Page 775 - ACCCN's Critical Care Nursing

752 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

13
of the duty of care to the family. This view is supported move to the bad news – the reality of the surgical inter-
by a survey of donor families, who indicated that they vention and the lack of guarantee that the organs will be
45
were grateful to have been provided with the option. 27,28,31 transplanted. Of note, a best practice approach aims to
Three elements are involved when approaching a family assist the family to make the decision that is ‘right’ for
regarding the option of organ donation: them and does not necessarily result in gaining consent.
1. their knowledge, beliefs and attitudes Meetings with the family
2. their in-hospital experience 29
3. any beliefs and biases of health professional/s con- The timing, location, content and process of discussions
ducting the approach. 30 with the family are all important considerations. An
effective protocol for communicating with the family of
The outcome of an approach cannot be predicted or potential donor must include: (1) frequent and honest
anticipated, as it may affect the ‘spirit’ in which the app- updates on the patient’s prognosis; (2) clear explanation
roach is made; a large US study demonstrated that clinical of brain death; (3) the option of organ donation not
staff were incorrect 50% of the time when asked to predict raised until the family accepts that the patient is dead;
the response of a next of kin. 31 (4) conversations held in a private and quiet setting; 32,47-50
and (5) involvement of an organ donation professional
Influence of knowledge, beliefs and attitudes with a clear definition of roles. 32
Attitudes to organ donation are influenced by spiritual There is compelling evidence that the meeting confirming
beliefs, cultural background, prior knowledge about diagnosis of brain death should be held separately or
organ donation, views on altruism and prior health expe- decoupled from the conversation about the option of
32
riences. Next of kin consider two aspects associated with organ and tissue donation. 31,34,47-50 In reality, the pace and
existing attitudes and knowledge: the decision maker(s)’ flow of discussions should be assessed on a case-by-case
own thoughts and feelings; and the previous wishes and basis, as there may be circumstances when the discussion
beliefs of the person on whose behalf they are making about organ donation is appropriately held prior to the
the decision. There is evidence of a link between consent confirmation of death. 13,25,46
rates and prior knowledge of the positive outcomes of
organ donation. 33,34 Three other influential components of this process come
from surveys completed with donor and non-donor
Delivery of relevant information families:
An important consideration for all health professionals 1. Use of inappropriate terms like ‘harvest’ to name
is that family members may have a diminished ability to the organ retrieval surgery (this is considered
receive and understand information because of their extremely harsh and undignified) and ‘life support’
stress and psychological responses at this time of family to name the ventilator (this could perpetuate the
crisis. 35,36 As interviews held with the family are the hope of a chance of survival or recovery). 13,26,36,41,51
foundation of the entire organ donation and transplant 2. Attire of the personnel involved: staff wearing sur-
process, the discussion about brain death must be clear gical scrubs or plastic aprons made families wonder
37
and emphatic, using language free of medical termino- what was being done to their relatives that required
logy, and include an explanation of the physical implica- health professionals to be wearing such clothing;
tions. 38,39 Diagrams, analogies, scans and written materials and donor coordinators not wearing uniforms
have been suggested as useful aids for enhancing under- were easier to speak to. 41
standing by next of kin. 25,40,41 One approach was to 3. Timing or use of the information from consent
describe brain death as like a jigsaw puzzle with a piece indicator sources like organ donor registers and
missing, to illustrate the relationship of the brain to the the driver’s licence. If staff come to the discussion
41
rest of the body. Opportunities for staff to train and ‘armed’ with this information, it could be seen as
role-play this scenario with programs like ADAPT (see coercive and disrespectful, so some caution and
Online resources) improves the likelihood of meeting the discretion about the introduction and use of this
needs of families. 38,42-44 information is recommended. 41
As the time of confirmation of brain death is the person’s
legal time of death, a discussion is held with the family Staff roles, delineation and involvement
to discuss their options and associated implications. Staff involved in the explanation of brain death must
Options are to: (1) cease ventilation and allow cardiac have a clear understanding of brain death themselves
49
standstill to occur; or (2) maintain ventilation and before attempting to explain it to a family. The process
haemo dynamic support to facilitate viable organ and of organ and tissue donation in critical care is significant
tissue donation. The retrieval process must be fully for all concerned. When death is confirmed it marks
explained to ensure an informed decision, but not to the end of an episode that has been catastrophic for
overload the next of kin. 25,45 Table 27.4 lists some aspects both patient and loved ones, and a potentially stressful
of the organ donation process that could be included in and exhausting experience for staff. 40,52-55 Approaching a
such a discussion. As information given to a family con- potential donor family is a multidisciplinary team effort,
tains both good news and bad news it is suggested to start and guidelines encourage treating medical staff to con-
with the good news – the benefits of donation, the right tinue their involvement with patient and family after
13
of the family to refuse consent, and the lack of cost; then brain death is confirmed, for continuity of care. Nursing