Jason ShahinMD Msc FRCPCAssistant ProfessorMcGill UniversityDepartment of Critical Care

DCD overview

Risk factors that predict time to death

Prediction models that predict time to death

Future research

•1st cadaveric transplants•Poor outcomes

•Concept of brain death emerges

•Legislation adopted approving neurologicaldefinition of death

•Field of transplantation is opened up

•Due to success organ need outstrips supply

•DCD re-examined

Criteria used to determine death

Time period required to confirm “irreversible death”

Autoresuscitation

Ethical considerations “violation of the dead donor rule”

Time to death prediction- warm ischemia

60-120

minutes

Withdrawal of life

support therapy

Are there risk factors and or models/clinical

decision rules that exist that can accurately

predict the time it will take a patient to die

after withdrawal of life sustaining therapy ?

Systematic review of the literature

1. Jason Shahin

2. Laveena Munshi

Intensive Care Med (2015) 41:1014

what are the risk factors/ risk prediction models/clinical decision tools that are associated with and/or predict time to death.

1. In general ICU patients who undergoes withdrawal of life support therapy

2. In potential organ donor who undergoes withdrawal of life support therapy

Participants Study type Outcome

Pediatric and adults RCT Time to death from WLST

Withdrawal of life sustaining therapy

(mechanical ventilation and or hemodynamic

support)

Observational studies

WLST occuring in a critical care unit

Single centre or multicentre

No case series

Most variables focus on pre withdrawal physiology and

clinical signs (neuro, cardiac, resp, treatment plan)

Most widely used models (University of Wisconsin)

developed using small sample sizes and require a ventilator

cessation trial

Other models exist but have not been externally validated

Physician assessment may be as good as any model??

www.ddepict.com

Sonny Dhanani Principal investigator- Critical Care, Children’s Hospital of Eastern Ontario,

University of Ottawa-Principal investigator

Laura Hornby Clinical Research Project Manager, Montreal Children’s

Hospital Research Institute

Katherine Smith Central coordinator, Loeb Research Chair in organ and tissue donation,

University of Ottawa

Sam Shemie Senior investigator-Critical Care, Montreal Children's Hospital, Chair Loeb

Research Consortium, Faculty of Arts, Univ. of Ottawa

Jason Shahin Lead investigator for complimentary study-time to death prediction tool-

Critical Care, McGill University Health Centre

www.ddepict.com

DePPaRT

Collaborators/Co-investigatorsCANADA

Andrew Baker

Stephen Beed

Jane Chamber-Evans

Jennifer Chandler

Chip Doig

Peter Dodek

Rob Fowler

Jan Friedrich

Teneille Gofton

Vanessa Gruben

AnneMarie Guerguerian

Christophe Herry

George Isac

Greg Knoll

Jim Kutsogiannis

Lauralyn McIntyre

Maureen Meade

Laveena Munshi

Tim Ramsay

Steven Reynolds

Damon Scales

Jason Shahin

Andrew Seely

Janet Squires

Alexis Turgeon

Bryan Young

US

Tom Nakagawa

Paul Shore

UK

Christian Brailsford

Dale Gardiner

OTHER

Frantisek Duska

TRAINEES

Alvin Li

Loretta Norton

Amanda van Beinum

TEAM

Laura Hornby

Katherine Smith

Nathan Scales

Criteria used to determine death

Time period required to confirm “irreversible death”

Autoresuscitation

Ethical considerations “violation of the dead donor rule”

Time to death prediction- warm ischemia

Resource use

www.ddepict.com

DePPaRTstudy

Complimentary study 1

Time to death prediction study

Complimentary study 2

Surrogate decision making in DCD

Primary Objective To determine the

incidence of autoresuscitation in critically ill adults and children who die in the ICU, following WLST

DePPaRT study

Complimentary study 1

Time to death prediction study

Complimentary

study 2

Surrogate decision making in DCD

Primary Objective-Complementary study To develop a new

reliable tool to predict time to death following WLST in critically ill adults eligible for DCD

DePPaRT study

Complimentary study 1

Time to death prediction study

WLST death declaration study end

consented

Waveform review

30 mins

Inclusion criteria

Patients who have a WLST in an ICU

Age > 1 month

Subjects will have a minimum of the following bedside monitors in place:

▪ Pulse oximeter

▪ 3-lead ECG

▪ Arterial line for B/P

▪ EEG- (a few centres)

Exclusion criteria Declared dead by NDD criteria

Functioning pacemaker

1. GROUP 1: DCD patients

2. GROUP 2: “DCD Eligible” patients

3. GROUP 3: “DCD non-Eligible” General ICU patients

At least 300

Up to 200

DATA COLLECTION

Demographic Comorbidities Physiological Imaging (Ct head) Analgesia and sedatives Withdrawal process Intensivist opinion Time to death

ANALYSIS

Multivariable logistic regression analysis

Parsimonious model building

Step 1-Systematic review, expert opinion

Step 2-Prospective data collection

Step 3Model development

Step 4Model

validation

Specific, high threshold

Sensitive, low threshold

Improved tool with best prediction

Validation studies

Utility and practical use of tool

Do clinicians like or believe it

Cost savings and resource utilization

Barrier to DCD includes uncertainty about time to death after WLST

Existing data has contributed to understanding of important variables- brain, heart , lungs, treatment related variables

Prediction tools may be insufficient

Future research on death determination being carried out at a hospital near you