Circulatory Death Determination in Uncontrolled Organ Donors

ACOT MeetingACOT Meeting

February 28, 2012February 28, 2012

James L. Bernat, M.D.James L. Bernat, M.D.Louis and Ruth Frank Professor of NeuroscienceLouis and Ruth Frank Professor of Neuroscience

Professor of Neurology and MedicineProfessor of Neurology and MedicineDartmouth Medical SchoolDartmouth Medical School

OverviewOverview

• Foundational principlesFoundational principles• Concepts of uncontrolled donation after the Concepts of uncontrolled donation after the

circulatory determination of death (uDCDD)circulatory determination of death (uDCDD)• Application of the foundational principles to Application of the foundational principles to

uDCDDuDCDD• The relationship between cessation of The relationship between cessation of

systemic circulation and cessation of brain systemic circulation and cessation of brain functionsfunctions

Foundational PrinciplesFoundational Principles

• Why cessation of systemic circulation causes Why cessation of systemic circulation causes deathdeath

• Permanent vs. irreversible cessation of Permanent vs. irreversible cessation of circulatory functioncirculatory function

• Necessary conditions for permanent Necessary conditions for permanent cessation of circulatory functioncessation of circulatory function

• Interference by resuscitation technologiesInterference by resuscitation technologies• Differences in death determination in organ Differences in death determination in organ

donorsdonors

Concepts of uDCDDConcepts of uDCDD

• Four clinical circumstancesFour clinical circumstances• Two studies failed to recruit donorsTwo studies failed to recruit donors• Prior reports were consented BD or DCD Prior reports were consented BD or DCD

donorsdonors• Hard to extrapolate European experience to Hard to extrapolate European experience to

the United Statesthe United States

Applications of Principles to uDCDDApplications of Principles to uDCDD

• UDCDD donor must have permanent UDCDD donor must have permanent cessation of circulationcessation of circulation

• Auto-resuscitation is an empirical questionAuto-resuscitation is an empirical question• Permanent cessation of circulation is death Permanent cessation of circulation is death

because it destroys the brainbecause it destroys the brain• Reperfusion technologies can retroactively Reperfusion technologies can retroactively

invalidate the death determination unless invalidate the death determination unless the brain is not perfusedthe brain is not perfused

Relationship between Circulation and Relationship between Circulation and Brain FunctionBrain Function

• Circulatory-respiratory criterion of death is a hybrid of Circulatory-respiratory criterion of death is a hybrid of circulatory and brain functionscirculatory and brain functions

• Brain circulation stops when systemic circulation stopsBrain circulation stops when systemic circulation stops• Cessation of breathing is tightly linked to cessation of Cessation of breathing is tightly linked to cessation of

circulation in the absence of resuscitationcirculation in the absence of resuscitation• TimelineTimeline

Time1 T1 T2 T3 T4 T5 T6

Event Circulation ceases clinically Brain functions cease clinically

Circulation ceases permanently

Brain functions cease permanently

Circulation ceases irreversibly

Brain functions cease irreversibly

Prerequisite None No brain circulation Auto-resuscitation impossible; CPR will not be performed2

No brain circulation Auto-resuscitation impossible; CPR would be unsuccessful if attempted2

No brain circulation or no brain function if brain circulation is restored

Evidence No pulse or heartbeat Unresponsiveness Apnea Pupils, corneals, other

brain stemreflexes absent

Absent systolic wave forms by A-line; or no aortic valve

opening on echocardiogram; electrical asystole is sufficient

but not necessary

Unresponsiveness Apnea Pupils, corneals, other brain

stemreflexes absent Absent EEG

activity Absent evoked potentials

Same as T3 with electrical asystole

“Brain death” tests fulfilled

Circulatory Cessation to Death