Controversies in defining and determining death in critical care

Abstract

Circulatory-respiratory or brain tests are widely accepted for definition and determination of death, but have several controversial issues. Both determinations have been stimulated by organ donation, but must be valid independently of this process. Current controversies in brain death include whether the definition is conceptually coherent, whether the whole-brain or brainstem criterion is correct, whether one neurological examination or two should be required, and when to conduct the examination following therapeutic hypothermia. Controversies about the circulatory determination of death include the minimum duration of asystole that is sufficient for death to be declared, and whether the distinction between permanent and irreversible cessation of circulatory functioning is important. In addition, the goal of organ donation raises issues such as the optimal way to time and conduct the request conversation with family members of the patient, and whether the Dead Donor Rule should be abandoned.

How Should Physicians Manage Organ Donation after the Circulatory Determination of Death in Patients with Extremely Poor Neurological Prognosis?

“…Permissible interventions vary among DCDD programs and remain a controversial subject with wide practice variations. 2,17 Proponents of allowing donor interventions for the health of the organ argue that the donor will die anyway and therefore cannot be harmed significantly and that, furthermore, premortem treatment with catheters, drugs, and fluids might improve donor organ health and therefore the chances of normal functioning of the organ once transplanted. 18 Advocates further claim that because the organ donor wishes to donate and these techniques will lead to more successful transplantation, their use is thereby following the donor's wishes.…”

“…8 Some scholars believe that valid donor or surrogate informed consent for premortem interventions adequately resolves the issue of harm from donor manipulation, but others disagree. 17 In any event, it is incumbent on physicians following DCDD protocols to fully explain to surrogates what, if any, premortem and postmortem interventions are planned and to seek surrogates' informed consent.…”

An interdisciplinary response to contemporary concerns about brain death determination

“…Determination of death is based on loss of clinical function of the heart and lungs or the brain, and the demise of every neuron or myocardial cell is not required. 16,17 The attendees further agreed that the 2010 AAN practice guideline is the contemporary paragon for brain death determination, as there have been no documented cases of recovery of neurologic function after determination of brain death provided the parameter is appropriately followed. 11 The parameter is intentionally conservative and appropriately prioritizes specificity to avoid false-positive determinations.…”

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“…Currently, the complete and irreversible failure of the functioning of the central nervous system is the definition of brain death. [1][2][3] This is a concept that is recognized by the scientific community and by law in most countries. 4 The definition and acceptance of this concept are key events in the donation and transplant process, given that most organ donors are people who have died and are in a state of brain death.…”