School aims to boost organ donation in brain-death cases

An Ohio training program says improving physician communication with families is crucial.

By Kevin B. O’Reilly — Posted June 5, 2006

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It's a challenge any time physicians are called upon to tell family members that a loved one has died, but the challenge is compounded in cases where patients are brain dead.

"Family members don't always understand that brain death is death because the body is still warm and pink while it's on the ventilator," said June Hinkle, RN, director of bereavement services at Ohio State University Hospital.

Sometimes, a doctor will miscommunicate information to a patient's family by saying things such as "He's almost dead," or "He's dead by brain criteria but still breathing," she said. "It's difficult when physicians say those kinds of words to families because they sit there thinking, 'Is he dead or not dead?' "

That's why Hinkle, with $13,000 in grant money from the Ohio Dept. of Health's Second Chance Trust Fund, last year launched a program to train Ohio State University Medical Center residents how to effectively and sensitively communicate with families in brain-death cases.

This program is especially important because the 5% of patients who die by brain-death criteria account for 95% of the organs recovered from deceased donors, according to the U.S. Organ and Procurement Transplant Network. In a healthy person who has died of brain death, up to seven solid organs can be recovered in the hours after death.

Anne Paschke, a spokeswoman at the United Network for Organ Sharing, said the Ohio State program addresses an important problem.

"People understand how death occurs when the heart stops beating," Paschke said. "Brain death is a more difficult concept to convey, and the terminology used can make a huge difference. When people use terms like 'life support,' it sends the wrong message. It doesn't support the message that the patient is dead."

Training physicians

Staged in an educational laboratory with dozens of mock exam rooms equipped with cameras and one-way mirrors, the training puts residents through a simulation of the entire process in brain-death cases. Residents first deliver the bad news of serious brain injury to hired actors playing family members. Then they come back after another round of tests has confirmed brain death to talk again with the family.

After each conversation, the actors -- who cry on cue at the bad news -- complete an evaluation form assessing how well doctors communicated. Afterward, residents can review video of their performance for cues on verbal and nonverbal communication. Nearly 80 physicians, mostly residents, have completed the training, and another round is set to begin in July.

"It was a great experience," said Bradley Harrold, MD, a fellow in pulmonary and critical care medicine at the Ohio State University Medical Center. "You get to see yourself on video, take a step back and get a better sense for how good your style is and maybe improve upon how you deliver bad news."

Dr. Harrold said the OSU training was useful even though he already had completed residency and already had faced communicating with families in brain-death cases.

One mistake often made by younger physicians is broaching organ donation too quickly, Hinkle said.

"They say, 'I'm sorry to have to tell you this, but your loved one is dead by brain criteria,' " she said. "They explain it and say, 'By the way, would you like to donate organs?' It's a confusing message."

Hinkle advises physicians to let organ donation be a "secondary conversation." She said physicians should allow families to accept the diagnosis and say their goodbyes, and then sit down with the people directly responsible for making the decision.

Hinkle said the program, if successful, might be made available to other physicians and hospitals. For the first quarter of 2006, OSU Hospital secured donations in 79% of brain-death cases, compared with 69% for all of 2005, she said.

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Delivering the news

It's critical for physicians to effectively and sensitively deliver news of a patient's brain death to family members and loved ones because although only 5% of patients die by brain-death criteria, that population comprises the largest group of potential organ donors. Here are some tips for physicians talking to families:

  • Identify the patient's family and other loved ones.
  • Use direct, nonmedical language -- injury instead of trauma; auto accident instead of MVA; breathing machine instead of ventilator.
  • Let the family ask questions. Respond with short explanations.
  • Use silence when the family is crying or having trouble concentrating.
  • Explain the death without mentioning organ donation.
  • If asked what's next, say: "There are some decisions and there is some information that we will need, and we will do that after you have some time to say goodbye."
  • Do not introduce the representative from the organ procurement agency as someone there to talk about "organ donation." Instead, say there is someone there who will talk about "important decisions that need to be made." This allows organ procurement agents to introduce the topic in their own way.

Source: Ohio State University Medical Center

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