Towards a holistic definition of death: the biological, philosophical and social deficiencies of brain stem death criteria.

With no statutory definition of death, the accepted medical definition relies on brain stem death criteria as a definitive measure of diagnosing death. However, the use of brain stem death criteria in this way is precarious and causes widespread confusion amongst both medical and lay communities. Through critical analysis, this paper considers the insufficiencies of brain stem death. It concludes that brain stem death cannot be successfully equated with either biological death or the loss of integrated bodily function. The overemphasis of the brain-stem and its consequences leaves  the criteria open to significant philosophical critique. Further, in some circumstances, the use of brain stem death criteria causes substantial emotional conflict for families and relatives. Accordingly, a more holistic and comprehensive definition of death is required.

[Death criteria - now and in the future].

Death can be pronounced on both circulatory and brain criteria. In both cases, irreversible loss of brain function is essential in understanding finale death, as irreversible loss of breathing - a brainstem function - is mandatory. Brain function ceases irreversibly as a consequence of lack of blood supply to the brain, caused by circulatory arrest or by raised intracranial pressure. Brain function is central in death, which must be reflected in a future death criterion, stated in WHO´s new death criterion based on irreversible loss of capacity for consciousness and loss of brainstem function.

[New Challenges: Diagnosis of Brain Death in Newborn, Children and Adolescents]. / Neue Herausforderungen: Feststellung des irreversiblen Ausfalls der Hirnfunktion bei Neugeborenen, Kindern und Jugendlichen.

BACKGROUND: According to the current update of the German guideline on brain death (BD), participation of paediatricians is now mandatory for the examination of BD in patients younger than 14 years. The present analysis focuses on the previous practice and highlights the challenges that arise from the current update. METHODS: Retrospective evaluation of the patient registry of the German organ procurement organisation (north-eastern bureau) between January, 2001 and December, 2010 with specified paediatric age groups according to the 4th update of the German guideline on BD from the 1st of July 2015. RESULTS: 133 patients (0-17 years) received at least one BD examination. Secondary brain damage was most frequent within the first 6 months of life whereas traumatic and other causes of primary brain damage were predominantly observed thereafter. The number of patients who received BD examination by paediatricians or were treated on neonatal/paediatric intensive care units declined with increasing age. In more than two-third of all paediatric patients, no paediatrician was involved in BD diagnostics. DISCUSSION: After enforcement of the 4th update of the German guideline on BD, the participation of qualified paediatric physicians must be increased significantly compared to previous practice. Advancements in the specialist training of paediatric physicians, adjustments in patient-centered paediatric care and interdisciplinary diagnostic teams may be solutions to meet this demand.

Do Spanish Medical Students Understand the Concept of Brain Death?

OBJECTIVE: To analyze the level of understanding of the brain death concept among medical students in universities in Spain. METHODS: This cross-sectional sociological, interdisciplinary, and multicenter study was performed on 9598 medical students in Spain. The sample was stratified by geographical area and academic year. A previously validated self-reported measure of brain death knowledge (questionnaire Proyecto Colaborativo Internacional Donante sobre la Donación y Transplante de Organos) was completed anonymously by students. RESULTS: Respondents completed 9275 surveys for a completion rate of 95.7%. Of those, 67% (n = 6190) of the respondents understood the brain death concept. Of the rest, 28% (n = 2652) did not know what it meant, and the remaining 5% (n = 433) believed that it did not mean that the patient was dead. The variables related to a correct understanding of the concept were: (1) being older ( P < .001), (2) studying at a public university ( P < .001), (3) year of medical school ( P < .001), (4) studying at one of the universities in the south of Spain ( P = .003), (5) having discussed donation and transplantation with the family ( P < .001), (6) having spoken to friends about the matter ( P < .001), (7) a partner's favorable attitude toward donation and transplantation ( P < .001), and (8) religious beliefs ( P < .001). CONCLUSIONS: Sixty-seven percent of medical students know the concept of brain death, and knowledge improved as they advanced in their degree.

Manual de rotinas e procedimentos operacionais padronizados da equipe de captação de orgãos de Goiás / Manual of standardized operational routines and procedures for the organ harvesting team in Goiás

A Central de Transplantes (CET) é um orgão executivo, subordinado Secretaria de Estado da Saúde e tem como responsabilidade planejar, coordenar, acompanhar e controlar todas as atividades de transplantes, ao nível estadual, em observância à legislação vigente referente ao processo de doação, captação, distribuição e transplantes de orgãos e tecidos no Brasil. Afim de organizar as atividades da CET-GO, criou-se este manual de rotina e procedimentos operacionais da Central de Transplantes de forma a oferecer qualidade e segurança nas tarefas executadas e resultados esperados

The Transplant Center (CET) is an executive body, subordinated to the State Health Department and is responsible for planning, coordinating, monitoring and controlling all transplant activities at the state level, in compliance with current legislation regarding the donation process, capture, distribution and transplantation of organs and tissues in Brazil. In order to organize the activities of CET-GO, this manual of routine and operational procedures of the Transplant Center was created in order to offer quality and safety in the tasks performed and expected results

Advances in organ preservation for transplantation.

Organ transplantation provides the best available therapy for a myriad of medical conditions, including end-stage renal disease, hepatic failure and type I diabetes mellitus. The current clinical reality is, however, that there is a significant shortage of organs available for transplantation with respect to the number of patients on organ waiting lists. As such, methods to increase organ supply have been instituted, including improved donor management, organ procurement and preservation strategies, living organ donation, transplantation education and the increased utilization of donation after circulatory death and expanded criteria donors. In particular, especially over the last decade, we have witnessed a significant change in the way donor organs are preserved, away from static cold storage methods to more dynamic techniques centred on machine perfusion (MP). This review highlights the current state and future of organ preservation for transplantation, focusing on both abdominal and thoracic organs. In particular, we focus on MP preservation of renal, hepatic, pancreatic, cardiac and lung allografts, also noting relevant advances in Australasia. MP of organs after procurement holds considerable promise, and has the potential to significantly improve graft viability and function post-transplantation, especially in donors in whom acceptance criteria have been expanded.

Is heart transplantation after circulatory death compatible with the dead donor rule?

Dalle Ave et al (2016) provide a valuable overview of several protocols for heart transplantation after circulatory death. However, their analysis of the compatibility of heart donation after circulatory death (DCD) with the dead donor rule (DDR) is flawed. Their permanence-based criteria for death, which depart substantially from established law and bioethics, are ad hoc and unfounded. Furthermore, their analysis is self-defeating, because it undercuts the central motivation for DDR as both a legal and a moral constraint, rendering the DDR vacuous and trivial. Rather than devise new and ad hoc criteria for death for the purpose of rendering DCD nominally consistent with DDR, we contend that the best approach is to explicitly abandon DDR.

[Non-heart-beating donors are ineligible]. / "Non-heart-beating donors" sind nicht geeignet.

The death of the donor is a mandatory prerequisite for organ transplantation (dead donor rule) worldwide. It is a medical, legal and ethical consensus to accept the concept of brain death, as first proposed in 1968 by the ad hoc committee of the Harvard Medical School, as a certain criterion of death. In isolated cases where the diagnosis of brain death was claimed to be wrong, it could be demonstrated that the diagnostic procedure for brain death had not been correctly performed. In March 2014 a joint statement by the German neuromedical societies emphasized that 1) the diagnosis of brain death is one of the safest diagnoses in medicine if performed according to accepted medical standards and criteria and 2) the concept of non-heart-beating donors (NHBD, i. e. organ donation after an arbitrarily defined duration of circulatory and cardiac arrest) practiced in some European countries must be absolutely rejected because it implicates a high risk of diagnostic error. According to the current literature it is unclear at what time cardiac and circulatory arrest is irreversible and leads to irreversible cessation of all functions of the entire brain including the brainstem, even though clinical signs of cessation of brain functions are always found after 10 min. Furthermore, is it often an arbitrary decision to exactly define the duration of cardiac arrest if continuous echocardiographic monitoring has not been carried out from the very beginning. Last but not least there are ethical concerns against the concept of NHBD because it might influence therapeutic efforts to resuscitate a patient with cardiac arrest. Therefore, the German Medical Council (BÄK) has repeatedly rejected the concept of NHBD for organ transplantation since 1995.

[Angiographic procedures for determination of cessation of cerebral circulation]. / Angiographische Verfahren zur Feststellung des zerebralen Zirkulationsstillstandes.

In several European countries catheter angiography is permitted as a confirmatory procedure for the determination of irreversible loss of brain function (brain death). In Germany catheter angiography requires the possibility of a therapeutic implication as a prerequisite. In the updated German guidelines computed tomography angiography (CTA) has been accredited as a new confirmatory procedure if a standardized protocol and predefined assessment parameters are adhered to. The CTA can be performed within a few minutes, even in situations with unstable intensive care patients. Magnetic resonance (MR) angiography has not yet been adequately validated and is not permitted in Germany as a confirmatory procedure for the determination of irreversible loss of brain function.

[Organ donation after circulatory death]. / Organspende nach Herz- und Kreislauftod.

Approximately 17 million inhabitants live in the Netherlands. The number of potential organ donors in 1999 was the lowest in Europe with only 10 donors per million inhabitants. Medical associations, public health services, health insurance companies and the government had to find common solutions in order to improve organ allocation, logistics of donations and to increase the number of transplantations. After a prolonged debate on medical ethical issues of organ transplantation, all participants were able to agree on socio-medico-legal regulations for organ donation and transplantation. In addition to improving the procedure for organ donation after brain death (DBD) the most important step was the introduction of organ donation after circulatory death (DCD). Measures such as the introduction of a national organ donor database, improved information to the public, further education on intensive care units (ICU), guidelines for end of life care on the ICU, establishment of transplantation coordinators on site, introduction of autonomous explantation teams and strict procedures on the course of organ donations, answered many practical issues about logistics and responsibilities for DBD and DCD. In 2014 the number of postmortem organ donations rose to 16.4 per million inhabitants. Meanwhile, up to 60 % of organ donations in the Netherlands originate from a DCD procedure compared to approximately 10 % in the USA. This overview article discusses the developments and processes of deceased donation in the Netherlands after 15 years of experience with DCD.

[Fourth update of the guidelines on determination of irreversible brain death. Procedural course and amendments]. / Vierte Fortschreibung der Richtlinie zur Feststellung des irreversiblen Hirnfunktionsausfalls. Verfahrensabläufe und Neuerungen.

In 2015 the fourth update of the directive for the determination of definitely irreversible loss of complete function of the cerebrum, cerebellum and brainstem was passed and came into force. This was preceded by several hearings of all professional societies and associations involved as well as a 2-year advisory process of an interdisciplinary working party. The directive is intended to determine irreversible brain death in the field of intensive care medicine and is independent of individual decisions about organ donation. Not only an update based on scientific data but also a clarification of the several procedures and a clear definition of the medical qualifications required were worked out. Furthermore, the technical procedures computed tomography (CT) angiography and duplex sonography were adopted for the diagnosis of cerebral circulatory arrest. The new directive including comprehensive explanatory notes was approved by the German Federal Ministry of Health and published by the German Medical Council (Bundesärztekammer).

[Determination of irreversibility of clinical brain death. Electroencephalography and evoked potentials]. / Irreversibilitätsnachweis der klinischen Ausfallssymptome des Gehirns. Elektroenzephalographie und evozierte Potenziale.

Principally, in the fourth update of the rules for the procedure to finally determine the irreversible cessation of function of the cerebrum, the cerebellum and the brainstem, the importance of an electroencephalogram (EEG), somatosensory evoked potentials (SEP) and brainstem auditory evoked potentials (BAEP) are confirmed. This paper presents the reliability and validity of the electrophysiological diagnosis, discusses the amendments in the fourth version of the guidelines and introduces the practical application, problems and sources of error.An EEG is the best established supplementary diagnostic method for determining the irreversibility of clinical brain death syndrome. It should be noted that residual brain activity can often persist for many hours after the onset of brain death syndrome, particularly in patients with primary brainstem lesions. The derivation and analysis of an EEG requires a high level of expertise to be able to safely distinguish artefacts from primary brain activity. The registration of EEGs to demonstrate the irreversibility of clinical brain death syndrome is extremely time consuming.The BAEPs can only be used to confirm the irreversibility of brain death syndrome in serial examinations or in the rare cases of a sustained wave I or sustained waves I and II. Very often, an investigation cannot be reliably performed because of existing sound conduction disturbances or failure of all potentials even before the onset of clinical brain death syndrome. This explains why BAEPs are only used in exceptional cases.The SEPs of the median nerve can be very reliably derived, are technically simple and with few sources of error. A serial investigation is not required and the time needed for examination is short. For these reasons SEPs are given preference over EEGs and BAEPs for establishing the irreversibility of clinical brain death syndrome.

[Access to brain death diagnostics]. / Zugang zur Hirntoddiagnostik.

BACKGROUND AND OBJECTIVES: In Germany the diagnosis of brain death must strictly adhere to the expert guidelines of the German chamber of physicians. For patients with primary supratentorial or hypoxic brain injury aged 2 years or more, repeat clinical examinations or one complete examination combined with an ancillary test are equally accurate. This study aimed to identify factors with potential impact on whether and by which means a formal brain death examination is pursued. MATERIAL AND METHODS: A retrospective analysis was carried out of recorded data of all patients who died in the acute phase after severe brain injury during mechanical ventilation in an intensive care unit and who were registered at the north east regional bureau of the German organ procurement organization (Deutsche Stiftung Organtransplantation) between 2001 and 2010. RESULTS: Of 5988 reported patients, a protocol-specified brain death examination was initiated in 3023, leading to a diagnosis of brain death in 2592. All other patients died due to permanent cardiac arrest. Patients were less likely to undergo brain death examinations in the presence of one or more of the following characteristics: perceived medical contraindication for organ donation, patient age greater than 69 years, hypoxic brain damage, treatment in a hospital without neurological and neurosurgical departments and death on a weekend or public holiday. In 2192 patients (72.5%), neurologists or neurosurgeons participated in the diagnostic procedures and in 926 of these cases members of specialized external diagnostic expert teams were involved. Ancillary tests were rarely used by physicians based at the treating hospitals (31.1%) but on a regular basis by members of the external teams (93.4%). The risk of death due to permanent cardiac arrest before completion of the brain death examination was increased approximately 7-fold when a neurological or neurosurgical consultation with ancillary studies was not performed. DISCUSSION: Access to neurological expertise and to ancillary tests has a significant impact on the provision of guideline-specified diagnostic procedures for suspected brain death. Centralized diagnostic teams offer an effective means to support qualified brain death examinations.