TRUST POLICY FOR IDENTIFICATION OF ORGAN DONORS

Transcription

1 TRUST POLICY FOR IDENTIFICATION OF ORGAN DONORS Reference Number CL- LP/2010/005 Version / Amendment History Version: V2 3 4 Status Final Version Date Author Reason V1 July 2005 Dr Marco Giovannelli New Policy Author: Dr Marco Giovannelli Job Title Clinical Lead for Organ Donation (CLOD) V2 April 2010 Pam Twine Formatted to NHSLA Standards V3 May 2013 Marco Giovannelli Updated definitions V4 May 2016 MG Inclusion of Midlands Donor care pathway Intended Recipients: All Staff Groups Training and Dissemination: Dissemination via the Trust Intranet To be read in conjunction with: Derby Hospitals ICU Framework for the Withdrawal of Life Prolonging Medical Treatment In consultation with and Date: Organ Donation Committee March 2010, Medical Advisory Committee, Clinical Effectiveness Committee. CLOD and SNOD May 2013 and March 2016 EIRA stage One Completed Stage Two Completed Yes No Procedural Documentation Review Group Assurance and Date Yes May 2010 Approving Body and Date Approved Clinical Effectiveness Committee Date of Issue May 2016 Review Date and Frequency May 2019 then every three years Contact for Review Specialist Nurse in Organ Donation (SNOD), Intensive Care Unit, RDH Template for Trust Policy AB/DL August

2 Executive Lead Signature Director of Nursing Approving Executive Signature Director of Nursing Template for Trust Policy AB/DL August

3 Contents Section Page 1 Introduction 4 2 Purpose and Outcomes 4 3 Definitions Used 4 4 Key Responsibilities/Duties 5 5 Main Body of the Policy Patients - Treatment Withdrawn Patients Die on ITU or ED Consent for organ donation Potential Donors on General Wards Donation of Bodies for Medical Research Identification of Potential Donors 7 6 Monitoring Compliance and Effectiveness 7 7 References 8 Appendices Appendix 1 Appendix 2 Organs for Transplants. A report from the Organ Donation Taskforce. Department of Health. January Procedures form part of the appendices. (pdf document) Midlands Integrated Care Guide for the Referral and Consideration of Adult Deceased Organ and Tissue Donation November 2015 Page 9 10 Template for Trust Policy AB/DL August

4 1. Introduction TRUST POLICY FOR IDENTIFICATION OF ORGAN DONORS The purpose of this policy is to outline how potential organ and tissue donors are identified within Derby Teaching Hospitals NHS Foundation Trust. 2. Purpose and Outcomes The purpose of this policy is to ensure that all potential organ and tissue donors are identified and referred to the organ / tissue donor team and that the wishes of the patient and their next of kin are ascertained and respected. This policy will apply to all areas of the Trust. However it is acknowledged that Intensive Care and Emergency Medicine departments will have the greatest organ and tissue donation potential. Other wards and departments within the Trust will only have potential for tissue donation. 3. Definitions Used Specialist Nurse for Organ Donation (SNOD): Fully trained Specialist Nurse who, as part of the Midlands Organ Donation Services Team has the role of promoting and facilitating organ donation at Derby Teaching Hospitals NHS Foundation Trust. They also provide an on call service for donor referrals covering the Midlands Region. Brain Stem Death: An irreversible loss of the capacity of consciousness with an irreversible loss of the capacity to breathe. Brain Stem Death is diagnosed and certified following neurological tests of brain stem function. Organ Donation: The process of allowing organs (such as kidneys, liver, heart, lungs and pancreas) to be removed after death and used for the purpose of transplantation. Organ donation may occur following the certification of brain stem death (Donation after Brain Death or DBD), or cardio respiratory death (Donation after circulatory Death or DCD). Tissue Donation: Donation of tissues such as corneas, heart valves, skin, bone, tendons and menisci after death. 4. Key Responsibilities/Duties Organ Donation Committee (ODC) This committee has representation from all of the areas within the Trust that is touched by Organ Donation. This includes medical and nursing staff from the Intensive Care unit, Emergency department and renal unit. Has staff representation from theatres, chaplaincy, and the mortuary and lay representatives as a donor family member, a Template for Trust Policy AB/DL August

5 transplant recipient, and a lay Chair. The ODC will review all organ donation procedures and will monitor the implementation of this policy. The Committee will receive reports on individual organ donations. Intensive Care Consultants Intensive Care Consultants will identify potential organ donors following a clinical assessment and where a clinical suspicion of Brain Stem Death has occurred, or when a patient is expected to die. Once this decision has been made, and active treatment is to be withdrawn, it is appropriate to consider organ donation. All potential donors will be followed up by the CLOD and details ascertained as to why any were not identified or actioned. This is to enable all those who expressed a wish to donate to do so if at all possible. Specialist Nurse for Organ Donation As described above. The SNOD will audit all deaths within Intensive Care and the Emergency Department and assess the potential for donation opportunities in RDH and highlight with the CLOD any that require a case review. Emergency Department Staff Referring to the Organ Donation Guidelines within the Resuscitation area of the Department when considering organ or tissue donation following the death of a patient. Clinical Staff Referring to organ donation and withdrawal of therapy guidance situated on Intensive care prior to referral to the Specialist Nurse for Organ Donation via the on-call Intensive Care Consultant. Nurse-led referral to the SNOD can be made following a multidisciplinary discussion that must include the ITU Consultant to assess for feasibility for on-going potential donation. 5. Main body of document 5.1 Withdrawal of Treatment When a decision has been taken in the best interests of the patient that there are no further treatment options available or appropriate and active treatment should be withdrawn in accordance with Derby Hospitals Withdrawal of Treatment framework, then Donation after Circulatory Death (DCD) may be possible. DCD takes place once death has been diagnosed using cardio-respiratory criteria. All patients in whom treatment is being withdrawn, who are intubated on a ventilator, and do not have any absolute contraindications to organ donation should be considered as potential donors and referred to the SNOD team. Derby Hospitals Controlled Non Heart Beating Donation Guideline was accepted by the trust in September This has since been superseded by the Midlands Integrated Care Guide for the Referral and Consideration of Adult Deceased Organ and Tissue Donation seen in Appendix 2. Template for Trust Policy AB/DL August

6 5.2 Patients who die in Intensive care and the Emergency Department All patients who die within the Intensive Care and Emergency Department who do not fulfil the above criteria should be considered for tissue donation and referred to the National Referral Centre- Tissue Donation. The Consultant in charge of the patient s care will co-ordinate liaison with the SNOD for advice regarding the medical suitability of any given potential donor. 5.3 Consent for Organ Donation The Organ Donor Register (ODR) should be consulted to ascertain whether the patient has registered their wish to donate. If a patient is registered on the ODR, this is deemed to be legal consent and will be discussed with their next of kin. Where the wishes of the patient are not known, their next of kin (in the highest ranking relationship in accordance with the Human Tissue Act (2004) 3 ) will be consulted. Information and support will be given to the next of kin by the SNOD, Medical and Nursing staff, to establish if there are any known wishes and to enable them to reach a consensus regarding donation. Advice may be sought from the on call SNOD 24 hours a day, or from Derby Hospitals SNOD on any aspect of organ donation. When the death of a patient has been confirmed following brain stem tests, Donation after Brain Death (DBD) may be possible. The Intensive Care medical staff together with the SNOD will approach the next of kin, and the Coroner if necessary, and seek written consent for organ donation. Only once the next of kin have been informed and understand that the death is imminent or occurred should the subject of organ or tissue donation be discussed. The request of organ donation should involve a collaborative approach involving the health care professional caring for the patient and a SNOD and all attempts to achieve this should be made within reason. In the case of DCD, HM Coroner will be consulted and permission sought for donation to take place. 5.4 Potential Donors on the General Wards In the event of a potential tissue donor being identified on a general ward advice may be sought from Intensive Care staff, the In-house SNOD or the SNOD on call. As a SNOD is not based in the Trust every day, it is essential that the pager number for the SNOD team or the National Referral Centre is used for all referrals and not simply documented for review in the medical records. 5.5 Donation of Bodies for Medical Research Any enquiries received in relation to the donation of a body for anatomical examination should be referred to the Department of Morphology, Nottingham University Hospitals NHS Trust. It may, however, assist to be able to show the enquirer copies of the Department of Morphology s information, together with appropriate forms which will need to be completed in support of any bequest. These can be obtained from the Bereavement Template for Trust Policy AB/DL August

7 Office at the Royal Derby Hospital. Out-of-hours, forms can be obtained through the Health Records Department. Any enquirer should be advised that no guarantee will be given by the Department of Morphology that the bequest will be accepted. 5.6 Identification of Potential Donors The decision to donate is a personal and individual choice. It is essential that all potential donors are identified and referred to the Donor Team to establish their wishes. The potential donor should be referred to the Donor/Tissue Specialist Nurse at the earliest opportunity for consideration for organ/tissue donation. 6. Monitoring Compliance and Effectiveness The key requirements of this policy will be monitored in a composite report presented on the Trusts Monitoring Report Template: Monitoring Requirement : Monitoring Method: Report Prepared by: Monitoring Report presented to: To ensure that the process outlined in this policy for the identification and management of potential organ and tissue donors is followed appropriately. Reports to the Organ Donation Committee Clinical Lead for organ donation Reports to the Organ Donation Committee Frequency of Report Six Monthly 7. References 1 Derby Hospitals ICU framework for the withdrawal of life prolonging medical treatment Critical%20Care/Content/ethic.html 2 A code of practice for the diagnosis and confirmation of death. A working party publication on behalf of the AoMRC - Academy of Medical Royal Colleges, October Human tissue Act 2004 Template for Trust Policy AB/DL August

8 Template for Trust Policy AB/DL August Appendix 1

9 Template for Trust Policy AB/DL August