YES     NO     

             r        r         Does my patient have a Neuro Injury?

                                                            Anoxia

                                                            CVA

                                                            Trauma, etc.

             r        r         Is my patient mechanically ventilated?

             r        r         Does my patient have a GCS of <5 and the absence of

two of the following brain stem reflexes?

                                                            Pupillary Response    Corneal Reflex

                                                            Cough                       Gag

                                                            Response to pain       Respiration

                                                            Doll's Eyes                 Cold Calorics
 

             r        r         Pediatric Verbal Score (V-score) of 1 (unresponsive)?

If you answered YES to all three questions above

and/or a physician plans a DNR discussion with the family of a potential organ donor

and/or there are plans to withdraw support of a potential organ donor  

Working Together with Hospitals

to Support Families

and to Save Lives

OneCall for Life

800 558-LIFE (5433)