GOLM Contact Within 1 Hour of Triggers Being Met
DCD Checklist
Referral Process
GOLM contact within 1 hour of triggers being met.
GOLM coordinator on-site. Time arrived on-site: ______
GOLM to ‘send word now’ Organ Donation Coordinator and Hospital Development Associate if not already done
Patient evaluated for suitability for DCD with GOLM coordinator and hospital staff. (Review of records and lab draws ONLY)
Consent Process
Huddle with GOLM coordinator and hospital staff (Physician, RN, RT, Chaplin Services, ect) to discuss:
○Patient diagnosis; history; hospital course
○Family dynamics / Next of kin identification
○Does family understand poor prognosis / What has been discussed with them
○Best way to support family
○Best way to approach family (collaborative); who will be involved
Team Members included in approach for consent: ______
Discuss with family regarding DCD process:
○Withdrawal of support process, comfort care measures, and declaration of death (5 minute period)
○Location and timing of extubation and final goodbye process
○During organ evaluation, explain that procedures, labs, tests may be preformed. Hospital consent may need to be obtained, and the attending physician and their staff will continue to provide authorization of care.
○Organ recovery process and Medical Examiner role, if applicable
○Follow-up communication
○Reasons why case may be discontinued; ie: Test results; patient does not expire within time frame; logistics; ect.
○Patient is full code for process unless family specifies otherwise.
○Ability to rescind consent at any point.
Consent obtained (NotifyHFH Organ Donation Coordinator) Date & Time consent signed: ______
Organ Placement
Begin comfort care medication (ordered by appropriate hospital staff)
GOLM to request hospital staff to print copies of necessary medical records.
GOLM to fax appropriate notification forms to Medical Examiners office.
Labs, tests, procedures ordered by appropriate hospital staff.
Wisconsin tool / Respiratory Drive assessment
After Organ Placement
When organs placed, contact OR to request a room. OR Date & Time: ______
Contact PACU to request use of designated DCD rooms (PACU rm#45 or 49, Pre-op rm# 9)
Contact Physician, RN, RT, Organ Donation Coordinator, Chaplin with OR time.
Inform family of OR time
Contact Medical Examiner with OR time IF pt ME case.
Huddle with Physician, RN, RT, GOLM coordinator, Chaplin Services, Organ Donation Coordinator, and other necessary team members to discuss
○process of DCD;
○DCD policy (bring policy);
○Withdrawal of Mechanical Ventilation policy (bring policy);
○Consider comfort care measures and begin if appropriate.
○Define Roles;
○Designate person to take family to waiting room until ready to extubate patient.
○Arrange time for all involved to meet to transfer patient to PACU/Pre-op. Meet time set for: ______
○Please make sure that ALL understand process; policy; and have no questions.
Contact Pathology if biopsy procedures needed after recovery. M-F Before 5pm 916-1279. M-F after 5pm; Sat and Sun pager on-call 714-0545.
Physician to obtain end of life paper work
Heparin ordered (if pt Heparin Induce Thrombocytopenia [HIT] NO heparin is to be given)
Heparin retrieved from pharmacy
Obtain supplies to take or have available in PACU
○Syringes ○ Flushes○ Mouth Swabs ○ DetachAll ○ Mouth moisturizer ○ Yaunker
○ Red dots ○ Gauze○ Stethoscope ○ Needles ○ Suction catheters ○ Tissue boxes
○Vaseoline ○ Wash Clothes / Towels ○ Aline Cable for bedside monitor
Scrubs for GOL coordinators (please get 30 mins prior to going to PACU)
Notify ICU unit clerk not to DC pt from assigned room until AFTER the recovery process completed in OR, in the event that patient must return back to unit
Notify Pre-op (16-7380)/PACU (16-1277) clerk of estimated time of arrival to that area.
If there are any issues with the OR time (bumped; OR time needs to be changed d/t: change in donor or recipients condition; time constraint issues) please contact HFH Organ Donation Coordinator immediately.
Transfer / Withdrawal of Care
Connect patient to portable monitor.
Discuss with family
- If they would like to come to PACU/Pre-op room for the extubation process, or wait in the waiting room. Explain that they will have to go to the waiting room while the patient is transferred and set-up in PACU/Pre-op area. Introduce designated person that will be taking them.
- Re-discuss process of DCD;
- What they may see or hear during extubation;
- Comfort care measures that will be used;
- Explain 5 minute waiting period for declaration and that they will be notified when that time begins. After the 5 minutes are up patient will be immediatelymoved to the OR.
Designated person (Chaplin) takes family to waiting room.
Take patient to PACU/Pre-op area in patient bed.
Connect patient to bedside monitor (be sure that there is capability to print rhythm strips)
ALL team members must be in room prior to extubation: GOLM coordinators; physician(s); RN; Organ Donation Coordinator; RT; other team members if appropriate.
Give comfort measures if appropriate
Give Heparin if appropriate. Time heparin given: ______
Physician to write order to extubate patient to room air.
Extubate patient to Room Air. Time pt extubated: ______
Start timing at time of extubation
Family may come into room if appropriate.
GOLM coordinator to track vital signs
RN to administer and chart comfort care measures under direction of physician.
RN to provide other comfort care measures as necessary (i.e.: suctioning; mouth care; ect.)
Notify family when final 5 minutes begins (if appropriate) [Please review 5.7 ‘Pronouncement of Death’ of DCD policy]
Time of death is pronounced after (chart time of death and 5 minute period of observation):
○5 minutes of asystole –OR-
○5 minutes of ventricular fibrillation (V-fib) –OR-
○5 minutes of pulseless electrical activity (PEA) –OR-
○5 minutes of absence of audible heart sounds, which were present before withdrawal –OR-
○5 minutes of absence of blood pressure as measured by an arterial line or Doppler.
Print rhythm strips for chart when time of death declared. Time of Death: ______
If patient expires within time frame, GOLM coordinator to take patient to OR.
If patient does not expire within time frame, patient will be taken back to ICU room.
Contact Medical Examiners with time of death.
GOLM coordinator to contact ICU RN after recovery procedure completed to DC patient from system.
GOLM coordinator to pick up copy of metavision chart after patient discharged from metavision system.
Amy Barber Rebecca Williams Gift of Life Michigan Dr. Varelas
Organ Donation Coordinator GOLMHospital Development Assoc. (800) 482-4881 Physician Champion
Pager: (313) 705-0755 Cell: (586) 255-7827 Pager: (313) 705-2919
Blackberry: (313) 585-0679
***** Please return this form to Amy Barber – Fax# (313) 916-1771*****
Revised: 8/4/08