Advertisement

Diagnosis of Brain Death and Organ Donation After Circulatory Death

  • Anthony A. Sochet
  • Alexandra K. Glazier
  • Thomas A. Nakagawa
Chapter

Abstract

Determination of death and provision of organ transplantation can result in controversy for the pediatric provider caring for a critically ill or injured child. Despite accepted legal definitions for death and guidelines for neurologic and circulatory determination of death, there remains an evolving and, at times, contentious dialogue among medical experts and the community. We provide the historical context and summarization of several legal and clinical aspects to define death and discussion of potential ethical controversies regarding death by neurologic and circulatory criteria. We highlight conflicts and controversies raised by both family and healthcare team members that are becoming increasingly prevalent in our practice of critical care medicine. We offer insight and proposed solutions into matters of autonomy, maleficence, non-beneficence, and the respectful, dignified care of the sick and dying child and their family.

Keywords

Brain death Donation after neurologic determination of death Donation after circulatory determination of death Ethics Pediatric Critical Care Medicine 

Abbreviations

AAP

American Academy of Pediatrics

CPR

Cardiopulmonary resuscitation

DCD

Donation after circulatory determination of death

DND

Donation after neurologic determination of death

DNR

Do not resuscitate

OPO

Organ procurement organization

PICU

Pediatric intensive care unit

SCCM

Society of Critical Care Medicine

UAGA

Uniform Anatomical Gift Act

UDDA

Uniform Determination of Death Act

WLST

Withdrawal of life-sustaining therapies

Notes

Conflict of Interest

Dr. Sochet: None

Dr. Nakagawa: Received funding from Up To Date and Fresenius Kabi. Dr. Nakagawa is the Assistant Medical Director for Carolina Donor Services.

Ms. Glazier: None

References

  1. 1.
    Farrell MM, Levin DL. Brain death in the pediatric patient: historical, sociological, medical, religious, cultural, legal, and ethical considerations. Crit Care Med. 1993;21(12):1951–65.CrossRefPubMedCentralGoogle Scholar
  2. 2.
    A definition of irreversible coma: report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA. 1968;205(6):337–40.Google Scholar
  3. 3.
    Sarbey B. Definitions of death: brain death and what matters in person. J Law Biosci. 2016;3(3):743–52.CrossRefPubMedCentralGoogle Scholar
  4. 4.
    National Conference of Commissioners on Uniform State Laws. Revised Uniform Anatomical Gift Act (2006). Available at: http://www.uniformlaws.org/shared/docs/anatomical_gift/uaga_final_aug09.pdf. Accessed 19 Jan 2018.
  5. 5.
    Defining death: medical, legal, and ethical issues in the determination of death. Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research 1981.Google Scholar
  6. 6.
    National Conference of Commissioners on Uniform State Laws. Uniform Determination of Death Act (1981). Available at: http://www.uniformlaws.org/shared/docs/determination%20of%20death/udda80.pdf. Accessed 18 Jan 2018.
  7. 7.
    Wijdicks EF. Determining brain death in adults. Neurology. 1995;45(5):1003–11.CrossRefPubMedCentralGoogle Scholar
  8. 8.
    Wijdicks EF, Varelas PN, Gronseth GS, et al. American Academy of Neurology. Evidence based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010;74(23):1911–8.Google Scholar
  9. 9.
    Task force for the determination of brain death in children. Guidelines for the determination of brain death in children. Pediatr Neurol. 1987;3(4):242–3.Google Scholar
  10. 10.
    Nakagawa TA, Ashwal S, Marthur M, et al. Guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations. Crit Care Med. 2011;39(9):2139–55.CrossRefPubMedCentralGoogle Scholar
  11. 11.
    Organ procurement and transplantation network. Available at: http://optn.transplant.hrsa.gov. Accessed 17 Jan 2018.
  12. 12.
    Workman JK, Myrick CW, Meyers RL, et al. Pediatric organ donation and transplantation. Pediatrics. 2013;131(6):e1723–30.CrossRefPubMedCentralGoogle Scholar
  13. 13.
    Committee on Hospital Care, Section on Surgery, and Section on Critical Care. Policy statement – pediatric organ donation and transplantation. Pediatrics. 2010;125(4):822–8.CrossRefGoogle Scholar
  14. 14.
    De Georgia MA. History of brain death as death: 1968 to the present. J Crit Care. 2014;29:673–8.CrossRefPubMedCentralGoogle Scholar
  15. 15.
    Souter MJ, Blissitt PA, Blosser S, et al. Recommendations for the critical care management of the devastating brain injury: prognostication, psychosocial and ethical management: a position statement for healthcare professionals from the Neurocritical Care Society. Neurocrit Care. 2015;23(1):4–13.CrossRefPubMedCentralGoogle Scholar
  16. 16.
    Kentish-Barnes N, Duranteau J, Montlahuc C, et al. Clinician’s perception and experience of organ donation from brain dead patients. Crit Care Med. 2017;45:1489–99.CrossRefPubMedCentralGoogle Scholar
  17. 17.
    MacDonald SI, Shemie SD. Ethical challenges and the donation physician specialist: a scoping review. Transplantation. 2017;101:S27–40.CrossRefGoogle Scholar
  18. 18.
    45 Code of Federal Regulation (CFR) Part 486. Subpart G. Requirements for certification and designation and conditions for coverage: organ procurement organizations. Available at: https://www.law.cornell.edu/cfr/text/42/part-486/subpart-G. Accessed 8 Mar 2018.
  19. 19.
    Rodrique JR, Cornell DL, Howard RJ. Pediatric organ donation: what factors most influence parents’ donation decisions? Pediatr Crit Care Med. 2008;9(2):180–5.CrossRefGoogle Scholar
  20. 20.
    Martin DE, Nakagawa TA, Siebelink MJ, et al. Pediatric deceased donation – a report of the Transplantation Society meeting in Geneva. Transplantation. 2015;99:1403–9.CrossRefPubMedCentralGoogle Scholar
  21. 21.
    Nakagawa TA, Shemie SD, Dreyden-Palmer K, et al. Donation following neurologic and circulatory determination of death. Ped Crit Care Med. 2018;(8S Suppl 2):S26–S32.Google Scholar
  22. 22.
    ACRE Trial Collaborators. Effect of “collaborative requesting” on consent rate for organ donation: randomized controlled trial (ACRE trial). BMJ. 2009;8:b3911.CrossRefGoogle Scholar
  23. 23.
    Gortmaker SL, Beasley CL, Sheehy E, et al. Improving the request process to increase family consent for donation. J Transpl Coord. 1998;8(4):210–7.CrossRefPubMedCentralGoogle Scholar
  24. 24.
    Chandler JA, Connors M, Holland G, Shemie SD. “Effective” requesting: a scoping review of the literature on asking families to consent to organ and tissue donation. Transplantation. 2017;101(5S Suppl 1):S1–16.CrossRefPubMedCentralGoogle Scholar
  25. 25.
    Burkle CM, Sharp RR, Wijdicks EF. Why brain death is considered death and why there should be no confusion. Neurology. 2014;83(16):1464–9.CrossRefPubMedCentralGoogle Scholar
  26. 26.
    Galofaro C. Brain-dead baby taken off life support. Cour J. 2014; Available at: https://www.courier-journal.com/story/news/crime/2014/07/23/baby-taken-life-support-judge-rules-mother-force-hospital-treat-legally-dead-child/13032423/. Accessed 19 Jan 2018.
  27. 27.
    Meert KL, Thurston CS, Sarnaik AP. End-of-life decision-making and satisfaction with care: parental perspectives. Pediatr Crit Care Med. 2000;1(2):179–85.CrossRefPubMedCentralGoogle Scholar
  28. 28.
    Hoover SM, Bratton SL, Roach E, Olson LM. Parental experiences and recommendations in donation after circulatory determination of death. Pediatr Crit Care Med. 2014;15(2):105–11.CrossRefPubMedCentralGoogle Scholar
  29. 29.
    Dalle Ave AL, Gardiner D, Shaw DM. Cardio-pulmonary resuscitation of brain-dead organ donors: a literature review and suggestions for practice. Transpl Int. 2016;29(1):12–9.CrossRefPubMedCentralGoogle Scholar
  30. 30.
    Shafer TJ, Cosio C. Cardiopulmonary resuscitation of organ donors. Prog Transplant. 2011;21(4):351–2.CrossRefPubMedCentralGoogle Scholar
  31. 31.
    Dalle Ave AL, Shaw DM, Bernat JL. Ethical issues in the use of extracorporeal membrane oxygenation in controlled donation after circulatory determination of death. Am J Transplant. 2016;16:2293–9.CrossRefPubMedCentralGoogle Scholar
  32. 32.
    Bernat JL, Capron AM, Bleck T, et al. The circulatory-respiratory determination of death in organ donation. Crit Care Med. 2010;38:972–9.Google Scholar
  33. 33.
    Weiss MJ, Hornby L, Witteman W, Shemie SD. Pediatric donation after circulatory determination of death: a scoping review. Pediatr Crit Care Med. 2016;17(3):e87–108.CrossRefPubMedCentralGoogle Scholar
  34. 34.
    Morrissey PE, Monaco AP. Donation after circulatory death: current practices, ongoing challenges, and potential improvements. Transplantation. 2014;97(3):258–64.CrossRefPubMedCentralGoogle Scholar
  35. 35.
    Pana R, Hornby L, Shemie SD, et al. Time to loss of brain function and activity during circulatory arrest. J Crit Care. 2016;34:77–83.CrossRefPubMedCentralGoogle Scholar
  36. 36.
    Rady MY, Verheijde JL. Neuroscience and awareness in the dying human brain: implications for organ donation. J Crit Care. 2016;34:121–3.CrossRefPubMedCentralGoogle Scholar
  37. 37.
    Norton L, Gibson RM, Gofton T, et al. Electroencephalographic recording during withdrawal of life-sustaining therapy until 30 minutes after declaration of death. Can J Neurol Sci. 2017;44:139–45.CrossRefPubMedCentralGoogle Scholar
  38. 38.
    Shapey IM, Mulesan P. Regional perfusion by extracorporeal membrane oxygenation of abdominal organs from donors after circulatory death: a systematic review. Liver Transpl. 2013;19:1292–303.CrossRefPubMedCentralGoogle Scholar
  39. 39.
    Shemie SD, Hornby L, Baker A, et al. International guideline development for the determination of death. Intensive Care Med. 2014;40(6):788–97.CrossRefPubMedCentralGoogle Scholar
  40. 40.
    American Academy of Pediatrics – Committee on Bioethics. Ethical controversies in organ donation after circulatory death. Pediatrics. 2010;125:822–8.CrossRefGoogle Scholar
  41. 41.
    Weiss MJ, Hornby L, Rochwerg B, et al. Canadian guidelines for controlled pediatric donation after circulatory determination of death – summary report. Pediatr Crit Care Med. 2017;18(11):1035–46.CrossRefPubMedCentralGoogle Scholar
  42. 42.
    Glazier AK. Principles of gift law and the regulation of donation. Transpl Int. 2011;24(4):368–72.CrossRefPubMedCentralGoogle Scholar
  43. 43.
    Overby KJ, Weinstein MS, Fiester A. Addressing consent issues in donation after circulatory determination of death. Am J Bioeth. 2015;15(8):3–9.CrossRefPubMedCentralGoogle Scholar
  44. 44.
    Marquis D. The impossibility of obtaining informed consent to donation after circulatory determination of death. Am J Bioeth. 2015;15(8):25–7.CrossRefPubMedCentralGoogle Scholar
  45. 45.
    Brierley J, Shad D. Premortem interventions in dying children to optimize organ donation: an ethical analysis. J Med Ethics. 2016;42(7):424–8.CrossRefPubMedCentralGoogle Scholar
  46. 46.
    Dalle Ave AL, Shaw DM, Gardiner D. Extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation or uncontrolled donation after circulatory determination of death following out-of-hospital refractory cardiac arrest – an ethical analysis of an unresolved clinical dilemma. Resuscitation. 2015;108:87–94.CrossRefGoogle Scholar
  47. 47.
    Peabody JL, Emery JR, Ashwal S. Experience with anencephalic infants as prospective organ donors. N Engl J Med. 1989;321:344–50.CrossRefPubMedCentralGoogle Scholar
  48. 48.
    American Academy of Pediatrics, Committee on Bioethics. Infants with anencephaly as organ sources: ethical considerations. Pediatrics. 1992;89:1116–9.Google Scholar
  49. 49.
    Nakagawa TA, Zollinger C, Chao J, et al. Anencephalic infants as organ donors after circulatory death. Transplantation. 2017;101:S60.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Anthony A. Sochet
    • 1
    • 2
  • Alexandra K. Glazier
    • 3
  • Thomas A. Nakagawa
    • 1
    • 2
  1. 1.Anesthesiology and Critical Care MedicineThe Johns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Division of Pediatric Critical Care MedicineJohns Hopkins All Children’s HospitalSt. PetersburgUSA
  3. 3.New England Donor ServicesWalthamUSA

Personalised recommendations