Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR

Ventilator withdrawal in case of DBD refusal

Francesco Procaccio

ISS – CNT - Rome

Neuro Intensive Care Unit

University City Hospital, Verona - Italy

F Procaccio 2012

ICU Admission Vegetative

StormBrain DeathDeclaration

OrganRetrieval

1 2 3 4

Treatment of the patient

Timing in Death declaration

BDcriteria observation

Flow chart for decisions regarding patients with devastating neurological injuries

Patients with devastating neurologic injury or illness

Weigh the pros and cons of various treatment options with next of kin, considering:

- likelihood of success of treatment options- likely long-term prognosis

- patient’s known previously expressed wishes

Continued aggressive care “try your best”

Comfort careWithdrawal of life support

Terminal extubationNon-escalation of therapy

Deteriorates to brain death

Condition stabilizes and survives

Dies in ICU or GW

Potential donor after circulatory death

Potential brain dead organ donor

Improves and regains cognition

Survives in PVS

End-of-life in ICU

DCD DBD

Death in ICUNew clinical scenarios:Death under ECMO • Artificial circulation• (before or after death)

Withdrawal of ventilator

• Before death • In BD without declaration• After BD declaration• Never

Aims of death declarationby neurological criteria

1) Clinical and legal definition that the patient is dead

2) Ethical aim3) Avoid treatment of cadavers4) Organ donation

April 1975

American BAR Association

After brain death declaration

• Legal time of death must be clear

• Time of death should not depend on organ retrieval or not

• Any treatment after death is inappropriate

• Practice should be uniform as possible

ICU Admission Vegetative

StormBrain DeathDeclaration

1 2 3

Treatment of the patient

Timing in Death declaration

BDcriteria observation ?

Family opposition To organ donation

Ventilator withdrawal after BD

• Physicians doubts• Unawareness of clear principles and rules

• Family opposition• External (social – religious) objections

After BD declaration in non donors

In Spain: withdrawal of all support ventilation included75% only vasoactive drugs 8%

progressive decrease of support9% all maintained 1% unknown 7%

ONT & D Escudero & B Dominguez-Gil, 2012 personal communication

In adults who have experienced irreversible cessation of the

functions of the entire brain……the heart usually stops beating

within two to ten days.

USA - The President’s Commission ,1981

Longest duration of successful maternal somatic support

following BD :more than 100 days

13

In Oakland, a family refused to accept JM’s death and went to court to prevent ventilator withdrawal

In Texas MM body was maintained on MV for 8 weeks after BD in an attempt to «rescue» her fetus without family consent.

These actions are for the family,not the patient

BMJ 2000

Continued treatment may offend the dignity of the individual, By using him or her as a means to achieve the ends of others.

It is a medical and social nonsense

BMJ, 6 May 2000

In Poland BD declaration

is not obligatory if the donation is not expected.

Social confidence in BD diagnosis and family trust in the dead donor rule

would take advantage from BD declaration in all the subjects who fulfill BD criteria

This medical practice could support the fundamental idea that

all the citizens must be equal in death, that is not different

in potential donors from other patients.

Thuong, Procaccio et al. VI Ed. COI Guide, in preparation

F Procaccio in M Thuong et al. COE Guide VI Ed., in preparation

Brain Death Algorithm

ICU Admission Vegetative

StormBrain DeathDeclaration

1 2 3 4Treatment of the

patient

Patient recovery

Timing in Death declaration

BDcriteria observation

ImmediateStop

ventilation

Death20

Family opposition To organ donation

The neurological determination of death has ensured the utmost respect for

the dignity of death for patients and their relatives

in the secure knowledge that there is no possible chance of recovery.

At the same time in some cases it has allowed the donation of organs as one of the finest

gestures for the benefit of humankind.

Organs, Tissues & Cells, (13), 179-189, 2010

Suggestions

1. Clear National (supra-national) principles (rules)

2. ICU personnel ad hoc education

3. Ad hoc procedures and transparency

4. Family understanding and support

5. Communication & conflict solving skills