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?
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?
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?
If it was an uncontrolled death. Had attempts been made to stabilise the patient?
Did a SN-OD ever attend?
If NO, why not?
Date and time of SN-OD first attendance

DayMonthYearHourMinutes
Absolute Contraindications
Were there any absolute contraindications to organ donation?
If Yes please specify
Organ Specific Contraindications
Were there any organ specific contraindications to organ donation?
Liver
Bowel
Kidney
Pancreas
Heart
Lungs
Confirmation of death using neurological criteria
Were the following criteria for neurological testing met:
Were there continuing effects of sedative which would prevent neurological testing?
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
Sedative 2
Date and time of last administration of Sedative 2

DayMonthYearHourMinutes
Sedative 2 Ongoing
Was the patient's cardiovascular and respiratory status compatible with requirements to undertake neurological testing?
If patient not stable, what attempts were made to stabilise patient for testing?
Did patient have a biochemical/endocrine abnormality recorded that would prevent neurological testing?
If Yes, what biochemical/endocrine abnormality?
If yes, were attempts made to correct the biochemical/endocrine abnormality
Were neurological tests to confirm death performed?
If neurological tests to confirm death not performed, why?
Was death confirmed using neurological criteria?
If death not confirmed using neurological criteria, why?
Did family witness the neurological testing?
If family did not witness neurological testing, why?
Donors after Circulatory Death
Was life sustaining treatment withdrawn? (i.e. withdrawal of active support)
If yes, what did the life sustaining treatment withdrawal involve?
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)
Date and time treatment withdrawn

DayMonthYearHourMinutes
Date and time of asystole

DayMonthYearHourMinutes
Were there any DCD/Infant donor exclusions?
If there were DCD/Infant donor exclusions what were they?
Was the patient deemed unsuitable for organ donation following screening?
Was the patient declined by the organ donation team following donor assessment?
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
Was the patient aged 18 or over at the time of their death? Y/N
Did the patient live in Wales for more than 12 months prior to death, and were they ordinarily resident there?
Did the patient have the capacity to understand the notion of deemed consent for a significant period before their death?
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
Was consent deemed under relevant legislation?
If consent not deemed why not?
Was permission for donation required from a Coroner / Procurator Fiscal?
If YES, was consent / authorisation requested from Coroner / Procurator Fiscal?
If NO, please specify reason why not
If YES, was permission granted by Coroner / Procurator Fiscal for donation?
If NO, please specify reason why not
Donation Decision Conversation
Were the family asked to make or support an organ donation decision?
If No, why?
Was the donation decision conversation discussed and planned with the input of a SN-OD?
If No, why?
Time of donation decision conversation planning?

DayMonthYearHourMinutes
Name of Dr

First NameLast Name
Role of Dr
Name of SN-OD

First NameLast Name
SN-OD Role
Format of donation decision planning conversation?
Did the donation decision conversation go to plan?
If No, why?
When did this donation decision conversation occur?
Who was present for the donation decision conversation?
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?
Was a Dr present?
Name of Dr

First NameLast Name
Role of Dr
Dr Input
Was a SN-OD present?
Name of SN-OD 1

First NameLast Name
SN-OD 1 Role
SN-OD 1 Input
Additional SN-OD Present
Name of SN-OD 2

First NameLast Name
SN-OD 2 Role
SN-OD 2 Input
Reason SN-OD not present?
If SN-OD not present were the family invited to speak with a SN-OD?
Family's initial reaction to donation being raised within the donation decision conversation?
Time family's donation decision ascertained?

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

First NameLast Name
SN-OD Role
Previous Donation Conversations
Was donation mentioned or discussed prior to the Donation Decision Conversation?
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?
Who initiated the mention of donation or the discussion?

Other
Family's attitude when donation was mentioned or discussed?
Main purpose of the discussion
Was a SN-OD present during the discussion?
Name of SN-OD 1

First NameLast Name
SN-OD 1 Role
SN-OD 1 Input
Additional SN-OD Present
Name of SN-OD 2

First NameLast Name
SN-OD 2 Role
SN-OD 2 Input
If SN-OD not present, why not?
If SN-OD not present were family invited to speak with a SN-OD?
Did another pre-mention conversation take place?
Pre-Mention Conversation 2
Date and Time of conversation

DayMonthYearHourMinutes
Location of conversation?
Who initiated the mention of donation or the discussion?

Other
Family's attitude when donation was mentioned or discussed?
Main purpose of the discussion
Was a SN-OD present during the discussion?
Name of SN-OD 1

First NameLast Name
SN-OD 1 Role
SN-OD 1 Input
Additional SN-OD Present
Name of SN-OD 2

First NameLast Name
SN-OD 2 Role
SN-OD 2 Input
If SN-OD not present, why not?
If SN-OD not present were family invited to speak with a SN-OD?
Outcome
Did solid organ donation occur?
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?
If yes, Why?
If Yes, what action is required?
If No, why?
Was this a genuine missed opportunity for a SNOD to be present?
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