The Definition of Death: Cerebral or Cardiovascular? · The Definition of Death: Cerebral or Cardiovascular? Jon N. Meliones, MD, MS, FCCM Professor of Pediatrics Duke University

The Definition of Death: Cerebral or Cardiovascular?

Jon N. Meliones, MD, MS, FCCM

Professor of Pediatrics Duke University

Medical Director PCVICU, PYCU, Life Flight

The Definition of Death: Cerebral or

Cardiovascular?

• Scenario 1:

– 16 y.o. on back of scooter, no helmet, major

crash

– Emergency medical team arrives at scene

– Child in full arrest

– Unable to resuscitated at scene

– Pronounced dead at ER


Cardiovascular?

• Scenario 2:

– 35 y.o. with intracranial hemorrhage

cerebral A-V malformation

– Severe neurologic injury with no chance for

a meaningful outcome

– Family considering withdrawal

– Should clinician ask about organ donation?


Cardiovascular?

• Scenario 3:

– 13 y.o. has tonsillectomy and tissue

removal for sleep apnea

– Post-op period she has massive bleeding

– Patient experiences cardiac arrest with

prolonged CPR

– CPR results in return of circulation

– Declared “Brain dead”


Cardiovascular?

• Defining the problem

• Cardiac Death

• Cerebral Death

Determination

Challenges

Organ Donation

Traditional

DCD

The Definition of Cardiovascular Death

• Scenario 1:

– 16 y.o. involved in major crash

– Pronounced dead at ER

• USA law: Uniform Determination of Death

(UDD) = irreversible, biological event with

permanent cessation of the critical functions

of the organism as a whole

• Cardiac death = irreversible cessation of

cardiac function

Donation without Cerebral or

Cardiovascular Death?

• Scenario 2:

– 35 y.o. with severe neurologic injury with

no chance for a meaningful outcome

– What are the options?

– How does Donation after Circulatory

death (DCD) work?

• Growing portions of donors

• Controversial in USA

• USA’s Dead Donor Rule (DDR) – “you got to be dead”

• DCD (non heart beating donor) = withdrawal of

ventilator and perfusion support in “catastrophic illness”

• Donation when neurologic criteria not met

• Pitfalls: Very controversial. Must have specific policies,

protocols, or practice guidelines

DCD = Controlled Donation after

Cardiac/circulatory Death

• Provider removed from: discussions / management

• Donor services coordinates consent, OR and transplant teams

• Support is withdrawn in OR: care per hospital protocol

• Death determined by the physician when meets IOM guidelines:

• Cessation of cardiac function for 2-10 minute confirmed by cardiac and/or arterial monitoring

• Wait 30-60 minutes; if no cessation patient moved

• Organs are surgically recovered and translanted

DCD = Controlled Donation after

Cardiac/circulatory Death

• Will some donors be denied potentially life-saving non-

conventional resuscitation procedures? (CPR-ECMO)

• In Hospital “ECPR” = 45% survival

• Out-of-hospital arrest: Will some benefit from

aggressive efforts in ER (CPR / ECMO)

• Out-of-hospital arrests; ECMO prior to wishes of the

potential donors or their families; is this justified?

DCD: Ethical Concerns

• More willing to donate kidneys

• 66% v. 81%; p < 0.0001

• Less willing to donate a heart

• 64% v. 38%; p < 0.0001

• Less willing to donate liver

• 40% v. 34%; p < 0.036

• Less willing to donate corneas

• 22% v. 15%, p < 0.0059

South African Willingness to

Donation: 1993 vs 2013

The Dilemma of Jahi McMath

• Scenario 3: Jahi McMath

September 2013:

– 13 y.o. has tonsillectomy and tissue

removal for sleep apnea

– Declared “Brain dead”

– Family refused to accept the

medical declaration of death by

neurological criteria; said McMath

was not dead, and initiated legal

proceedings in an effort to require

the hospital to continue treatment


• Jahi has the following evidence for

brain death:

– No cereberal activity

– No brain stem activity

– No EEG activity

– No cerebral blood flow


• On December 20, 2013, McMath's family

filed a lawsuit petitioning the court to

require Children's Hospital Oakland to keep

McMath on life support.

• Provide for Tracheostomy and G-Tube

• Court appointed an independent Pediatric

Neuro specialist

• Specialist x 5 confirm “Brain death”


• On December 24, 2013, judge states that Jahi is

legally dead, orders physicians to continue

support while family adjusts to order

• Family again challenges court ruling:

– Uniform Determination of Death (UDD) is a violation

of constitutional religious and privacy rights

– Jahi's heart was still beating, she was still alive

– Hospital: "grotesque" to require the hospital and its

doctors to provide further medical care to a dead

body


• Hospital agrees: they will release Jahi to the

mother on the ventilator and on IV fluids

• Coroner issues a death certificate declaring Jahi

dead

• Jahi is moved to New Jersey catholic hospital

where tracheostomy and G- tube placed

• Now living in a New Jersey apartment with

around the clock nursing

• Cerebral death = irreversible functions of all parts

of the entire brain, including the brain stem

• Diagnosis of cerebral death

• Neurological exam

• Apnea test

• Timing• Neurologic death must be distinguished from persistent

vegetative state (PVS)

• In PVS, the brainstem remains intact and functions to

maintain respiratory effort and normal circulation

The Definition of Cerebral Death?

• Performed after all other criteria for brain death have been met.

• Core temperature ≥36ºC or 97ºF

• Systolic blood pressure ≥100 mmHg

• Eucapnia (PaCO2 35 to 45 mmHg)

• Absence of hypoxia

• Euvolemic status are prerequisites

• Brain Dead: A positive apnea test = no respiratory response to a

PaCO2 >60 mmHg or 20 mmHg greater than baseline values and

a final arterial pH of <7.2

• Preoxygenate with FiO2 = 1.0

Apnea Test

• In USA, two examinations separated by an

observation period are required:

• a 48-hour evaluation interval for infants age

seven days to two months

• 24 hours for those greater than two months to

one year

• 12 hours for those between 1 and 18 years

• EEG remains strongly recommended USA for all

patients and is required to determine brain death in

very young children

The Definition of Cerebral Death?

• Confirmatory tests:

• Recommended;

• Hypoxic-ischemic injury

• <12 hours

• Isoelectric EEG

• Arteriogram or nuclear medicine study

demonstrating absence of cerebral circulation

The Definition of Cerebral Death:

Confirmatory Tests

• Pupils fixed: anticholinergic, neuromuscular blockers,

preexisting disease

• No oculovestibular reflexes: ototoxic agents,

vestibular suppressants, preexisting disease

• No respiration: posthyperventilation syndrome,

neuromuscular blockers

• No motor activity: neuromuscular blockers, "locked-

in" state, sedative drugs

• Isoelectric EEG: sedative drugs, anoxia, hypothermia,

encephalitis, trauma

Misleading findings in ? Cerebral Death

Proportion of Physicians Facing a Malpractice Claim Annually, According to Specialty.

Jena AB et al. N Engl J Med 2011;365:629-636

Data on Law Suits in USA

Amount of Malpractice Payments, According to Specialty.


However Pediatrics Highest Settlements

Cumulative Career Probability of Facing a Malpractice Claim or Indemnity Payment, According to Risk of Specialty and Age of Physician.


If You Work Long Enough In the ICU:

You Will Get sued!

• Two types of settlements in medical

malpractice in the USA:

• Non-economic = Pain and suffering;

• Many states limit this including

California to $250,000 USD

• Economic = Life care plans

• Children Life care plans can be >$20M


The Dilemma: Jahi McMath: “Alive!”

• October of 2014 family states “Jahi” now

has EEG activity and Brain blood flow and

petition court to determine Jahi “Alive”

• Court refuses: No evidence presented to

experts

• Law suit filed in March 2015 alleging

malpractice and that the $250,000 cap does

not apply as she is alive



• What are the ethical consequences?

• What defines “Brain Dead?”

• Some health system's mandate that

families sign a binding agreement:

– If their child is declared brain dead or no

chance for a meaningful recovery:

• Withdrawal of care mandatory

• Cap on amount of money paid in case of

error

Cultural Differences about Death

0

10

20

30

40

50

60

70

80

90

Hope Pain allowed MD assist Own life

White African American

The Definition of Death Cerebral or

Cardiovascular?

• Defining the problem

• Cardiac Death

• Cerebral Death

Determination

Challenges

Organ Donation

Traditional

DCD

This is a REAL crisis

• That is 7,665 people who die every year

• That is the equivalent of 18 Boeing 747

crashes in a year.

• One Commercial Airplane crash, every 20

days.

Cultural Differences about Death– Stop if no hope:

• W= 72% /AA=32%

– Disclose Pain in terminal disease:

• W=71% / AA=42%

– Allowed to die:

• W=80% / AA=41%

– Approve of physician assisted suicide:

• W=53 / AA=22

– Moral right for suicide:

• W=78 / AA=34%

The Definition of Death: Cerebral or Cardiovascular? · The Definition of Death: Cerebral or Cardiovascular? Jon N. Meliones, MD, MS, FCCM Professor of Pediatrics Duke University

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