RUSH University Medical Center has consistently been a top hospital in organ donation referrals, family approaches and authorized cases for the last several years.
We talked with Sayona John, MD, a neurointensivist, leads RUSH's efforts to improve its organ donation processes and educates providers on how and when they should declare brain death and the importance of providing continued care to patients with devastating brain injuries.
Dr. John is the section chief of Neurocritical Care and the medical director of the Neuroscience Intensive Care Unit and Neuroemergency Transfer Program at RUSH.
Q: What drives your passion for organ donation?
A: I believe every patient should be given an opportunity to contribute in some way. As a physician, it’s my job to preserve and extend life. When that is no longer an option, can it be possible for someone else to have life through this patient? That’s my motivation. When I first started at RUSH 13 years ago, I saw an opportunity for us to do much better in this area. With the right approach, training and management, we can make it possible for others to get the gift of life.
Q: Why can it be difficult for providers to transition from care for one individual to thinking about organ donation?
A: Providers see their responsibility as caring for the patient in front of them, and it is hard to extend that process to patients who are not within their care environment. Once it’s determined that the patient won’t survive, oftentimes that physician’s responsibility is complete. Transitioning to considering organ donation is an added responsibility where we go from treating a patient who is alive to providing continued care for a patient who has expired.
Once a brain death has been declared, the body can remain in the ICU for 24 to 48 hours with continued medical support as it is, prepped for the OR. If successful, a well-managed organ donation process can help one to five people receive life-saving organs. By educating and refining the process, RUSH has been able to provide 230 organs for transplantation over the last five years.
Q: What were the steps you took to help educate your colleagues?
A: First, the improvement of our processes was only possible because of institutional buy-in. Second, education had to be delivered to a wide group of providers. Trainees aren’t always exposed to the process of declaring brain death, let alone organ donation.
As a neurointensivist, I mostly see patients with brain injuries, many of whom have devastating injuries that may progress to brain death. What may be a straightforward and normal part of my job isn’t the case for providers in other ICU settings.
We provide training in understanding brain death — interpreting the physical exam and performing apnea testing while avoiding mistakes. One of the cardinal rules in determining brain death is to know the underlying cause for the neurological state and to recognize its irreversibility.
Once patients meet certain trigger criteria, Gift of Hope is contacted. Its staff evaluates the patient for organ donation potential. Once brain death is declared, Gift of Hope meets with the family to discuss and consent for organ donation.
Q: RUSH has become a leader in Chicago for organ donor approaches and authorizations. Can you talk about what an approach is and why it’s important to know?
A: Approaches are the number of families of patients who consent to organ donation for their loved one (providing the patient did not already register). They are heightened, emotionally charged conversations for everyone involved — the families, first and foremost, the providers and the representatives from Gift of Hope. RUSH had 227 approaches over the last five years, which was the highest number of all the academic medical centers in Chicago.
That number is significant particularly since RUSH isn’t a Level I trauma center. In comparison to other Level I centers, we’re not seeing as high a case volume where brain death is related to traumatic brain injury. Our educational workshops, which focus on identifying, declaring and managing brain death and educating practitioners on how to have difficult conversations with the families, have definitely helped us support organ donation.
Rush has consistently been one of Gift of Hope’s top donor hospitals in referrals, family approaches and authorized cases. For example, from January through September 2019, 50% of all RUSH organ donation referrals, 82% of family approaches and 95% of authorized cases were generated from the Neuroscience ICU. This translated into 19 authorizations, 40 transplanted organs and 36 lives saved.
Q: How do you foresee overcoming any hurdles so the program at Rush continues to grow and more lives are saved?
A: The challenge remains in getting all providers to understand the value in brain death declaration when appropriate. A patient who is brain dead has an opportunity to potentially help several other people through organ donation. Practitioners have to “buy in” to the process and provide continued care for patients with a devastating brain injury who have no likelihood for meaningful recovery in order to provide lifesaving organs to patients whom they will never treat or know.
It is also important to keep abreast of best practices. Involving Gift of Hope as soon as the patient meets the clinical triggers for brain death leads to earlier organ management and better outcomes. Time is critical in these circumstances; the sooner we can start the process, the more lives we can save.
