptive)
4) Brother/sister (any birth order)
5) Grandparent
6) Grandchild (any birth order)
7) Anyone else related by birth or adoption
8) Close friend
9) A person immediately related by marriage
Conditions for a TSDM
- 19+ years
- capable of making decisions
- have no dispute with the individual
- have been in contact in the past year.
who will be asked to make decisions for you (5)
- you
- committee
- representative
- advanced directive
- TSDM
that advance care planning is not just something we do when nearing end of life:
it is about planning and living well at any age or stage of life.
All deaths and impending deaths under the age of ___ are to be
- 75
- reported to the donor referral line
universal referral process ensures
- consistency with the Human Tissue Gift Act for all eligible patients
- allows BCT to check patient registry decision
- all patients are provided with the option of organ donation as a part of end of life planning
___ % of British Columbians have registered their decision
- 25%
families often find organ donation brings
a sense of comfort in a time of loss
avoid making assumptions that
someone’s background means the family would decline donation
Pathways for donation
Death by neurological criteria (DNC)
Death by circulatory criteria (DCC)
DNC definition-
irreversible cessation of all functions of the brain, including the brainstem
Brain death is equivalent to
death of the individual, even though the heart continues to beat and spinal cord functions may persist
requirements for DNC
Two physicians must determine:
- Deep unresponsive coma with an established etiology
- Absent brainstem reflexes
- Core Temperature >36⁰C
- Absent confounding factors
Two physicians must perform
- Clinical examination
- Apnea Testing
brainstem reflexes (6)
- bilateral absence of motor responses (excluding spinal reflexes)
- absent cough
- absent gag
- bilat absence of corneal responses
- bilat absence of vestibulo-ocular responses
- bilat absence of pupillary response to light
If the physician cannot be sure of validity of the apnea test or clinical exam,
an ancillary test should be performed.
Apnea testing
- determines
Two certified physicians must
- Continuously
- Both be
- absence of the respiratory reflexes in the brainstem when an intense physiologic stimulation to breathe takes place.
observe the patient for any respiratory effort throughout test
present for testing
If both are not present, a second apnea test must be done
At completion of apnea test
- pH
PaCO2
pH ≤ 7.28
PaCO2 ≥ 60 mmHg & ≥ 20 mmHg
above pre-apnea test level
confounding factors
- Unresuscitated shock
- Hypothermia (core temperature <36 degrees Celsius)
- Severe metabolic disorder
- Peripheral nerve or muscle dysfunction or neuromuscular blockade
- Clinically significant drug intoxications (most prominent)
- Less than 48 hours post cardiorespiratory arrest (clinical judgement)
Ancillary test=
recommended tests (2)
an additional test to the clinical examination and/or apnea testing that cannot be conducted (still need clinical/apnea completed when able)
- Radionuclide cerebral blood flow imaging
- Cerebral Angiogram (Cerebral CTA)
DCC
- Non-recoverable injury/illness
- Two attending physicians support poor prognosis and movement towards end-of-life care
- Anticipation of imminent death after withdrawal life sustaining measures (WLSM)
- Organ Donation after MAiD follows ____pathway
DCC
BC Transplant is not involved in
decision to withdraw life-sustaining therapy
BCT may discuss the option of donation with family only after
their decision to WLST has been made
Benefits of DCC
- provides the option of
- families sometimes
- increases
- organs from DCC donors
- organ donation for patients/families when brain death criteria is not met
- have a better understanding of DCC death as they see their loved one stop breathing and become asystolic
- number of donors and organs = decreasing wait time for those in need of organ transplant
- similar outcomes to those from DNC donation
Organ allocation 4 things to consider
- blood type
- size
- medically urgent
- time on wait list
who organ goes to
- High Status & Highly Sensitized Recipient
- BC Recipients
- Canadian Recipient: Closest province to furthest
- US Recipients: UNOS (United Network for Organ Sharing
Cold ischemic times (CIT)
Heart
lungs
liver
kidneys
pancreas
4-6 hours
4-6 hours
8-12 hours
8-24 hours
6-8 hours
WIT=
period it takes to die
benefits of eye donation (3)
- Up to 2 corneal transplants
- Up to 6 receive sclera grafts
- Tissue may be used in research and education
Donor screening
basic rule-outs:
- Infectious Diseases (HIV, Hepatitis, Syphilis)
- CNS Disorders with symptoms like CJD (MS, ALS, Alzheimer’s, Parkinson’s, Dementia)
- Certain Malignancies (Blood borne, lymphoproliferative cancers and some ocular cancers)
- Septicemia
Who can obtain consent from the patient or family for eye donation?
Nurses
Physicians
Eye Bank Coordinator
Spiritual care
Social work
How do I care for the Eyes if the patients is a donor?
Instill 5 drops, of one of the following, in each eye every hour:
- Sterile normal saline, artificial tears, balanced salt, or antibiotic eye drops
After the family has said their final good-byes then:
- Tape the eye shut with paper tape and place a small bag of crushed ice over their eyes.
