Managing Staff Morale in a Changing Donor Environment

Kathryn DAquila CNS Westchester Medical Center Monica James RN, BSN, CPTC New York Organ Donor Network Karin Porter-Williamson M.D. University of Kansas Medical Center

Objectives
Understand how the environment of organ donation has evolved in the past 5 years Identify stressors to the multidisciplinary teams involved- Primary hospital team, OPO team, others Formulate strategies to manage and improve morale for all invested parties

What is the Changing Donor Environment?

Expanded Criteria Donors
Increased co- morbidity
Hypertension, elevated creatinine >2.0, h/o CVA

Relates to kidney donors only Increased age (>60 yr.)

Donation after Cardiac Death Donors

Strict neurologic criteria definition with GCS < 5 Devastating spinal injury with maintained consciousness Any ventilated patient with plan for palliative shift off or deceleration of artificial support

WOW- Look at the record books

Oldest liver donor 96 years old Oldest lung donor 65 year old (NYODN) 779 donors over the age of 85 in the US in 2006
578 of them donated kidneys

Youngest heart transplant recipient was 3 hours old at the time of transplant - now 14 Oldest heart recipient was 79 at transplant Longest uninterrupted wait for a kidney transplant was 28 years
recipient was 42 at transplant

Why is This Environment Stressful?

Ever expanding pool of potential donors who dont look like traditional donors
somebody is crazy to think this person is a donor I wouldnt want their organs

Expanding population of consent not recovered cases

All that work was for nothing!

Why is This Environment Stressful?

Multiple teams must communicate seamlessly for low stress success
Fast paced medical environment
Need efficiency, attention to detail

Relationship building across team lines is critical Build trust, understand motives, respect each others strengths, forgive each others weaknesses

Case Analysis #1- Brain Death Case, Extenuating Circumstances

54 year old female post op day 1 from OLT Intra-operative intracranial hemorrhage with progression to brain death that day New liver starting to function, renal failure on dialysis, respiratory failure, pressors Family wanted to give the gift theyd just received by organ donation Eventually, successful donation of lungs to a 19 year old female

Perspectives- OPO

Elation and celebration The goals of organ donation were met and a life was saved Much hard work and commitment paid off Initial unit follow up from OPO revealed no issues or concerns at the hospital

Perspectives- Donor family

Pts husband had initiated discussion of donation Happy to be able to donate
they had discussed donation for the first time when she was listed for transplant.

Perspectives- Physician
Critical Care physician- deeply moved by the ordeal
Prior to this event he was cerebrally a strong advocate for organ donation After this event:
Invested emotionally Mission driven vis-a-vis organ donation and the collaborative

Perspectives- Other Physicians

Renal team Before:
resisted performing dialysis on a brain dead, deceased patient Much chagrin and discussion up the chain of command

After:
Surprised to know that donation could be successful

Perspectives- Bedside Nurse

Not a positive perception
Morally wrong Weird science experiment Disrespect of someones body for no gain

Didnt think it would work Not involved in goals discussions with family
took over care after family consented

Perspectives- Bedside Nurse

These feelings came up in a casual conversation between OPO coordinator and the nurse 6 months after the event Nurse seeing picture of the recipient helped her to get past the negative feelings

Outcomes- Positives
19 year olds life was saved Donor family lives with knowledge that their loved one gave as she received Increased awareness by medical staff of donation potential in extenuating circumstances

Outcomes- Lessons Learned

Cannot assume that all reactions will be the same
Perception is critical Perception is reality (even when it is not) Perceptions of one event can affect subsequent attitude and behavior

Increased OPO attention to immediate and delayed follow up at the care team and unit level

Theme Stressor: What are we doing here? Why am I doing this?

Mitigating the Stress Proactively

Care providers do better when they know they are doing something FOR their patient rather than TO their patient Sense of purpose
I am doing this care because it is important to my patient to try to donate

Mitigating the Stress Proactively

Sharing the answers to these questions may decrease care provider stress:
Is donation what the patient and family want to see happen? Is it realistic to think that donation could work?

Mitigating the Stress Retrospectively

Follow up with the teams involved is critical

Positive outcomes for recipient Positive feedback from donor family Share systematic process improvements

Immediate and delayed debriefing important Unit level feedback also important

Mitigating the Stress Retrospectively

Follow up is just as important when attempts are not successful
Share what we could have done to make it work in the next case Share positive outcomes achieved for donor family Share the feelings of disappointment together!

Case Analysis # 2 Donor After Cardiac Death

63y Male admitted 2/12/07 post fall SAH,SDH Referred 3/4/07 after second SDH Neurological Status Health Care Proxy wanted Withdrawal of Care Living Will Patient Stated he wanted to be an Organ Donor

Perspective- Hospital Staff

Case identified as challenge Inappropriate for DCD Elicited feelings of outrage, anger Misconstrued message of DCD to one of killing for organs Negative feelings evolved in MD, PA, RN, anesthesia.

Perspective- Hospital Staff

Staff/ PA attempt to clarify process, contacted resources. Nurses felt the TC onsite was inexperienced and nervous. Pressure from family dynamics and OPO to bring pt to OR. OR and anesthesia not adequately informed on DCD.

Perspective- Donor Family

Misinformed about organ donation
must be alive during recovery

Wanted Donation to remain Confidential Requested frequent updates Time constraints < 24 hours Directed Donation

OPO Perspective
Stressors
Navigating through all the concerns of the Donor Hospital Maintaining open line of communication with hospital and family Anesthesias Refusing to participate
Unfamiliarity/Inexperience with DCD process
(OR Pronouncement)

OR Delays

Theme Stressors
Is patient appropriate for DCD? Will meet expiration goal of 60 minutes of hospital policy defined time after withdrawal of care? If exceptions are made outside of the OPO evaluation tool (example: Wisconsin Donation After Cardiac Death Tool), then appropriate communication should take place.

Mitigating the Stress

Short Term
Multidisciplinary Open Communication Post Referral Rounds/ After Action Review Reinforce Family Initiated/Driven process

Long Term
Experience Education Consider ICU/ PACU or Holding Room Disconnection

Outcomes
Patient eventually taken to OR Didnt Arrest in OR 1 1/2 hours Cardiac Arrested 4 hours after D/C Family appreciated effort.

Outcomes- Positive
ICU staff continue to refer DCD potential Collaborative approach between Hospital and OPO Anesthesia Education resulted in improved support for process Experienced DCD Staff Involved in Potential Cases Hospital Organ Donor Council Case Review.

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Ideas to Create an Effective Collaborative Relationship

Think WIN:WIN not US:THEM. Know Organ Donor process,
policies on withdrawal of care and DCD. Seek hospital resources when needed. Dont wait.

Establish separate ongoing annual education for ICU units (RN, MD, NP, PA, nsg leadership)
Include recipient and donor families speakers.

Create forum which meets to discuss issues surrounding organ donation

i.e. policies, QA/QI Multidisciplinary involvement

Questions to Run On

What strategies have you heard today that you will implement in your centers to help improve staff morale?

Families give the gift of life...

if only we give them the opportunity.

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