Donation Decision Conversation Prototype

Potential Donor Audit - Prototype
Patient Information
PDA ID
NHS/CHI Number
Date of Completion

DayMonthYear
Hospital Name
Unit where patient was identified as potential donor
Unit patient was referred from
Place where patient died
Person completing the PDA
Date and Time of Admission to Hospital

DayMonthYearHourMinutes
Date and Time of Admission to Critical Care Area

DayMonthYearHourMinutes
Was the patient transferred from another hospital?

YesNo
If Yes, Hospital Name
Patient Initials

First InitialSurname Initial
Date of Birth

DayMonthYear
EPOCH Difference
Remainder (for Y/M/D)
Age
Years
Months
Days
Postcode of Residence
Biological Sex
Ethnic Origin
Primary Diagnosis
Cause of Death
Referral
Was the patient referred to the Organ Donation Services team?

YesNo
If NO, please specify why not
Timing of the referral to Organ Donation Services Team
Referral made to (name of SN-OD)
Date and time of referral to Organ Donation Services team

DayMonthYearHourMinutes
Name of person referring
Role of person referring
How was the patient ventilated?
Was this a controlled death?

YesNo
If it was an uncontrolled death. Had attempts been made to stabilise the patient?

YesNo
Did a SN-OD ever attend?

YesNo
If NO, why not?
Date and time of SN-OD first attendance

DayMonthYearHourMinutes
Absolute Contraindications
Were there any absolute contraindications to organ donation?

YesNo
If Yes please specify

Age >85 years (on or after their 85th birthday )Primary intra-cerebral lymphomaAll secondary intracerebral tumoursAny active cancer with evidence of spread outside affected organ within 3 years of donation **Melanoma (except completely excised Stage 1 cancers)Active (not in remission) haematological malignancy (myeloma, lymphoma, leukaemia)Definite, probable or possible case of human transmissible spongiform encephalopathy (TSE), including CJD and vCJD, individuals whose blood relatives have had familial CJD, other neurodegenerative diseases associated with infectious agents.TB: active and untreated or donation within first 6 months after treatment. (NB: Organs can be considered for transplant if a recipient has received a 6-month course of chemotherapy, unless the isolate is found to be resistant to anti-tuberculous drugs)West Nile Virus (WNV) infection#HIV disease (but not HIV infection*)A history of infection with Ebola virus
Organ Specific Contraindications
Were there any organ specific contraindications to organ donation?

YesNo
Liver
Bowel
Kidney
Pancreas
Heart
Lungs
Confirmation of death using neurological criteria
Were the following criteria for neurological testing met:

Mechanically ventilatedNo evidence of spontaneous respiratory effortIn a coma with a Glasgow Coma Scale 3 that is not explained by sedationFixed pupilsNo evidence of cough reflexNo evidence of gag reflex
Were there continuing effects of sedative which would prevent neurological testing?

YesNo
If ‘Continuing effects of sedative’, please record sedatives with time and date of last administration
Sedative 1
Date and time of last administration of Sedative 1

DayMonthYearHourMinutes
Sedative 1 Ongoing

Yes
Sedative 2
Date and time of last administration of Sedative 2

DayMonthYearHourMinutes
Sedative 2 Ongoing

Yes
Was the patient's cardiovascular and respiratory status compatible with requirements to undertake neurological testing?

YesNo
If patient not stable, what attempts were made to stabilise patient for testing?

Fluid bolusesCentral lineArterial lineNoradrenalineVasopressinAdrenalineOther centrally adminstered inotropePeripherally adminstered inotropes (eg. Metaraminol, Ephedrine)FiO2 >50%Lung recruitment manoevuresPEEP >5 cm H2OEfforts to improve Minute VolumeECMONo attempts recorded in medical notesOther
Did patient have a biochemical/endocrine abnormality recorded that would prevent neurological testing?

YesNo
If Yes, what biochemical/endocrine abnormality?

Abnormal SodiumAbnormal PotassiumAbnormal PhosphateAbnormal MagnesiumAbnormal GlucoseRenal FailureLiver FailureEndocrine DisturbanceOther
If yes, were attempts made to correct the biochemical/endocrine abnormality

Yes - Successfully CorrectedYes - Unable to correctNoUnknown
Were neurological tests to confirm death performed?

YesNo
If neurological tests to confirm death not performed, why?
Was death confirmed using neurological criteria?

YesNo
If death not confirmed using neurological criteria, why?
Did family witness the neurological testing?

YesNo
If family did not witness neurological testing, why?
Donors after Circulatory Death
Was life sustaining treatment withdrawn? (i.e. withdrawal of active support)

YesNo
If yes, what did the life sustaining treatment withdrawal involve?

Reduction/withdrawal of cardiovascular support (Inotropes)Extubation with conservative measures to maintain airway patencyExtubation, supine positionRemoval of non-invasive ventilationWithdrawal of Intra Aortic Balloon PumpWithdrawal of ECMOWithdrawal of Ventricular Assist DeviceCessation of Pacemaker/ICDCessation of Renal Replacement TherapyOther
What was the reason for the planned WLST ?
Was imminent death anticipated by the medical staff? (asystole following WLST within a suitable timeframe to enable organ donation to take place)

YesNo
Date and time treatment withdrawn

DayMonthYearHourMinutes
Date and time of asystole

DayMonthYearHourMinutes
Were there any DCD/Infant donor exclusions?

YesNo
If there were DCD/Infant donor exclusions what were they?

> 75 not dying of a neurological condition> 70 not dying of either a neurological condition or respiratory disease> 70 dependent on RRT> 70 with CKD 3b or greaterCurrent clinical diagnosis of ischaemic bowel or necrotising enterocolitis or faecal peritonitisPrevious cancer in last 5 yearsCurrent clinical diagnosis of multi organ failureCurrent clinical diagnosis of Septicaemia/Sepsis with severe multi organ dysfunction
Was the patient deemed unsuitable for organ donation following screening?

YesNo
Was the patient declined by the organ donation team following donor assessment?

YesNo
If yes, why?
Patient Donation Decisions
What was the patients last recorded NHS Organ Donor Register (ODR) status?
When was the ODR consulted?
Reason ODR not consulted
Who initiated the ODR check?
What was the patient’s last known decision regarding organ donation?
What was method by which patient’s last known decision was expressed?
Which country did the patient die in? (Enabling question)
Did the patient die in Wales? Y/N

YesNo
Was the patient aged 18 or over at the time of their death? Y/N

YesNo
Did the patient live in Wales for more than 12 months prior to death, and were they ordinarily resident there?

YesNoUnknown
Did the patient have the capacity to understand the notion of deemed consent for a significant period before their death?

YesNoUnknown
Could deemed consent be applied to this patient? i.e. have they: - died in Wales aged 18 or over at the time of their death, and - lived in Wales for more than 12 months and is ordinarily resident there, and - had the capacity to understand the notion of deemed consent for a significant period before their death

YesNo
Was consent deemed under relevant legislation?

YesNo
If consent not deemed why not?
Was permission for donation required from a Coroner / Procurator Fiscal?

YesNo
If YES, was consent / authorisation requested from Coroner / Procurator Fiscal?

YesNo
If NO, please specify reason why not
If YES, was permission granted by Coroner / Procurator Fiscal for donation?

Yes - Restricted consent / authorisationYes - Full consent / authorisationNo
If NO, please specify reason why not
Donation Decision Conversation
Were the family asked to make or support an organ donation decision?

YesNo
If No, why?
Was the donation decision conversation discussed and planned with the input of a SN-OD?

YesNo
If No, why?
Time of donation decision conversation planning?

DayMonthYearHourMinutes
Name of Dr

First NameLast Name
Role of Dr

ConsultantOther Dr
Name of SN-OD

First NameLast Name
SN-OD Role

Team ManagerSN-ODSN-OD Family CareSpecialist RequesterPDSTrainee
Format of donation decision planning conversation?

TelephoneFace to face
Did the donation decision conversation go to plan?

YesNoUnknown
If No, why?
When did this donation decision conversation occur?

During conversation planning NDT or WLSTWithin the DNC results conversationAfter the DNC or WLST conversation - Separate conversation
Who was present for the donation decision conversation?

ConsultantOther DoctorNurseTeam ManagerSN-ODSpecialist RequesterPDSFamilyFriendsAppointed RepresentativeOtherTranslator
Number of family, friends or appointed representatives present for the conversation?
Relationship of key person to potential donor
Time donation decision conversation commenced?

DayMonthYearHourMinutes
Location of donation decision conversation?

EDICUBy phoneOther
Was a Dr present?

YesNo
Name of Dr

First NameLast Name
Role of Dr

ConsultantOther Dr
Dr Input

ActivePassive
Was a SN-OD present?

YesNo
Name of SN-OD 1

First NameLast Name
SN-OD 1 Role

Team ManagerSN-ODSN-OD Family CareSpecialist RequesterPDSTrainee
SN-OD 1 Input

ActivePassive
Additional SN-OD Present

Yes
Name of SN-OD 2

First NameLast Name
SN-OD 2 Role

Team ManagerSN-ODSN-OD Family CareSpecialist RequesterPDSTrainee
SN-OD 2 Input

ActivePassive
Reason SN-OD not present?
If SN-OD not present were the family invited to speak with a SN-OD?

YesNo
Family's initial reaction to donation being raised within the donation decision conversation?

PositiveNeutralNegative
Time family's donation decision ascertained?

DayMonthYearHourMinutes
Was Consent/Authorisation given?

YesNo
If No Consent/Authorisation, please specify main reason why
Name of SN-OD completing consent / authorisation paperwork?

First NameLast Name
SN-OD Role

Team ManagerSN-ODSN-OD Family CareSpecialist RequesterPDSTrainee
Previous Donation Conversations
Was donation mentioned or discussed prior to the Donation Decision Conversation?

YesNo
Please input data for up to two pre-mention conversations. If there are more than two pre-mention conversations, please select two which exemplify the conversation narrative. Please consider the conversations in chronological order.
Date and Time of conversation

DayMonthYearHourMinutes
Location of conversation?

EDICUOther
Who initiated the mention of donation or the discussion?

ConsultantOther DoctorNurseTeam ManagerSN-ODSN-OD Family CareSN-OD TraineeSpecialist RequesterPDSFamilyOther
Family's attitude when donation was mentioned or discussed?

PositiveNeutralNegativeUnknown
Main purpose of the discussion

Family initiated general conversation (often this conversation is at the bedside)General Conversation( focus was on general care, often this conversation is at the bedside)Clinical update (focus was on the treatment being delivered even if likely possibility of death discussed)Conversation to discuss DNC or WLST (focus was gaining the family’s understanding and acceptance of the impending / expected death)Earlier donation decision conversation (family asked to make a partial or intermediate decision on donation proceeding)
Was a SN-OD present during the discussion?

YesNo
Name of SN-OD 1

First NameLast Name
SN-OD 1 Role

Team ManagerSN-ODSN-OD Family CareSpecialist RequesterPDSTrainee
SN-OD 1 Input

ActivePassive
Additional SN-OD Present

Yes
Name of SN-OD 2

First NameLast Name
SN-OD 2 Role

Team ManagerSN-ODSN-OD Family CareSpecialist RequesterPDSTrainee
SN-OD 2 Input

ActivePassive
If SN-OD not present, why not?
If SN-OD not present were family invited to speak with a SN-OD?

YesNo
Did another pre-mention conversation take place?

YesNo
Pre-Mention Conversation 2
Date and Time of conversation

DayMonthYearHourMinutes
Location of conversation?

EDICUOther
Who initiated the mention of donation or the discussion?

ConsultantOther DoctorNurseTeam ManagerSN-ODSN-OD Family CareSN-OD TraineeSpecialist RequesterPDSFamilyOther
Family's attitude when donation was mentioned or discussed?

PositiveNeutralNegativeUnknown
Main purpose of the discussion

Family initiated general conversation (often this conversation is at the bedside)General Conversation( focus was on general care, often this conversation is at the bedside)Clinical update (focus was on the treatment being delivered even if likely possibility of death discussed)Conversation to discuss DNC or WLST (focus was gaining the family’s understanding and acceptance of the impending / expected death)Earlier donation decision conversation (family asked to make a partial or intermediate decision on donation proceeding)
Was a SN-OD present during the discussion?

YesNo
Name of SN-OD 1

First NameLast Name
SN-OD 1 Role

Team ManagerSN-ODSN-OD Family CareSpecialist RequesterPDSTrainee
SN-OD 1 Input

ActivePassive
Additional SN-OD Present

Yes
Name of SN-OD 2

First NameLast Name
SN-OD 2 Role

Team ManagerSN-ODSN-OD Family CareSpecialist RequesterPDSTrainee
SN-OD 2 Input

ActivePassive
If SN-OD not present, why not?
If SN-OD not present were family invited to speak with a SN-OD?

YesNo
Outcome
Did solid organ donation occur?

Yes - DCDNoYes - DBD
If NO, please specify main reason why not
Please enter any additional general comments and notes related to the case in the box below
Office Use Only - Case Review
Was this a genuine missed referral?

YesNo
If yes, Why?
If Yes, what action is required?
If No, why?
Was this a genuine missed opportunity for a SNOD to be present?

YesNo
If yes, Why?
If Yes, what action is required?
If No, why?
Should be Empty:

Potential Donor Audit - Prototype

Patient Information

Referral

Absolute Contraindications

Confirmation of death using neurological criteria

Donors after Circulatory Death

Patient Donation Decisions

Donation Decision Conversation

Previous Donation Conversations

Outcome

Office Use Only - Case Review