Donation after Cardiac Death Changes OR Culture
Susan Driscoll, RN, was a member of the team that conducted BWH’s first lung transplant in 1990, and since then, she has participated in many organ transplant surgeries. “There is probably nothing more gratifying for an OR nurse than to watch organs give life to a patient who needs them,” she said.
Driscoll added, “But what’s always in the back of my mind in these situations is that in order to save a life, someone has died.”
This reality of organ donation became more obvious to OR staff when laws around brain death criteria changed. The New England Organ Bank and the hospital were faced with operationalizing a new donor category for severely neurologically-injured patients who do not meet brain death criteria to donate organs. “The level of brain function varies for these patients, but their prognosis is poor and their condition irreversible,” Kathy Leavitt, BSN, RN, OR assistant nurse manager, said.
The family decision to withdraw support from their loved one is made before the subject of organ donation is discussed with them.
Organ donation after cardiac death (DCD) involves families accompanying patients to the Pod J line room where life support is removed. Guidelines dictate that the patient expire within a designated time period —usually within an hour—in order for organs to be procured. Patients return to the ICU in the event that this timeline is prolonged.
Culture Shift
“Despite what people think, death in the OR is not a common occurrence,” said Barbara DiTullio, MA, BSN, RN, OR assistant nurse manager, who participated in BWH’s first DCD case in 2003.
The OR is performing an increasing number of these types of organ donations, and each one presents an emotional challenge for nurses. “Waiting for a patient to die is against our nature, so I have to keep in mind the immense benefits of transplantation,” Driscoll said.
That’s especially important as OR nurses often support patients’ families during this time. Debbie Deegan, RN, recalled when a patient’s son and sister accompanied him to the line room.
“The son was sitting alone by his father’s bed,” Deegan said. “I spoke to him about the gift his father was about to provide, and he was comforted despite his loss.”
Families talk with personnel from the Organ Bank before coming to the OR and understand time is short once the patient is asystolic. “They are supported when this happens,” Leavitt said. “The patient is transferred to the OR while the family is escorted from the room by NEOB family support personnel and staff from BWH Chaplaincy and Social Work/Care Coordination. We do this as sensitively as possible.”
Intense Disappointment
One of the greatest challenges in DCD procedures is when a patient doesn’t expire within the designated time for organ procurement. Driscoll experienced this during her first case. About 12 family members accompanied the patient, a middle-aged man, to the line room to say good-bye. “I felt an intense disappointment reflecting that of the family,” Driscoll said. “This was their and the patient’s wish.”
Soon after, Driscoll was involved in another organ procurement where the patient expired four to five minutes after extubation. The OR team and family knew the patient’s wish had been fulfilled and other lives would be saved because of it. “We recovered a liver and it was taken directly to a patient in New York,” Driscoll recalled. “His kidneys went to a patient in New England.”
Supporting Nurses
The OR provides the support nurses need during DCD. A nurse who has previously participated in a DCD supports a nurse who is new to the procedure leading up to, during and after the case. Chaplaincy also plays a critical role in supporting caregivers before and after DCD.
“There is a lot of communication,” Leavitt said. “We talk about the patient’s and family’s wishes, and that makes it easier to go forward.”
It’s important for staff to talk about their feelings and acknowledge their feelings, according to Leavitt. “We’ll never get to the point where it’s easy, but we know that this is what the patient and family want,” she said.
DiTullio stressed that the outcome for the patient doesn’t change. “The patient will expire whether it’s here or in the ICU,” she said. “One way to look at it is from the good that can come from this very difficult situation.”