Week 10- Advanced care planning, organ donation

Question 1

the most important element of advanced care planning

Answer 1

open, honest and informed discussions that occur between the person and his/her substitute decision-maker and family

Question 2

what is ACP

Answer 2

• tell people what matters to you
• future health care wishes
• so they can speak to you if you cant

Question 2

3 examples of ACP

Answer 2

organ donor
life measures
MOST

Question 3

MOST

Answer 3

M1= comfort
M2= care within your location
M3= transferring to higher acuity bed
C2= full code

Question 4

according to Ipsos- Reid poll
- 82% of Canadians believe that recording their wishes would ________
- 77% of Canadians agree that having an advance care plan makes them feel ______. Only ___ of the general population have an advanced care plan.
- People with disabilities are
- _____of Canadians think the best time to plan for their future health and personal care needs is when
- ___% of Canadians say ______ made them think or talk more abut their wishes for their health and personal care.
- ______think one should start planning under the age of 50.

Answer 4

• help take the pressure off their loved ones.
• relieved, 17%
• more likely to think about their future health and personal care (81%) and many talk about it with others (76%).
• 43%, they are healthy
• 60, COVID-19
• almost half

Question 5

barriers to ACP

Answer 5

• emotional responses to thinking about death
• stigma around death
• assume people know what they would want
• dont know how or to get advice
• cost of lawyer
• lack o access to resources
• young and healthy so dont need

Question 6

Why ACP

Answer 6

• If wishes are expressed in advance, a person is more likely to have end of life wishes known and followed.
• Family members will have less stress and anxiety – because they know the person’s wishes.
• The person is more satisfied with care (as is the family).
• The person will have a better QOL and death.
• People hope that they will be able to communicate until the very end, but most death does not occur this way.

Question 7

ACP now
- process is
- our
- linked to

Answer 7

• part of a continuum of decisions people make about medical treatment
• ethical and legal obligation
• informed consent

Question 8

ACP historically
- part of
- process of

Answer 8

• good palliative and end-of-life care.
• looking forward to preferences for care with the aim of supporting “good” decision making that enables “good” death.

Question 9

ACP can answer
- Who will
- what
- would
- what

Answer 9

• make health care decisions for an individual?
• health care treatment(s)are acceptable or unacceptable?- can be specific for each situation
• the individual accept or refuse life support and life-prolonging medical interventions for certain conditions?
• preferences an individual has with respects to his/her/their care?

Question 10

ACP basics
- makes
- provides
- eases

Answer 10

• ones wishes and instructions for future health care known – written record;
• the health care team with information to guide them in one’s care
• the burden for ‘loved ones’ at a difficult time.

Question 11

ACP
- conversations about
- appointment of
- Development of

Answer 11

• values, wishes, preferences
• substitute decision maker
• AC plans and instructional directive

Question 12

3 components for care consistent with patients values and goals

Answer 12

ACP
Documentation
Decisions about GofC or consent for treatment

Question 13

Representation agreements

Answer 13

A legal document made to appoint a representative

Question 14

Enhanced (section 9) agreement
- made by
- the adult can use this agreement to
- this agreement does not

Answer 14

• an adult who can understand what the agreement is about, and what it allows their representative to do.
• name someone to make health care and personal care decisions on their behalf.
• This includes refusal of life-supporting care and treatments.
• Personal care refers to ADLs, living arrangements, diet, clothing, hygiene, exercise and safety.
• include legal or financial decisions

Question 15

standard (section 7) agreement
- allows
- does not
- can be created
- people involved

Answer 15

• an individual to name a person to make and/or help make health care, personal care, legal, and routine financial decisions
• include decisions to refuse life supporting treatments.
• without a lawyer or notary.
• One or more people can be appointed as representatives. Unless specified in the agreement, the representatives must act unanimously on all decisions.

Question 16

Advanced directive=
- used if
- a representative must

Answer 16

• A legal document that contains an individual’s instructions to accept or refuse specific health care treatments.
• an individual is not capable of providing consent.
• consider the instructions in the advance directive when making the decision(s).

Question 17

TSDM list

Answer 17

1) Spouse (married, common-law, same sex)
2) Son/daughter (age 19+, and birth order)
3) Parent (either, includes adoptive)
4) Brother/sister (any birth order)
5) Grandparent
6) Grandchild (any birth order)
7) Anyone else related by birth or adoption
8) Close friend
9) A person immediately related by marriage

Question 18

Conditions for a TSDM

Answer 18

• 19+ years
• capable of making decisions
• have no dispute with the individual
• have been in contact in the past year.

Question 19

who will be asked to make decisions for you (5)

Answer 19

• you
• committee
• representative
• advanced directive
• TSDM

Question 20

that advance care planning is not just something we do when nearing end of life:

Answer 20

it is about planning and living well at any age or stage of life.

Question 21

All deaths and impending deaths under the age of ___ are to be

Answer 21

• 75
• reported to the donor referral line

Question 22

universal referral process ensures

Answer 22

• consistency with the Human Tissue Gift Act for all eligible patients
• allows BCT to check patient registry decision
• all patients are provided with the option of organ donation as a part of end of life planning

Question 23

___ % of British Columbians have registered their decision

Answer 23

• 25%

Question 24

families often find organ donation brings

Answer 24

a sense of comfort in a time of loss

Question 25

avoid making assumptions that

Answer 25

someone’s background means the family would decline donation

Question 26

Pathways for donation

Answer 26

Death by neurological criteria (DNC) Death by circulatory criteria (DCC)

Question 27

DNC definition-

Answer 27

irreversible cessation of all functions of the brain, including the brainstem

Question 28

Brain death is equivalent to

Answer 28

death of the individual, even though the heart continues to beat and spinal cord functions may persist

Question 29

requirements for DNC

Answer 29

Two physicians must determine: - Deep unresponsive coma with an established etiology - Absent brainstem reflexes - Core Temperature >36⁰C - Absent confounding factors Two physicians must perform - Clinical examination - Apnea Testing

Question 30

brainstem reflexes (6)

Answer 30

- bilateral absence of motor responses (excluding spinal reflexes) - absent cough - absent gag - bilat absence of corneal responses - bilat absence of vestibulo-ocular responses - bilat absence of pupillary response to light

Question 31

If the physician cannot be sure of validity of the apnea test or clinical exam,

Answer 31

an ancillary test should be performed.

Question 32

Apnea testing - determines Two certified physicians must - Continuously - Both be

Answer 32

- absence of the respiratory reflexes in the brainstem when an intense physiologic stimulation to breathe takes place. observe the patient for any respiratory effort throughout test present for testing If both are not present, a second apnea test must be done

Question 33

At completion of apnea test - pH PaCO2

Answer 33

pH ≤ 7.28 PaCO2 ≥ 60 mmHg & ≥ 20 mmHg above pre-apnea test level

Question 34

confounding factors

Answer 34

- Unresuscitated shock - Hypothermia (core temperature <36 degrees Celsius) - Severe metabolic disorder - Peripheral nerve or muscle dysfunction or neuromuscular blockade - Clinically significant drug intoxications (most prominent) - Less than 48 hours post cardiorespiratory arrest (clinical judgement)

Question 35

Ancillary test= recommended tests (2)

Answer 35

an additional test to the clinical examination and/or apnea testing that cannot be conducted (still need clinical/apnea completed when able) - Radionuclide cerebral blood flow imaging - Cerebral Angiogram (Cerebral CTA)

Question 36

DCC

Answer 36

- Non-recoverable injury/illness - Two attending physicians support poor prognosis and movement towards end-of-life care - Anticipation of imminent death after withdrawal life sustaining measures (WLSM)

Question 37

- Organ Donation after MAiD follows ____pathway

Answer 37

DCC

Question 38

BC Transplant is not involved in

Answer 38

decision to withdraw life-sustaining therapy

Question 39

BCT may discuss the option of donation with family only after

Answer 39

their decision to WLST has been made

Question 40

Benefits of DCC - provides the option of - families sometimes - increases - organs from DCC donors

Answer 40

- organ donation for patients/families when brain death criteria is not met - have a better understanding of DCC death as they see their loved one stop breathing and become asystolic - number of donors and organs = decreasing wait time for those in need of organ transplant - similar outcomes to those from DNC donation

Question 41

Organ allocation 4 things to consider

Answer 41

- blood type - size - medically urgent - time on wait list

Question 42

who organ goes to

Answer 42

1. High Status & Highly Sensitized Recipient 2. BC Recipients 3. Canadian Recipient: Closest province to furthest 4. US Recipients: UNOS (United Network for Organ Sharing

Question 43

Cold ischemic times (CIT) Heart lungs liver kidneys pancreas

Answer 43

4-6 hours 4-6 hours 8-12 hours 8-24 hours 6-8 hours

Question 44

WIT=

Answer 44

period it takes to die

Question 45

benefits of eye donation (3)

Answer 45

- Up to 2 corneal transplants - Up to 6 receive sclera grafts - Tissue may be used in research and education

Question 46

Donor screening basic rule-outs:

Answer 46

- Infectious Diseases (HIV, Hepatitis, Syphilis) - CNS Disorders with symptoms like CJD (MS, ALS, Alzheimer’s, Parkinson’s, Dementia) - Certain Malignancies (Blood borne, lymphoproliferative cancers and some ocular cancers) - Septicemia

Question 47

Who can obtain consent from the patient or family for eye donation?

Answer 47

Nurses Physicians Eye Bank Coordinator Spiritual care Social work

Question 48

How do I care for the Eyes if the patients is a donor?

Answer 48

Instill 5 drops, of one of the following, in each eye every hour: - Sterile normal saline, artificial tears, balanced salt, or antibiotic eye drops After the family has said their final good-byes then: - Tape the eye shut with paper tape and place a small bag of crushed ice over their eyes.