Transcript Cardiac Transplant at the Freeman Hospital

NPPG PICU SIG
Study Day Recap
Law and Ethics
22nd July 2013
Stephen Morris
NPPG Conference - London
8th November 2013
Aims and Objectives
AIMS
– To inform and update pharmacists on the current guidance around withholding and
withdrawing life-prolonging treatment
– To recap and develop our understanding of the evidence and practice basis for
hormonal resuscitation of potential heart-beating organ donors
– To introduce the concept of “Donation after Cardiac Death” and how medicines may
affect this
– To outline a regional strategy for provision of palliative care to children in the
community
OBJECTIVES
– Understand and the current legal framework concerning withdrawing care, including
the application of “Limitation of Treatment Agreements” and “DNR Orders”
– Be able to differentiate between escalating therapy and routine care
– Discuss and critique the evidence base for Hormonal Resuscitation methods
– Understand how medicines may impact on Donation after Cardiac Death
– Understand the principles of palliative care and symptom control
– Consider how to move forward with palliative care at home as an option for PICU
patients at the end of their treatment course.
Futility and Withdrawing Care
Medical Ethics
– Four principles
1. Respect for autonomy
– Patients, parents or carers should make own decision
– To what extent do parents/carers/patients make informed decisions
– Parents may be over-ridden as surrogate decision makers by courts in
interests of protecting child
2. Principle of Non-maliference
1. E.g. opioids may treat pain but do they hasten death?
3. Principle of Beneficence
– Varying views on what constitutes benefit
4. Principle of Justice
Activities:
– Decide who to admit to PICU from selection of scenarios
Discussion:
– To what extent practice under law (case law) and follow guidance
– What happens with older patients
Reference
Brierley J., Brain Stem Death & Management of the Donor GOSH NHS Trust, London 2007
RCPCH Guidance
• Recognised five situations of withdrawing care:
– Brain dead – as specified in other guidelines
– Permanent vegetative state – no reaction to outside
world, entirely dependant on carers
– No chance – treatment delays death without
improvement in suffering
– No purpose – may survive but treatment may leave
lasting physical/mental scars
– Unbearable – progressive or irreversible illness that
child and/or parents believe treating further is too
much to bear
Reference
Royal College of Paediatrics and Child Health, Withholding or Withdrawing Life
Sustaining Treatment in Children: A Framework for Practice 2nd Edition, May 2004
Developments in Organ Donation
• 10 years prior to 2008 very little change in deceased
donor number
• Following Spanish model of transplantation
• April 2013 achieved 50% increase in donor numbers from
2008
• Specialist Nurses in Organ Donation (SNOD)
–
–
–
–
–
12 regions
Identification and assessment
Documenting consent
Logistics, liaise with retrieval teams
Post-donation care
• Donation of Brain Stem / Cardiac Death
• Better techniques to improve graft survival
Further Reading
NHSBT – Role of the Specialist nurse in organ donation
http://www.odt.nhs.uk/donation/deceased-donation/organ-donation-services/role-of-specialist-nurse/
Supporting Donation - DBD
• Recognised treatments to solely improve graft function
(not actively treating patient, but following their wishes)
• Cardiovascular Support
– Anti-arrhythmics
– Short acting betablockers for sympathetic storm (e.g. IV Esmolol)
– Fluids, inotropes, vasodilators to maintain CVP 6-10 mmHg
• Respiratory Support
• Hormonal Support
– Insulin
– Vasopressin
– Lio-thyronine
Reference
Brierley J., Brain Stem Death & Management of the Donor GOSH NHS Trust, London 2007
John D. Rosendale,et al. Hormonal resuscitation yields more transplanted hearts, with improved
early function. Transplantation Vol. 75, 1336–1341, No. 8, April 27, 2003
Care at the End of Life: What gets in
the way?
• Statistics:
– >98% of neonates that die will be in hospital
– 75% of children that die will be in hospital
• Challenges:
– Not diagnosing death
– Not having the skills to talk to families about death
and support them in planning
– Not having the right drug and skills to use them
•
•
•
•
•
Right drugs
Right doses
Right method of delivery
Right plan for review
Right prescription!
Are we here?
Or are we
here?
Rapid discharge pathway for end of life
care
• Tool to help transfer a child to the preferred place of
death
• Includes all areas needing to be considered
• Symptom control key component
– Anticipatory prescribing of drugs likely to be required
– Identification of who will prescribe drugs
– Where they will come from
– Who will administer them
– And how
– And what happens if the child doesn’t die
Summary / Reflections
• Withdrawing care is a very sensitive situation both legally
and ethically
– Collective approach of MDT in decision making, discussions
– Important to convey same message
– Professionalism
• The donor side of the story
Thank You!!
– Recognising as a society
– Improving Viability of Donor Organ
– Respecting wishes of donor
• Importance of planning around palliative discharges
– Experience with adults useful