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McGill University Health Centre, Montreal Children’s Hospital, MUHC Research Institute

Division of Critical Care

McGill UniversityProfessor of Pediatrics

Canadian Blood ServicesMedical Director, Deceased Donation

Brain DeathMedical Pro (vs Con)

Sam D. Shemie

Critical Care Canada ForumToronto Nov 7th 2018

Disclosures & Influences

1. Full time pediatric med/surg/cardiac ICU physician

2. ECMO specialist & former ECMO team medical director

3. Trauma team leader

4. Research and health policy program in organ replacement during critical illness, deceased organ donation and death determination

5. Medical advisor for deceased donation at Canadian Blood Services, a non-profit, government funded organization to help coordinate the donation & transplant system in Canada

6. No industry funding

7. No transplant funding

Death: Heart or Brain?

Summary1. Fascinating & challenging advances in technology & in

the ability to support & replace organ failure.

2. Brain death was discovered, not invented.

3. 2 concepts of ‘heart’ & ‘brain’ death are no longer relevant

4. It is inevitable that all death will become brain-based.

8. Canadian Association of Transplantation9. Canadian Society of Transplantation10. Quebec Transplant11. Trillium Gift of Life Network12. Alberta HOPE Programs13. Newfoundland OPEN Program14. Transplant Atlantic15. New Brunswick Transplant 16. Canadian Council for Donation and

Transplantation.

Endorsed by 16 Organization in Canada:1. Canadian Critical Care Society2. Canadian Neurological Society3. Canadian Neurosurgical Society 4. Canadian Neurocritical Care Group5. Conference of Chief Coroners and Medical

Examiners of Canada6. Canadian Association of Critical Care Nurses7. Canadian Association of Emergency

Physicians

Can J Anes 2006

Major differences diagnostic procedures:• apnea testing• observation time• age related criteria• required expertise of physicians• provisions for anoxic BD• confirmatory lab tests• legal standards & time of death

1. Clear medical standards for NDD & defining qualifications of physicians augment quality & rigour of the determination.

2. Protect dying patients and minimize risk of diagnostic error

Bank Vault Cranial Vault

Intelligent Design or Evolution

86 Billion Neurons & 100 Trillion Interconnections

Human Connectome ProjectGE Healthcare

• Senses - vision, smell, touch, pain, hearing• Movement - voluntary, purposeful, involuntary brain mediated• Autonomic functions- breathing, airway control, brainstem reflexes• Consciousness

- awake, thinking, feeling, doing, reacting, planning, memory• Need driven commercial exchange with environment

- sensory, energy/nutrition, O2/CO2

NY Times

No Brain Function Some Brain Function

Brain Death: Refractory Intracranial PressureDownward Herniation of Brainstem

No blood flow, no function

How Can Someone Be Dead?With a heartbeat, pulse, lungs moving, skin warm, growth, strange

movements?Able sustain a fetus & give life to a baby???

“Dead”

“Cadaver”

“Corpse”

“Irreversible Apneic Coma”

“Loss of capacity for consciousness”

“As good as dead”

“Death by Neurological Criteria”“Brain Death”

“Integration/disintegration”

“Whole Brain”

“Deceased”

“Passing away”

“Deep unresponsive coma”

“Heart beating death” “Cessation of brain function”

“Menstruating Resurrected Corpse”Alan Shewmon, Harvard Brain Death, April 2018

The Difference Between Life and DeathOxygen & Nutrient Delivery

Monolayer cell culture Mitochondria

Human Cellular Respiration Consumes Oxygen

To Create Energy Required for Cell Life

Monolayer cell culture

37 Trillion Cells(Smithsonian)

Biology of Life = Oxygen & Nutrient DeliveryOxygenated Circulation

Organs as Functioning PartsBrian drives the lung to bring in O2

Lungs load O2Red blood cells carry O2

Heart circulatesLiver metabolizes, Kidney filters

86 Billion Neurons & 100 Trillion Interconnections

Biology of Life = Oxygen & Nutrient Delivery

If oxygenated circulation stopsto the body or an individual organ, and does not resume within a finite periodthe body/organ will never function again.

Two Concepts of Death1. Heart and circulation stops2. Brain stops

Shemie, Gardiner Frontiers CV Medicine, 2018

All Death Occurs This WaySaving Life Interrupts this Process

What is the purpose of Critical Care?

Resuscitation of heart & lung is notthe purpose, it’s the method.

The purpose is to resuscitate the brain.

Inference = resuscitate heart & lung?

Living patients 1. Intrinsic cardiopulmonary support• mechanical ventilation, hemodynamic support, cardiac compressions

2. Extrinsic extracorporeal support • ventricular assist devices, ECMO

Dead people1. Intrinsic cardiopulmonary support • somatic support after brain death• mechanical ventilation/cardiac compressions in uDCD

2. Extrinsic extracorporeal support • normothermic regional perfusion=donor ECMO

Individual organs • ex-vivo organ support

Options for Oxygenated Circulation

Shemie, Gardiner FCVM 2018

Via Ivan Ortega Deballon, with thanks

O2 Circulation: Intrinsic Cardiopulmonary SupportMechanical Ventilation, Cardiac Compressions

ECMO/Extracorporeal Oxygenated CirculationOutside the Body, but into the Patient

PICU Montreal Children’s Hospital, McGill UniversityECMO

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Artificial Heart Artificial KidneyArtificial Lung

Is not death if you have a machineto provide oxygenated circulation.

Complete and Irreversible Arrest of Heart Function

PICU, Montreal Children’s Hospital, McGill University

Oxygenated Circulation

Reviving Organs Outside the Body

Toronto Ex Vivo Lung Program

Keshavjee, Cypel with thanks

Edmonton Ex-situ Cardiac Program

D Freed with thanks

NRP/Normothermic Regional Perfusion after DeathReviving Organs Inside the Body

= Donor ECMO after deathReperfusion of abdomen +/- chest/heart

Oxygenated Circulation to the BrainNo blood flow, no function

No Brain Function But……

As long as oxygen & nutrients are delivered artificially

the body, organs, intestines, & spinal cord still work.

Growth occurs, & a mother’s body can support a fetus.

Thought Experiment

1.Intubate and ventilate

2.Control bleeding

3.Somatic support in ICU

Monolayer cell culture

The Ability to Sustain the Function of Cells,

Individual Organs or a Body

1.Brain death is the unintended consequence of

the attempt to save life

2.It is the final expression of irreversible

cessation of brain function

3.We are our brains- when our brain is no

longer, we are no longer

4.It extinguishes personhood

5.The person has died, but not the body parts

Summary1. Fascinating & challenging advances in technology & in

the ability to support & replace organ failure.

2. Brain death was discovered, not invented.

3. 2 concepts of‘heart’ & ‘brain’ death are no longer

relevant

4. It is inevitable that all death will become brain-based.

Register todaycampus.blood.ca

This curriculum is an accredited learning activity

(Sections 1 and 3) as defined by the

Maintenance of Certification program of

The Royal College of Physicians and Surgeons

of Canada.

The Canadian Clinical Guide to Organ Donation is

a free self-directed, interactive, online

e-learning course featuring case scenarios.

First module available

Neurological Determination of

Death (NDD)

Canadian Clinical Guide to Organ Donation

END

https://www.youtube.com/watch?v=KDqh-r8TQgs