Advance Directives & Tissue Management

This category covers important patient rights related to end-of-life care and the stringent protocols for handling surgical tissues and specimens.

Advance Directives

DNR vs. AND (Allow Natural Death)

• AND (Allow Natural Death): Always includes a plan for palliative care.
• DNR (Do Not Resuscitate): Can potentially withhold palliative care depending on the specific order.

DNR Orders in Surgery

• Effectiveness: A DNR order remains in effect during surgery UNLESS the physician writes an order in the chart to temporarily amend or suspend it.
• Specifics: The order must clearly document the particulars of the amendment or suspension.
• Patient/Provider Conversation: The patient, physician, and anesthesiologist must have a conversation to establish a plan for surgery (e.g., “Fix my hip fracture but don’t intubate me,” or “If I become hemodynamically unstable, let me go”).
• Clarification: Clarify whether interventions (e.g., for bleeding, bradycardia) can be performed to address immediate surgical complications.

RN Authority to Suspend a DNR

• RNs CANNOT accept verbal or telephone orders for DNR-related changes. Any amendment or suspension of a DNR must be a written order by the physician.

Surgical Tissue Banks and Specimens

Regulation of Surgical Tissue Banks

• Surgical tissue banks are regulated by:
  • AATB (American Association of Tissue Banks).
  • The Joint Commission.
  • FDA (Food and Drug Administration).

Why Autologous Tissue Must Be Separated from Allografts

• Infection Testing: Autologous tissue (from the patient’s own body) has not undergone testing for infectious diseases.
• Contamination Risk: It must be kept strictly separate from allografts (from donors) to prevent cross-contamination.

Required Information on Surgical Tissue

• Expiration date is mandatory.

Storage Requirements for Tissue Grafts

• Temperature Control: Must be kept in a refrigerator or freezer with limited access.
• Monitoring: Requires a temperature monitor with an alarm.
• Alarm Protocol: The alarm must be set to sound in a location that is continuously monitored.

Retention Period for Surgical Tissue Bank Records

• Surgical tissue bank records (consent, donor assessment, procurement, processing, preservation, labeling, storage, quarantining, testing, release, distribution, quality control) must be kept for 10 years.

Law Guiding Surgical Tissue Donors

• The Uniform Anatomical Gift Act of 1968 provides guidelines for tissue procurement from donors.

Donor Eligibility Guidelines (Uniform Anatomical Gift Act)

• Exclusions:
  • No active infection (sepsis).
  • No autoimmune disease (e.g., lupus).
  • No neurological disease.
  • No bone disease.
  • No systemic medication (e.g., chemotherapy).
  • Immobility: Cannot have been on a vent or immobile for more than 7 days prior to brain death (due to potential damage to heart and lungs).
  • Temperature: Must have been normothermic for the week before death.
• Inclusions (No “Lifestyle” Exclusions): Donors who were OD patients, IV drug users, or prostitutes are still eligible if testing confirms no infectious diseases.

Handling Dropped Human Donor Tissue

• Procedure:
  1. Thoroughly rinse the tissue with betadine and/or an antibiotic solution.
  2. Report the incident to infection prevention personnel.
  3. The surgeon should be placed on prophylactic antibiotics.
• Crucial Point: Do not discard the anatomical gift and retrieve another. However, if using donor tissue is no longer feasible, artificial materials may be used.

Unrecommended Practice for Donor Bone Tissue

• Do not steam sterilize bone, as it damages the bone structure.

Storing Autologous Tissue (e.g., Skull Flap)

• If autologous tissue is not going to be used immediately, it should be sent to the tissue bank immediately to prevent drying or contamination.

Required Information for Storing Autologous Tissue

• Patient Identification: Confirm with two unique identifiers.
• Origin: Specify the source of the tissue, including laterality (e.g., “right femur,” “T-L-level”).
• Tissue Type: Clearly state the type of tissue.
• Clinical Information: Include the diagnosis and any pertinent clinical details.

Specimen and Label Confirmation

• Specimens and their labels must be confirmed:
  • At the time of collection.
  • During debriefing with the surgeon.

Handling Legal Evidence Specimens

• Chain of Custody: Maintain a strict chain of custody to prevent tampering.
• Prevent Alteration: Prevent alteration of the specimen (e.g., remove a bullet with a plastic instrument or fingers; metal instruments can alter scoring).
• Prevent Decomposition: Place in a proper specimen container. (Crucial for exam).

Specimen Containers: Dry vs. Preservative

• Dry Container: For fresh, frozen, or cytology specimens.
• Preservative Container: For preserved or permanent (e.g., formalin) specimens.

Cytology vs. Microbiology

• Cytology: Examination of cell types in fluid (e.g., ascites).
• Microbiology: Culturing for microbial growth.

Container for Microbiology Specimens

• Microbiology specimens are placed in a culture medium (e.g., swabs).