Defining Death. Defining Death. Defining Death. Death at 50 & Organ Donation ORGAN TRANSPLANTATION. Dying (obvious) Death (not so obvious)

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1 Page 2 Page 4 Page 2 Page 4 Page 3 Page 5 Page 3 Page 5 Death at 50 & Organ Donation Dr. Mark Twite MA MB BChir FRCP Director of Congenital Cardiac Anesthesiology Associate Professor Department of Anesthesiology University of Colorado, Anschutz Medical Campus & Children s Hospital Colorado No Relevant Financial Disclosures 0 1 Defining Death Defining Death Severe neurological injury even when biological functions remain intact? Dying (obvious) Death (not so obvious) Dead (obvious) Biological failure of the organism to maintain integrated functioning? Loss of higher brain function? Social and cultural construct that can be defined in different ways? 2 3 Defining Death Until the 1950s death defined in terms of failure of 3 critical organ systems: 1. Circulatory 2. Respiratory Mechanical Ventilation 3. Neurological ORGAN TRANSPLANTATION 4 5

2 Page 6 Page 8 Page 10 Page 6 Page 8 Page 10 Page 7 Page 9 Page 11 Page 7 Page 9 Page First Kidney Transplant, Chicago USA Organ Transplantation 1. Supply of Organs Demand 2. Optimize the organ(s) for the recipient AND Protect the donor and their family, to facilitate the gift of organ donation 6 7 Supply Demand: Global Organ Transplants Supply Demand: USA Organ Transplants 120,000 organ transplants per year Only resolves 10% of the annual worldwide transplant need 35,000 organ transplants per year 120,000 people on the waitlist 8 9 Two Pathways to Organ Donation Is the Patient Dead? Donation after Brain Death (DBD) Pathway Donation after circulatory death (DCD) Pathway Irreversible loss of all brain function Irreversible loss of circulatory function Organs removed without ischemic injury Organs removed 2-5 minutes after cardiac arrest 10 11

3 Page 12 Page 14 Page 16 Page 12 Page 14 Page 16 Page 13 Page 15 Page 17 Page 13 Page 15 Page 17 Diagnosis of Brain Death 1. Confirm unconsciousness 2. Loss of vital brainstem functions 3. Rule out any reversible causes Permanent apneic unconsciousness Low Body Temperature Metabolic disturbances Exclude Reversible Drugs Causes Motor Reflex Brain Death Apnea Exam Lack of brain activity Lack of brain blood flow Confirm Wait Repeat 6hrs in adults 12hrs in children 24hrs in neonates Second physician Does Brain Death = Dead? Patients look alive, warm & pink Digest & metabolize food Excrete waste Undergo sexual maturation The Jahi McMath case Two Pathways to Organ Donation Is the Patient Dead? Donation after Brain Death (DBD) Pathway Donation after circulatory death (DCD) Pathway Irreversible loss of all brain function Irreversible loss of circulatory function Organs removed without ischemic injury Organs removed 2-5 minutes after cardiac arrest Ischemia for donor organs Worlds First Human to Human Heart Transplant December 3 rd 1967 Louis Washkansky DBD DCD Jonathan van Wyk Frontiers Cardiovasc Med

4 Page 18 Page 20 Page 22 Page 18 xxx00.#####.ppt 2/10/ :08:09 AM Page 20 xxx00.#####.ppt 2/10/ :08:09 AM Page 22 Suite 555, 2000 K Street, NW., Washington, DC (202) Page 19 Page 21 Page 23 Page 19 xxx00.#####.ppt 2/10/ :08:09 AM Page 21 Page 23 Death at 50yrs Harvard Report on Brain Death The Uniform Determination of Death Act 1981 President s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research July 9, 1981 The Honorable Thomas P. O'Neill, Jr. Speaker U.S. House of Representatives Washington, D.C Dear Mr. Speaker: On behalf of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, I am pleased to transmit our report concerning the "definition" of death. This is one of several subjects which Public Law directs the Commission to study and regarding which we are to report to the President, the Congress and the relevant Departments of government. We have concluded that, in light of the ever increasing powers of biomedical science and practice, a statute is needed to provide a clear and socially-accepted basis for making determinations of death. We recommend the adoption of such a statute by the Congress for areas coming under federal jurisdiction and by all states as a means of achieving uniform law on this subject throughout the Nation. We are grateful for the opportunity to assist in resolving this issue of public concern and importance. Respectfully, Uniform Determination of Death Act Legal definitions of death: Irreversible cessation of brain function and/or Irreversible cessation of cardiac and respiratory function Morris B. Abram Chairman Two Pathways to Organ Donation Is the Patient Dead? Dead Donor Rule Donation after Brain Death (DBD) Pathway Donation after circulatory death (DCD) Pathway Reflects the widely held belief that it is wrong to kill one person to save the life of another Irreversible loss of all brain function Organs removed without ischemic injury Irreversible loss of circulatory function Organs removed 2-5 minutes after cardiac arrest An organ donor must be dead before vital organs are removed 22 23

5 Page 24 Page 26 Page 28 Page 24 Page 26 Page 28 Page 25 Page 27 Page 29 Page 25 Page 27 Page 29 Donation after Cardiocirculatory Death Devastating neurological injury but do not meet strict brain death criteria Mechanical ventilation is withdrawn Heart stops Death declared How long should we wait? } Organs removed 2 5 Minutes Heart Stops now what? Taphophobia Dr. Eugene Bouchut Dr. Rene Laennec Death of George Washington, December 1799 How long should we wait? After the first donation, the ethics committee recommended a period of observation of 75 seconds to reduce the risk of injury from warm ischemia. This recommendation was based on the longest reported period before autoresuscitation of a child or adult, 60 seconds Dr. Mark Boucek 2008 NEJM 2008; 359:

6 Page 30 Page 32 Page 34 Page 30 Page 32 Page 34 Page 31 Page 33 Page 35 Page 31 Page 33 Page 35 Heart stops now what? 1997 Institute of Medicine (IOM) suggested that 5 minutes should elapse between cardiocirculatory death and organ retrieval 2000 IOM suggested that empirical data indicates that cardiopulmonary arrest becomes irreversible in a shorter time interval less than 60 seconds Society for Critical Care Medicine recommends waiting 2-5 minutes Lazarus Phenomenon Vincent Van Gogh The resurrection of Lazarus Lazarus first tomb in Bethany his second tomb was in Cyprus What happens if the heart doesn t stop? Heart donation: circulatory death must occur < 30 minutes of extubating patient Other organ donations: circulatory death must occur < 1 hour of extubating patient After these time periods, the patient is taken back to the ICU for further comfort care and is no longer eligible to donate their organs Future State DBD DCD DCD

7 Take Home Messages. Future State? 1. Death is difficult to define 3-D Printing organs 2. DCD offers another pathway to organ donation which a. Helps fulfill the wishes of the patient / family to be a donor Growing organs in the lab b. Increases the number of available organs Gene editing animals 3. The primary team, usually the intensivist, should care for the patient during the dying and death process. Page 36 Page Page 37 Page If one subject in health law and bioethics can be said to be at once well settled and persistently unresolved, it is how to determine that death has occurred. Alexander M. Capron, LL.B., Executive Director, President's Commission 1981 New England Journal of Medicine (2001) 344:1244. Page 38 Page Thank you Thank you Mark.Twite@childrenscolorado.org Page 40 Page Page 39 Page 39