A 10-month-old infant with reversible findings of brain death.

Death has occurred when there is irreversible loss of integration of the organism as a whole, and brain death is said to be a criterion for death. In the present case, a 10-month-old boy was found submerged in a bathtub and was given cardiopulmonary resuscitation for 37 minutes. He had received therapeutic dosing of phenobarbital and midazolam up to 5 hours prior to a brain death examination. He fulfilled all criteria for brain death according to Canadian Neurological Determination of Death Forum recommendations on an examination 42 hours after the drowning event, but started breathing another 15 hours later. Eleven previously published cases of purported reversal of findings of brain death are discussed here, including two infants who fulfilled all criteria for brain death for more than 24 hours. Recommendations for brain death determination may require revision for infants, to more clearly define a time interval between examinations and to incorporate consideration of confounding sedative drug effects. Together with previous reports, the present case calls into question the assumption that brain death as currently diagnosed is irreversible, and therefore equivalent to death of the patient.

The approach to delayed resuscitation in paediatric cardiac arrest: A survey of paediatric intensivists in Canada.

AIM: To determine how long a period of having had no cardiopulmonary-resuscitation (CPR) (delay time) is considered to result in subsequent futile efforts at resuscitation. METHODS: In 2007 a survey was mailed to all 77 paediatric intensivists in Canada. Three scenarios of witnessed cardiac arrest were presented: out-of-hospital, in-hospital, and in-hospital with extracorporeal-CPR (E-CPR). Each scenario asked what delay time would make attempts at resuscitation futile for survival to hospital discharge, and for survival to hospital discharge in a better than vegetative state. Comparisons of median [inter-quartile range] used Wilcoxon-signed-rank or Friedman tests with Bonferroni corrections. RESULTS: The response rate was 49/77 (64%). The delay time was significantly different between rhythms within all scenarios (p<.001); and was significantly shorter for survival than for better than vegetative survival (p<.006) except when E-CPR was to be used. The delay time was not significantly different between the in-hospital and out-of-hospital scenario with the same rhythms (p>.01). The delay time was significantly shorter in scenarios with asystole versus pulseless electrical activity with (p=.010) or without (p<.001) an arterial line with absent pulsation. In out-of-hospital arrest, the delay time for survival varied from 15 [10-20]min for asystole to 20 [15-20]min for pulseless electrical activity. In in-hospital scenarios, the delay time for survival varied from 10 [10-20]min for asystole, to 15 [10-20]min for most other rhythms. CONCLUSION: A delay time of 15 [10-20] (range 5-30)min was considered futile for survival. This has implications for pronouncing death in donation after cardiac death.

Donation after cardiac death: a survey of university student opinions on death and donation.

OBJECTIVE: To determine if university students consider the donation after cardiac death donor as dead. DESIGN: Survey. SETTING: University students. PARTICIPANTS: Medical (n = 142) and nursing (n = 76) students in a medical ethics class and philosophy students (n = 102). INTERVENTION: Survey during class time with four patient scenarios in which a decision was made to donate organs after 5 min of absent circulation. MEASUREMENTS AND RESULTS: Half the surveys had brief background information, and half had more detailed background information. Responses between groups were compared using the Chi-square statistic. The response rate of 320 students was 100%. In each scenario, 42-51% of those given detailed information strongly agree or agree that the patient is 'definitely dead', versus 55-58% given brief information (ns). When asked in what state this patient is, 26-30% given detailed information chose "dead," versus 41-45% given brief information (P < 0.025). Thirty-six to 39% given detailed information strongly agree or agree that the physician was truthful informing the family that at 5 min of absent circulation the patient is definitely dead, versus 48-52% given brief information (P < 0.01). On at least one of the scenarios, 65% of those given detailed information, and 50% of those given brief information responded uncertain, disagree, or strongly disagree that the patient is definitely dead (P < 0.01). Medical students were significantly less likely to agree that the patients in the scenarios were "dead," or that the physicians were being truthful in describing the patients as dead. CONCLUSIONS: Most respondents were not confident that a donation after cardiac death donor was actually dead.

Survey of pediatricians' opinions on donation after cardiac death: are the donors dead?

OBJECTIVE: There has been debate in the ethics literature as to whether the donation-after-cardiac-death donor is dead after 5 minutes of absent circulation. We set out to determine whether pediatricians consider the donation-after-cardiac-death donor as dead. METHODS: A survey was mailed to all 147 pediatricians who are affiliated with the university teaching children's hospital. The survey had 4 pediatric patient scenarios in which a decision was made to donate organs after 5 minutes of absent circulation. Background information described the organ shortage, and the debate about the term "irreversibility" applied to death in donation after cardiac death. Descriptive statistics were used, with responses between groups compared by using the chi(2) statistic. RESULTS: The response rate was 54% (80 of 147). In each scenario, when given a patient described as dead with absent circulation for 5 minutes,