Ethical controversies at end of life after traumatic brain injury: Defining death and organ donation

Abstract

Death is more than a mere biological occurrence. It has important legal, medical, and social ramifications that make it imperative that those who are responsible for determination of death be accurate and above suspicion. The medical and legal definitions of death have evolved to include consideration of such concepts as loss of integration of the whole organism, loss of autonomy, and loss of personhood. Development of the concept of brain death coincided with advances in medical technology that facilitated artificial ventilation and organ transplantation. More recently, the process of "timed" death with subsequent organ donation (controlled donation after cardiac death transplantation) has raised controversial questions having to do with the limits of treatments that facilitate organ transplant but might hasten death, and the duration of cardiac arrest necessary for declaration of death and the commencement of organ procurement. In this review, we discuss the background and ethical ramifications of the concepts of brain death, and of controversies involved in controlled donation after cardiac death organ transplantation.

External validation of prediction models for time to death in potential donors after circulatory death

“…A potential cDCD donor poses considerable challenges in terms of: (a) identification of those dying within a predefined timeframe after WLST, (b) dealing with family expectations when the donor does not die within the timeframe for donation, and (c) efficient utilization of the organ procurement teams. 4 For organ procurement to occur in a cDCD setting, a maximum time is set in which circulatory death must occur following WLST. In the Netherlands, this timeframe varies according to the donated organ between 20-120 minutes, as each organ has different warm ischemia time thresholds.…”

“…A potential cDCD donor poses considerable challenges in terms of: (a) identification of those dying within a predefined timeframe after WLST, (b) dealing with family expectations when the donor does not die within the timeframe for donation, and (c) efficient utilization of the organ procurement teams 4. …”

Delayed Graft Function in the Kidney Transplant

“…Anticoagulation is routinely used during organ recovery from donors diagnosed with brain death; whereas the same treatment remains ethically controversial for DCD donors because anticoagulation does not relieve suffering but may hasten death if the patient is at risk of hemorrhage (39). Macroscopic thrombosis at time of procurement is a rare event.…”

Brain death: time for an international consensus

“…7 Although the determination of death by neurological criteria meets with widespread public and professional acceptance, the relationship between death of the brain and the death of the individual continues to be misunderstood. 8 Notwithstanding the legal and societal importance of identifying the actual moment of a person's death, death is not a single event but a process that leads progressively to the failure of all functions that constitute the life of the human organism.…”

“…However, the concept that death is a process, but one that can nevertheless be determined at a particular moment in time, is not widely appreciated and this leads to misunderstanding by both the public and professionals. 8 Reports of brain-dead patients being 'kept alive on a ventilator' are familiar. There have also always been individuals and whole societies that do not accept under any circumstances that brain death equates to the death of the individual.…”