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Death at 50&
Organ DonationDr. 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
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Defining Death
Dying
(obvious)
Death
(not so obvious)
Dead
(obvious)
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Defining Death
• Severe neurological injury even when biological functions remain intact?
• 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?
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Defining Death
Until the 1950s death defined in terms of failure of 3 critical organ systems:
1. Circulatory
2. Respiratory
3. Neurological
Mechanical Ventilation
ORGAN TRANSPLANTATION
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1950 First Kidney Transplant, Chicago USA
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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
Organ Transplantation
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Supply ≠ Demand: Global Organ Transplants
120,000 organ transplants per year
120,000 organ transplants per year
Only resolves 10% of the annual
worldwide transplant need
Only resolves 10% of the annual
worldwide transplant need
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Supply ≠ Demand: USA Organ Transplants
35,000 organ transplants per year
35,000 organ transplants per year
120,000 people on the waitlist
120,000 people on the waitlist
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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
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Diagnosis of Brain DeathExclude
Reversible Causes
• Low Body Temperature• Metabolic disturbances• Drugs
Brain Death Exam
• Motor• Reflex• Apnea
Confirm
• Lack of brain activity• Lack of brain blood flow
Wait
• 6hrs in adults• 12hrs in children• 24hrs in neonates
Repeat
• Second physician
1. Confirm unconsciousness
2. Loss of vital brainstem functions
3. Rule out any reversible causes
‘Permanent apneic unconsciousness’
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• Patients look alive, warm & pink
• Digest & metabolize food
• Excrete waste
• Undergo sexual maturation
Does Brain Death = Dead?
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The Jahi McMath case
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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
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Ischemia for donor organs
Frontiers Cardiovasc Med 2018
DCD
DBD
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Worlds First Human to Human Heart Transplant December 3rd 1967
Jonathan van Wyk
Louis Washkansky
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Death at 50yrs
Harvard Report on Brain Death
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The Uniform Determination of Death Act 1981
President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research Suite 555, 2000 K Street, NW., Washington, DC 20006 (202) 653-8051
July 9, 1981
The Honorable Thomas P. O'Neill, Jr. Speaker U.S. House of Representatives Washington, D.C. 20515
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 95-622 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,
Morris B. Abram Chairman
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Uniform Determination of Death Act
Legal definitions of death:
Irreversible cessation of brain function
and/or
Irreversible cessation of cardiac and respiratory function
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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
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Reflects the widely held belief that it is wrong to kill one person to save the life of another
An organ donor must be dead before vital organs are removed
Dead Donor Rule
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• Devastating neurological injury but do not meet strict brain death criteria
• Mechanical ventilation is withdrawn
• Heart stops
• Death declared
• Organs removed
Donation after Cardiocirculatory Death
} How long should we wait?
2– 5 Minutes
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Dr. Eugene Bouchut
Heart Stops – now what?
Dr. Rene Laennec
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Taphophobia
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Death of George Washington, December 1799
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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: 709-14
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• 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
Heart stops – now what?
Lazarus Phenomenon
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Vincent Van Gogh The resurrection of Lazarus Lazarus’ first tomb in Bethany – his second tomb was in Cyprus
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• 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
What happens if the heart doesn’t stop?
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Future State
DBD
DCD
DCD +
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• 3-D Printing organs
• Growing organs in the lab
• Gene editing animals
Future State?
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1. Death is difficult to define
2. DCD offers another pathway to organ donation which
a. Helps fulfill the wishes of the patient / family to be a donor
b. Increases the number of available organs
3. The primary team, usually the intensivist, should care for the patient during the dying and death process.
Take Home Messages……….
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“If one subject in health law and bioethicscan 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.
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Thank youThank you
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