Diagnosis of Death Masterclass

1. Diagnosis of Death Masterclass Alex Manara Dale Gardiner Paul Murphy 31 March 2010 “Improving organ donation within your hospital” 1

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3. Diagnosis of Death MasterclassThe six big wins 3

4. 2. Increased diagnosis of brain stem death 3. Increased donation after cardiac death Diagnosis of Death Masterclass 4

5. Incidence of Brainstem Death on ICU (< 75 years, non-cardiac ICUs)

6. Incidence of Brainstem Death on ICU (< 75 years, non-cardiac ICUs) • 350 missed potential donors • 172 actual donors • 619 additional transplanted patients • Extra 2.8 donors pmp

7. Reasons for not testing (approx 350 / year) Diagnosis of Brainstem Death

8. Diagnosis of Brainstem Death

9. Is NHBD organ donation maximised in the UK? • The Potential Donor Audit has been assessing the potential for NHBD in the UK for the last five years. The map below shows NHB donor numbers by DTC region for 2009. • Significant regional variation • Only 50% of suitable patients given the option of NHBD • Significant clinical variation • Diagnosis of death • warm ischaemic times • organ retrieval 9

10. Aims: Promote national consistency in the use of the criteria used to diagnose death. You to feel confident in the criteria used to diagnose death whilst being alert to potential pitfalls. For you to be aware of potential criticisms by colleagues and the literature and have thought about possible counter arguments. 10

11. Agenda

12. A Defence of the British Criteria Dale Gardiner 12

13. 30 years on… 13

14. Critics Edmund Pellegrino Margaret Lock Alan Shewmon UK critics David EvansDavid Hill Philip Keep Peter Singer Rinaldo Bellomo 14

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16. = The irreversible cessation of brain-stem function => Irreversible unconsciousness + Irreversible apnoea Criteria for Human Death => intra-cranial or extra-cranial cause => 5 mins absent cerebral circulation DO NOT restore Cerebral Circulation 16

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19. Transplant Technique • Split livers • Marginal Donors • Immunosuppressants • Tacrolimus • Mycophenolate 19

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21. The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants. Transplants Brain Death 1st Renal auto-Tx (unsuccessful) 1902 Cushing Transplants Transplants Transplants Transplants Transplants Transplants Transplants Transplants Transplants 21

22. The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants. Transplants Brain Death 1902 • EEG discovered • In electric potential = Death • Loss cortical potentials seen in ischaemia 1st xeno-Tx (unsuccessful) Transplants Transplants 1st Renal cadaveric Tx (unsuccessful) Transplants Transplants Transplants Transplants Transplants 1950 Transplants 22

23. The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants. Transplants Brain Death 1950 Cessation of brain blood flow = Death Cortical circulatory arrest seen in coma patients 1st successful live Renal Tx Transplants Death of the nervous system = Coma dépassé Transplants Transplants Transplants 1960 Transplants Transplants Transplants 23

24. The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants. Transplants Brain Death 1960 1st successful cadaveric Renal Tx Irreversible cessation of the EEG = Death Transplants Transplants Transplants Transplants Transplants Transplants Transplants 24

25. The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants. Transplants Brain Death 1967-68 1st successful Heart Tx Harvard Criteria Brain Death = DEATH Transplants Transplants Transplants Transplants Transplants Transplants Transplants 25

26. 3rd December 1967 26

27. Ad Hoc Committee of the Harvard Medical School JAMA5th Aug 1968 27

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29. ‘Our Primary purpose is to define irreversible coma as a new criterion for death……Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation.’ 29

30. The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants. Transplants Brain Death Future 1st xeno Tx 1st lab grown organ Tx Brain Death = DEATH Transplants Transplants Transplants Transplants Transplants Transplants Transplants Transplants Transplants 30

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33. diagnosis decision 33

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35. Whole Brain Death Rest of the World Brain Stem Death UK Higher Brain Death Philosophers 35

36. Higher Brain Death Philosophers Peter Singer 36

37. Whole Brain Death Rest of the World Rinaldo Bellomo ICM 2004 37

38. Brain Stem Death UK 38

39. Whole Brain Death Rest of the World 39

40. Whole Brain Death Rest of the World 40

41. Whole Brain Death Rest of the World 41

42. Brain Stem Death UK 42

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44. NEJM 2010 44

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46. DEAD ALIVE 46

47. Brain Stem Death UK 47

48. Brain Stem Death UK 48

49. Brain Stem Death UK 49

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