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Adams BL, Brenner L, Levan M, Parent B. cDCDD-NRP is consistent with US legal standards for determining death. Am J Transplant 2022; 22:2302-2305. [PMID: 35510751 PMCID: PMC10138106 DOI: 10.1111/ajt.17083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/07/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
Donation after circulatory determination of death (DCDD) has increased organ donation rates in the US over the past decade within an established legal framework, which is consistent with and supports individual and family decisions regarding organ donation in the context of end-of-life care. A new application, controlled DCDD donation utilizing thoracoabdominal normothermic regional perfusion (NRP) protocols (cDCDD-NRP), provides the opportunity to maximize a donation decision by recovering additional organs for transplant, including the heart, and to limit the detrimental impact of warm ischemic time by perfusing organs in situ following the declaration of circulatory death. In this viewpoint, we narrate our rationale for why cDCDD-NRP is consistent within the existing legal framework for organ donation in the United States and recommend no changes to the Uniform Determination of Death Act.
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Affiliation(s)
| | | | - Macey Levan
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, New York, USA
| | - Brendan Parent
- Department of Population Health, Division of Medical Ethics, NYU Langone Health, New York, New York, USA
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2
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Dees RH. Primum Non Nocere Mortuis: Bioethics and the Lives of the Dead. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2020; 44:732-755. [PMID: 31628794 DOI: 10.1093/jmp/jhz024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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3
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Steensma DJ. Brain Death and the Dutch Organ Donation Law. LINACRE QUARTERLY 2020; 87:161-170. [PMID: 32549633 DOI: 10.1177/0024363919897441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
According to many legal systems that regulate organ donation, such as Dutch law, a brain-dead patient is regarded as a mortal remains. In general, these systems do not take into account the fact that this definition is being heavily criticized and the far-reaching consequences thereof. In the case of organ transplantation, vital organs are procured from persons who, from a biological perspective, may not yet be dead. A government that values scientific data and wants to provide honest and reliable information to its citizens has to account for this critique of its policy as citizens have the right to be well-informed. Whoever makes the decision to donate organs performs a special act of human solidarity, but the readiness to donate organs in the case of brain death is not inherent to the demand to love one's neighbor as one loves oneself. Summary According to legislation on organ donation in many countries, a brain-dead patient is regarded as a mortal remains. The law disregards the fact, however, that this definition is being heavily criticized and that it has far-reaching consequences. In the case of organ transplantation, vital organs are procured from persons who, from a biological perspective, may not yet been dead. A government that values scientific data and wants to provide honest and reliable information to its citizens has to account for this critique in its policy. Citizens have the right to be well-informed.
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Abstract
Prompted by concerns raised by the rise in litigations, which challenge the legal status of brain death (BD), Lewis and colleagues recently proposed a revision of the Uniform Determination of Death Act (UDDA). The revision consists of (i) narrowing down the definition of BD to the loss of specific brain functions, namely those functions that can be assessed on bedside neurological examination; (ii) requiring that the determination of BD must be in accordance with the specific guidelines designated in the revision; and (iii) eliminating the necessity for obtaining consent prior to performing the tests for BD determination. By analyzing Lewis and colleagues' revision, this article shows that this revision is fraught with difficulties. Therefore, this article also proposes two approaches for an ethical revision of the UDDA; the first is in accordance with scientific realism and Christian anthropology, while the second is grounded in trust and respect for persons. If the UDDA is to be revised, then it should be based on sound ethical principles in order to resolve the ongoing BD controversies and rebuild public trust. Summary This article critically examines the recent revision of the Uniform Determination of Death Act (UDDA) advanced by Lewis and colleagues. The revision only further reinforces the status quo of brain death without taking into account the root cause of the litigations and controversies about the declaration of death by neurological criteria. In view of this deficiency, this article offers two approaches to revising the UDDA, both of which are founded on sound moral principles.
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Affiliation(s)
- Doyen Nguyen
- St. Mary Seminary and Graduate School of Theology, Wickliffe, OH, USA
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5
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Othman MH, Dutta A, Kondziella D. Public opinion and legislations related to brain death, circulatory death and organ donation. J Neurol Sci 2020; 413:116800. [PMID: 32251871 DOI: 10.1016/j.jns.2020.116800] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/12/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND It is poorly understood how public perception of the difference between brain death and circulatory death may influence attitudes towards organ donation. We investigated the public opinion on brain death versus circulatory death and documented inconsistencies in the legislations of countries with different cultural and socioeconomic backgrounds. METHODS Using a crowdsourcing approach, we randomized 1072 participants from 30 countries to a case report of organ donation after brain death or to one following circulatory death. Further, we sampled guidelines from 24 countries and 5 continents. RESULTS Of all participants, 73% stated they would be willing to donate all organs, while 16% would want to donate some of their organs. To increase the rate of donations, 47% would agree with organ donation without family consent as the default. Exposure to "brain death" was not associated with a lesser likelihood of participants agreeing with organ donation (82.1%) compared to "circulatory death" (81.9%; relative risk 1.02, 95% CI 0.99 to 1.03; p = .11). However, participants exposed to "circulatory death" were more certain that the patient was truly dead (87.9% ± 19.7%) than participants exposed to "brain death" (84.1% ± 22.7%; Cohen's d 0.18; p = 0:004). Sampling of guidelines revealed large differences between countries regarding procedures required to confirm brain death and circulatory death, respectively. CONCLUSIONS Implementation of organ donation after circulatory death is unlikely to negatively influence the willingness to donate organs, but legislation is still brain death-based in most countries. The time seems ripe to increase the rate of circulatory death-based organ donation.
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Affiliation(s)
- Marwan H Othman
- Departments of Neurology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Anirban Dutta
- Department of Biomedical Engineering, University at Buffalo, State University of New York, NY, United States
| | - Daniel Kondziella
- Departments of Neurology, Rigshospitalet, Copenhagen University Hospital, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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6
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Migdady I, Stephens RS, Price C, Geocadin RG, Whitman G, Cho SM. The use of apnea test and brain death determination in patients on extracorporeal membrane oxygenation: A systematic review. J Thorac Cardiovasc Surg 2020; 162:867-877.e1. [PMID: 32312535 DOI: 10.1016/j.jtcvs.2020.03.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To review practices of brain death (BD) determination in patients on extracorporeal membrane oxygenation (ECMO). METHODS A systematic search was applied to PubMed and 6 electronic databases from inception to May 22, 2019. Studies reporting methods of BD assessment in adult patients (>18 years old) while on ECMO were included, after which data regarding BD assessment were extracted. RESULTS Twenty-two studies (n = 177 patients) met the inclusion criteria. Eighty-eight patients (50%) in 19 studies underwent the apnea test (AT); most commonly through decreasing the ECMO sweep flow in 14 studies (n = 42, 48%), followed by providing CO2 through the ventilator in 2 studies (n = 6, 7%), and providing CO2 through the ECMO oxygenator in 1 study (n = 1, 1%). The details of the AT were not reported in 2 studies (n = 39, 44%). In 19 patients (22%), the AT was nonconfirmatory due to hemodynamic instability, hypoxia, insufficient CO2 rise, or unreliability of the AT. A total of 157 ancillary tests were performed, including electroencephalogram (62%), computed tomography angiography (22%), transcranial Doppler ultrasound (6%), cerebral blood flow nuclear study (5%), cerebral angiography (4%), and other (1%). Forty-seven patients (53% of patients with AT) with confirmatory AT still underwent additional ancillary for BD confirmation. Only 21 patients (12% of all patients) were declared brain-dead using confirmatory ATs alone without ancillary testing. CONCLUSIONS Performing AT for patients with ECMO was associated with high failure rate and hemodynamic complications. Our study highlights the variability in practice in regard to the AT and supports the use of ancillary tests to determine BD in patients on ECMO.
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Affiliation(s)
- Ibrahim Migdady
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert Scott Stephens
- Medical Intensive Care, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Carrie Price
- Welch Medical Library, Johns Hopkins University, Baltimore, Md
| | - Romergryko G Geocadin
- Departments of Neurology, Neurological Intensive Care, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Glenn Whitman
- Cardiovascular Surgical Intensive Care, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Sung-Min Cho
- Departments of Neurology, Neurological Intensive Care, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
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Biel S, Durrant J. Controversies in Brain Death Declaration: Legal and Ethical Implications in the ICU. Curr Treat Options Neurol 2020; 22:12. [PMID: 38624320 PMCID: PMC7223748 DOI: 10.1007/s11940-020-0618-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Purpose of review This article provides a brief overview of the history and complexities of brain death determination. We examine a few legal cases that highlight some of the controversies surrounding the validity of brain death tests in light of varying state laws and institutional policy, the appropriateness of making religious accommodations, the dilemma of continuing organ-sustaining support in a pregnant brain-dead patient, and the issue of whether to obtain informed consent from surrogate decision makers before proceeding to testing. Recent findings In response to physician concerns about navigating these complex cases, especially with laws that vary from state to state, the American Academy of Neurology has published a position statement in January of 2019 endorsing brain death as the irreversible loss of all functions of the entire brain. It provides positions on the determination of brain death as well as guidance surrounding requests for accommodation. Summary Although death by neurologic criteria has been accepted as death medically for over 40 years, legal variance exists throughout the states, especially regarding religious accommodations and in pregnancy. Questions of whether to obtain informed consent from surrogate decision makers prior to brain death testing remain, and there is no guideline regarding obtaining ancillary testing. We expect to see continued cases that cause medical, legal, and ethical controversies in our ICUs. As such, uniform training in proper methodology in performing the brain death examination and appropriate use of ancillary testing is crucial, and there is a need for legal consistency in the acceptance of the medical standard.
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Buckingham L, Janssen M, Ray EM, Tucker K, Davidson BA, Arenth J, Lefkowits C, Jones JA, Gehrig P, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Serious Illness in Pregnancy. J Palliat Med 2020; 23:712-718. [PMID: 31928374 DOI: 10.1089/jpm.2019.0651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Palliative care (PC) teams are increasingly being called upon to provide care earlier and more remote from end of life. Because much of the field has grown out of hospice and geriatric care, most teams have little to no experience caring for pregnant women or their fetuses when serious or life-threatening illness strikes. This article, written by a team of oncologists (gynecologic, medical, and radiation) and PC providers, seeks to demystify the care of seriously ill pregnant women and their fetuses by exploring the diagnostic, treatment, prognostication, symptom management, and communication needs of these patients. Truly comprehensive PC extends throughout the life span, from conception to death, regardless of age. Accordingly, increased knowledge of the unique needs of these vulnerable groups will enhance our ability to provide care across this continuum.
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Affiliation(s)
- Lindsey Buckingham
- Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Matthew Janssen
- Division of Maternal Fetal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily M Ray
- Division of Hematology and Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Katherine Tucker
- Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brittany A Davidson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Joshua Arenth
- Divisions of Pediatric Critical Care and Pediatric Palliative Care, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Carolyn Lefkowits
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Division of Palliative Care, Department of Internal Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Joshua A Jones
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paola Gehrig
- Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christopher A Jones
- Department of Medicine and the Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Junn A, Hwang DY. Practice Variability in Determination of Death by Neurologic Criteria for Adult Patients. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2019; 92:719-724. [PMID: 31866786 PMCID: PMC6913831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 2010, the American Academy of Neurology (AAN) published updated official guidelines for specific practices involved in the determination of death by neurologic criteria for adult patients, otherwise known as brain death. Most states, however, do not have laws mandating the standard adoption of the AAN guidelines. The responsibilities for creating and implementing brain death determination policies thus falls on individual hospitals. As a result, significant variability in practice exists between hospitals and even between providers. This review highlights the ways in which and the extent to which adult brain death determination varies across the US, while also making the case that such persistent levels of heterogeneity call for improvements in standardizing training in brain death determination.
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Affiliation(s)
| | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Department of Neurology, Yale School of Medicine, New Haven, CT,To whom all correspondence should be addressed: David Y. Hwang, MD, FAAN, FCCM, FNCS, Associate Professor, Division of Neurocritical Care and Emergency Neurology, Division of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520; Tel: 203-785-7171, Fax: 203-737-4419,
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10
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Darby JM, Shutter LA, Elmer J, Hirzallah M, Khandker N, Molyneaux BJ, Kaynar AM, Nigra KR, Wechsler LR. Reliability of the Telemedicine Examination in the Neurologic Diagnosis of Death. Neurol Clin Pract 2019; 11:13-17. [PMID: 33968467 DOI: 10.1212/cpj.0000000000000798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 11/19/2019] [Indexed: 11/15/2022]
Abstract
Objective To determine whether telemedicine technology can be used to reliably determine the neurologic diagnosis of death (NDD) in patients with catastrophic brain injury (CBI). Methods We included a convenience sample of patients with CBI at a single academic medical center from November 2016 through June 2018. We simultaneously performed brain death evaluation at the bedside and remotely via telemedicine. Remote examiners were neurointensivists who were experienced and knowledgeable in the NDD. In addition to standard clinical examination, we used quantitative pupillometry to evaluate pupil size and reactivity. We determined the proportion of agreement for each NDD examination element and the overall diagnosis of brain death between bedside and remote examiners. Results Twenty-nine patients with mean age 46 ± 18 years underwent 30 paired NDD examinations. Twenty-eight (97%) patients met the NDD criteria and were pronounced dead. One patient did not meet the NDD criteria and died after withdrawal of life support. With the exception of qualitative assessment of pupillary reactivity, we observed excellent agreement (97%-100% across NDD examination elements) between bedside and remote examiners and 97% agreement on the overall diagnosis of brain death. Unlike qualitative pupillary assessment, quantitative pupillometry was consistently interpretable by remote examiners. Conclusions Our results suggest that remote telemedicine technology can be used to verify the findings of bedside examiners performing NDD examinations when a pupillometer is used to assess pupillary reactivity. When performed by neurocritical care experts, the telemedicine NDD examination has potential to facilitate timely and accurate certification of brain death in patients with CBI. Classification of Evidence This study provides Class IV evidence on the concordance of neurologic diagnosis of death by telemedicine and bedside examiners.
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Affiliation(s)
- Joseph M Darby
- Department of Critical Care Medicine (JMD, LAS, JE, MH, NK, BJM, AMK), University of Pittsburgh School of Medicine; Department of Neurology (LAS, JE, BJM, LRW), University of Pittsburgh School of Medicine; Department of Emergency Medicine (JE), University of Pittsburgh School of Medicine; Department of Anesthesiology and Perioperative Medicine (AMK), University of Pittsburgh; and UPMC Presbyterian (KRN), Pittsburgh, PA
| | - Lori A Shutter
- Department of Critical Care Medicine (JMD, LAS, JE, MH, NK, BJM, AMK), University of Pittsburgh School of Medicine; Department of Neurology (LAS, JE, BJM, LRW), University of Pittsburgh School of Medicine; Department of Emergency Medicine (JE), University of Pittsburgh School of Medicine; Department of Anesthesiology and Perioperative Medicine (AMK), University of Pittsburgh; and UPMC Presbyterian (KRN), Pittsburgh, PA
| | - Jonathan Elmer
- Department of Critical Care Medicine (JMD, LAS, JE, MH, NK, BJM, AMK), University of Pittsburgh School of Medicine; Department of Neurology (LAS, JE, BJM, LRW), University of Pittsburgh School of Medicine; Department of Emergency Medicine (JE), University of Pittsburgh School of Medicine; Department of Anesthesiology and Perioperative Medicine (AMK), University of Pittsburgh; and UPMC Presbyterian (KRN), Pittsburgh, PA
| | - Mohammad Hirzallah
- Department of Critical Care Medicine (JMD, LAS, JE, MH, NK, BJM, AMK), University of Pittsburgh School of Medicine; Department of Neurology (LAS, JE, BJM, LRW), University of Pittsburgh School of Medicine; Department of Emergency Medicine (JE), University of Pittsburgh School of Medicine; Department of Anesthesiology and Perioperative Medicine (AMK), University of Pittsburgh; and UPMC Presbyterian (KRN), Pittsburgh, PA
| | - Namir Khandker
- Department of Critical Care Medicine (JMD, LAS, JE, MH, NK, BJM, AMK), University of Pittsburgh School of Medicine; Department of Neurology (LAS, JE, BJM, LRW), University of Pittsburgh School of Medicine; Department of Emergency Medicine (JE), University of Pittsburgh School of Medicine; Department of Anesthesiology and Perioperative Medicine (AMK), University of Pittsburgh; and UPMC Presbyterian (KRN), Pittsburgh, PA
| | - Bradley J Molyneaux
- Department of Critical Care Medicine (JMD, LAS, JE, MH, NK, BJM, AMK), University of Pittsburgh School of Medicine; Department of Neurology (LAS, JE, BJM, LRW), University of Pittsburgh School of Medicine; Department of Emergency Medicine (JE), University of Pittsburgh School of Medicine; Department of Anesthesiology and Perioperative Medicine (AMK), University of Pittsburgh; and UPMC Presbyterian (KRN), Pittsburgh, PA
| | - A Murat Kaynar
- Department of Critical Care Medicine (JMD, LAS, JE, MH, NK, BJM, AMK), University of Pittsburgh School of Medicine; Department of Neurology (LAS, JE, BJM, LRW), University of Pittsburgh School of Medicine; Department of Emergency Medicine (JE), University of Pittsburgh School of Medicine; Department of Anesthesiology and Perioperative Medicine (AMK), University of Pittsburgh; and UPMC Presbyterian (KRN), Pittsburgh, PA
| | - Karen R Nigra
- Department of Critical Care Medicine (JMD, LAS, JE, MH, NK, BJM, AMK), University of Pittsburgh School of Medicine; Department of Neurology (LAS, JE, BJM, LRW), University of Pittsburgh School of Medicine; Department of Emergency Medicine (JE), University of Pittsburgh School of Medicine; Department of Anesthesiology and Perioperative Medicine (AMK), University of Pittsburgh; and UPMC Presbyterian (KRN), Pittsburgh, PA
| | - Lawrence R Wechsler
- Department of Critical Care Medicine (JMD, LAS, JE, MH, NK, BJM, AMK), University of Pittsburgh School of Medicine; Department of Neurology (LAS, JE, BJM, LRW), University of Pittsburgh School of Medicine; Department of Emergency Medicine (JE), University of Pittsburgh School of Medicine; Department of Anesthesiology and Perioperative Medicine (AMK), University of Pittsburgh; and UPMC Presbyterian (KRN), Pittsburgh, PA
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11
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Leemputte M, Paquette E. Consent for Conducting Evaluations to Determine Death by Neurologic Criteria: a Legally Permissible and Ethically Required Approach to Addressing Current Controversies. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00204-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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Girkar UM, Palacios R, Gupta A, Schwamm LH, Singla P, May H, Estrada J, Whitney C, Matiello M. Teleneurology Consultations for Prognostication and Brain Death Diagnosis. Telemed J E Health 2019; 26:482-486. [PMID: 31503539 DOI: 10.1089/tmj.2019.0033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The diagnosis of brain death and the determination of neurologic prognosis following cardiac arrest are important reasons for neurology consultation in the intensive care unit. In hospitals without access to neurology consultation, it may be challenging to address these important questions with high reliability in a timely manner. The American Academy of Neurology has established consensus criteria for diagnosis of brain death, which include (i) comatose state; (ii) presence of apnea; and (iii) absence of brainstem reflexes in the setting of a diagnosis of underlying brain injury compatible with brain death. It has recently been shown that virtual assessment of coma using standardized scales is feasible with good inter-rater reliability. The supervision of apnea testing and the neurologic examination of the brainstem by a remote neurologist are possible if conducted in conjunction with a well-trained and experienced bedside team. In this communication, we explore the essential clinical and legal framework that can support using virtual teleconsultations to address this complex topic.
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Affiliation(s)
- Uma M Girkar
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Boston, Massachusetts
| | - Rafael Palacios
- Institute for Research in Technology, Pontifical Comillas University, Madrid, Spain.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Boston, Massachusetts
| | - Amar Gupta
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Boston, Massachusetts
| | - Lee H Schwamm
- Center for TeleHealth Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Pooja Singla
- SOAR Management Consulting Group, Brookline, Massachusetts
| | - Hanna May
- Computer Science Department, Wellesley College, Wellesley, Massachusetts
| | - Juan Estrada
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cindy Whitney
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Marcelo Matiello
- Harvard Medical School, Harvard University, Boston, Massachusetts.,Neurology Inpatient Services, Massachusetts General Hospital, Boston, Massachusetts
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13
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de Tantillo L, González JM, Ortega J. Organ Donation After Circulatory Death and Before Death: Ethical Questions and Nursing Implications. Policy Polit Nurs Pract 2019; 20:163-173. [PMID: 31407946 DOI: 10.1177/1527154419864717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Scientific advances have enabled thousands of individuals to extend their lives through organ donation. Yet, shortfalls of available organs persist, and individuals in the United States die daily before they receive what might have been lifesaving organs. For years, the legal foundation of organ donation in the United States has been known as the Dead Donor Rule, requiring death to be defined for organ donation purposes by either a cardiac standard (termination of the heartbeat) or a neurological one (cessation of all brain function). In this context, one solution used by an increasing number of health care facilities since 2006 is donation after circulatory death, generally defined as when care is withdrawn from individuals who have known residual brain function. Despite its increased use, donation after circulatory death remains ethically controversial. In addition, some ethicists have advocated forgoing the Dead Donor Rule altogether and allowing donation before or near death in certain circumstances. However, nurses and other health professionals must carefully consider the practical and ethical implications of broadening the Dead Donor Rule-as may be already occurring-or removing it entirely. Such changes could harm both the integrity of the health care system as well as efforts to secure organ donation commitments from the public and are outweighed by the moral and pragmatic cost. Nurses should be prepared to confront the challenge posed by the ongoing scarcity of organs and advocate for ethical alternatives including research on effective care pathways and education regarding organ donation.
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Affiliation(s)
- Lila de Tantillo
- University of Miami School of Nursing and Health Studies, Coral Gables, FL, USA
| | - Juan M González
- University of Miami School of Nursing and Health Studies, Coral Gables, FL, USA
| | - Johis Ortega
- University of Miami School of Nursing and Health Studies, Coral Gables, FL, USA
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14
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Su YY, Chen WB, Liu G, Fan LL, Zhang Y, Ye H, Gao DQ, Liu YF, Jiang MD. An Investigation and Suggestions for the Improvement of Brain Death Determination in China. Chin Med J (Engl) 2019; 131:2910-2914. [PMID: 30539902 PMCID: PMC6302658 DOI: 10.4103/0366-6999.247193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Brain death is the irreversible cessation of the function of the brain including the brainstem. In 2013, the Brain Injury Evaluation Quality Control Centre (BQCC) of the National Health and Family Planning Commission issued criteria and practical guidelines for the determination of brain death. This study aimed to evaluate whether the institutions have adopted these guidelines and to make suggestions for the improvement of the current criteria and practical guidelines for brain death determination in China. Methods: Consecutive brain death cases from 44 hospitals were evaluated for summary statistics for the following data: the performance of BQCC criteria and practical guidelines, clinical examination, apnea testing, ancillary testing, and the number of examinations as well as the waiting periods between examinations and details of who determined brain death. Data analysis was conducted from January 2013 to December 2017. Results: A total of 550 cases were obtained. All patients were determined to have deep coma and met the prerequisites for clinical testing. The performance rates of four brainstem reflex examinations (except cough reflex) ranged from 97.5% to 98.0%, and the completion rate as well as the coincidence rate were both 100.0%. The 238 cases (50.7%) completed apnea testing, and 231 cases (42.0%) had to stop apnea testing during the examination because of instability. The performance rates of the three ancillary tests, including electroencephalogram, short-latency somatosensory evoked potential, and transcranial Doppler, were 89.5%, 67.5%, and 79.5%, respectively; furthermore, the coincidence rates were 98.6%, 96.5%, and 99.5%, respectively. The combination of two ancillary tests was more accurate than one single ancillary test. A total of 401 (72.9%) cases successfully underwent two separate examinations to determine brain death with at least a 12-h waiting period. All brain death cases were determined by at least two qualified physicians. Conclusion: This study might provide suggestions for brain death determination in China.
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Affiliation(s)
- Ying-Ying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Health Commission of the People's Republic of China/Brain Injury Evaluation Quality Control Centre, Beijing 100053, China
| | - Wei-Bi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Health Commission of the People's Republic of China/Brain Injury Evaluation Quality Control Centre, Beijing 100053, China
| | - Gang Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Health Commission of the People's Republic of China/Brain Injury Evaluation Quality Control Centre, Beijing 100053, China
| | - Lin-Lin Fan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Health Commission of the People's Republic of China/Brain Injury Evaluation Quality Control Centre, Beijing 100053, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Health Commission of the People's Republic of China/Brain Injury Evaluation Quality Control Centre, Beijing 100053, China
| | - Hong Ye
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Health Commission of the People's Republic of China/Brain Injury Evaluation Quality Control Centre, Beijing 100053, China
| | - Dai-Quan Gao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Health Commission of the People's Republic of China/Brain Injury Evaluation Quality Control Centre, Beijing 100053, China
| | - Yi-Fei Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Health Commission of the People's Republic of China/Brain Injury Evaluation Quality Control Centre, Beijing 100053, China
| | - Meng-Di Jiang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Health Commission of the People's Republic of China/Brain Injury Evaluation Quality Control Centre, Beijing 100053, China
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15
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Guzik-Makaruk EM, Olesiuk-Okomska M, Matuszkiewicz-Rowińska J, Małyszko J. Selected Legal Aspects of Donation After Circulatory Death in Poland. Ann Transplant 2019; 24:93-99. [PMID: 30773527 PMCID: PMC6394144 DOI: 10.12659/aot.912567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Organ transplantation is one of the most critical ethical topics in law and medicine and a matter of debate in various countries. Lack of organs for engraftment to meet the existing demand has resulted in a substantial crisis due to organ shortage and a rise in the critical conditions of certain waitlisted patients, as well as increased mortality of patients while waiting. Organ shortages for transplantation raised the issue of procurement of organs not only from living donors and cadaveric donors after brain death, but also after circulatory death. Renewed interest in donation after circulatory death started in the 1990s, and has been on the rise in recent years, reaching up 40% of donation in some countries. Both legislation on and practice of donation after circulatory death differ significantly throughout the world. Lack of unified guidelines and regulations have challenged the medical, ethical, legal, and transplant communities. Moreover, studies on legal aspects of donation after circulatory death are still lacking. In this review, we present selected legal issues in regulation of donation after circulatory death, and we address the most important legal challenges in this regard with particular attention to category III of donors after circulatory death.
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Affiliation(s)
- Ewa M Guzik-Makaruk
- Department of Criminal Law and Criminology, Faculty of Law, University of Białystok, Białystok, Poland
| | - Magda Olesiuk-Okomska
- Department of Criminal Law and Criminology, Faculty of Law, University of Białystok, Białystok, Poland
| | | | - Jolanta Małyszko
- Department Nephrology, Dialysis, and Internal Diseases, Warsaw Medical University, Warsaw, Poland
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Moschella M. Brain Death and Human Organismal Integration: A Symposium on the Definition of Death. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2016; 41:229-36. [PMID: 27107428 DOI: 10.1093/jmp/jhw007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Does the ability of some brain dead bodies to maintain homeostasis with the help of artificial life support actually imply that those bodies are living human organisms? Or might it be possible that a brain dead body on life support is a mere collection of still-living cells, organs and tissues which can coordinate with one another, but which lack the genuine integration that is the hallmark of a unified human organism as a whole? To foster further study of these difficult and timely questions, a Symposium on the Definition of Death was held at The Catholic University of America in June 2014. The Symposium brought together scholars from a variety of disciplines-law, medicine, biology, philosophy and theology-who all share a commitment to the dead donor rule and to a biological definition of death, but who have differing opinions regarding the validity of neurological criteria for human death. The papers found in this special issue are among the fruits of this Symposium.
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Moschella M, Condic ML. Symposium on the Definition of Death: Summary Statement. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2016; 41:351-61. [PMID: 27102243 DOI: 10.1093/jmp/jhw009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This statement summarizes the conclusions of the Symposium on the Definition of Death, held at The Catholic University of America in June 2014. After providing the background and context for contemporary debates about brain death and describing the aims of the symposium, the statement notes points of unanimous and broad agreement among the participants, and highlights areas for further study.
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Affiliation(s)
- Melissa Moschella
- The Catholic University of America, Washington, DC, USA University of Utah, Salt Lake City, Utah, USA
| | - Maureen L Condic
- The Catholic University of America, Washington, DC, USA University of Utah, Salt Lake City, Utah, USA
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