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The primary purpose of this statement is to improve neuroprognostication after devastating brain injury (DBI), with a secondary benefit of potential organ and tissue donation.
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BackgroundExtracorporeal membrane oxygenation (ECMO) is used to provide temporary cardiorespiratory support to critically ill children. While short-term outcomes and costs have been evaluated in this population, less is known regarding... more
BackgroundExtracorporeal membrane oxygenation (ECMO) is used to provide temporary cardiorespiratory support to critically ill children. While short-term outcomes and costs have been evaluated in this population, less is known regarding long-term survival and costs.MethodsPopulation-based cohort study from Ontario, Canada (October 1, 2009 to March 31, 2017), of pediatric patients (< 18 years of age) receiving ECMO, identified through the use of an ECMO procedural code. Outcomes were identified through linkage to provincial health databases. Primary outcome was survival, measured to hospital discharge, as well as at 1 year, 2 years, and 5 years following ECMO initiation. We evaluated total patient costs in the first year following ECMO.ResultsWe analyzed 342 pediatric patients. Mean age at ECMO initiation was 2.9 years (standard deviation [SD] = 5.0). Median time from hospital admission to ECMO initiation was 5 days (interquartile range [IQR] = 1–13 days). Overall survival to hospi...
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Background:Donation after circulatory death (DCD) can reduce organ transplant waiting times. When defining death using circulatory criteria, brain function is usually not assessed. Residual brain function and the state of consciousness at... more
Background:Donation after circulatory death (DCD) can reduce organ transplant waiting times. When defining death using circulatory criteria, brain function is usually not assessed. Residual brain function and the state of consciousness at the time of circulatory arrest is unknown. We have an ethical responsibility to ensure the donor is free of pain and psychological distress.Methods:We performed a scoping review of the literature to determine the time intervals associated with the loss brain function after circulatory arrest.Results:A total of 1133 articles were reviewed and 38 were included in the review. In humans, 8 studies showed loss of EEG activity under 30 seconds. Four studies revealed loss of EEG between 39.6 and 66 seconds. Clinically, loss of consciousness was shown to occur between 4 and 21 seconds. In animals, 13 studies also revealed loss of EEG under 30 seconds. In four other animal studies, EEG was lost between 37 and 120 seconds.Conclusion:The time required to lose...
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Research Interests: Law, Focus Groups, Library and Information Science, Organ Donation, Adolescent, and 15 moreMedicine, Canada, Humans, Donation, Female, Organ Transplantation, Male, Data Collection, Registries, Aged, Middle Aged, Public Administration and Policy, Adult, Public health systems and services research, and attitude to health
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Research Interests: Medicine, Brain Death, Canada, Canadian, Humans, and 15 moreChild, INTENSIVE CARE, Anesthesia, Data Collection, Organizational Policy, Clinical Sciences, Intensive Care Unit, Adult, Cross Section, Age Factors, Apnea, Cross Sectional Studies, Diagnostic Criteria, guidelines as topic, and area of concern
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Research Interests: Computed Tomography, Magnetic Resonance Imaging, Nuclear medicine, Electroencephalography, Positron Emission Tomography, and 15 moreMedicine, Literature Review, Brain Death, Canadian, Humans, Anesthesia, Clinical Sciences, Intensive Care Medicine, Brain Function, Brain Chemistry, Magnetic resonance angiography, Cerebral Angiography, Brain stem, Neurologic Examination, and False Positive
Research Interests: Organ Donation, Medicine, Brain Death, Canada, Humans, and 13 moreEnd of life care, INTENSIVE CARE, Resuscitation, Clinical Sciences, Cardiopulmonary Resuscitation, Intensive Care Unit, Mechanical Ventilation, Intensive Care Medicine, Intensive Care Units, Terminal care, Critical Illness, Brain injuries, and withholding treatment
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IntroductionIn a patient-centred and family-centred approach to organ donation, compassion is paramount. Recent guidelines have called for more research, interventions and approaches aimed at improving and supporting the families of... more
IntroductionIn a patient-centred and family-centred approach to organ donation, compassion is paramount. Recent guidelines have called for more research, interventions and approaches aimed at improving and supporting the families of critically ill patients. The objective of this study is to help translate patient-centred and family-centred care into practice in deceased organ donation.Methods and analysisThis will be a national, qualitative study of family members of deceased organ donors in Canada. We will include family members who had been approached regarding an organ donation decision, including those who agreed and declined, at least 2 months and no later than 3 years after the patients’ death. Data collection and analysis is ongoing and will continue until September 2020 to include approximately 250 participants. Family members will be identified and recruited from provincial organ donation organisation databases. Four experienced qualitative researchers will conduct telephon...
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IntroductionIn Canada, deceased organ donation provides over 80% of transplanted organs. At the time of death, families, friends or others assume responsibility as substitute decision-makers (SDMs) to consent to organ donation. Despite... more
IntroductionIn Canada, deceased organ donation provides over 80% of transplanted organs. At the time of death, families, friends or others assume responsibility as substitute decision-makers (SDMs) to consent to organ donation. Despite their central role in this process, little is known about what barriers, enablers and beliefs influence decision-making among SDMs. This study aims to explore the experiences and perspectives of SDMs involved in making decisions around the withdrawal of life-sustaining therapies, end-of-life care and deceased organ donation.Methods and analysisSDMs of 60 patients admitted to intensive care units will be enrolled for this study. Ten hospitals across five provinces in Canada in a prospective multicentre qualitative cohort study. We will conduct semistructured telephone interviews in English or French with SDMs between 6 and 8 weeks after the patient’s death. Our sampling frame will stratify SDMs into three groups: SDMs who were not approached for organ ...
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Background A shortage of transplantable organs is a global problem. The purpose of this study was to explore frontline intensive care unit professionals' and organ donor coordinators' perceptions and beliefs around the process of,... more
Background A shortage of transplantable organs is a global problem. The purpose of this study was to explore frontline intensive care unit professionals' and organ donor coordinators' perceptions and beliefs around the process of, and the barriers and enablers to, donation after circulatory determination death (DCDD). Methods This qualitative descriptive study used a semistructured interview guide informed by the Theoretical Domains Framework to interview 55 key informants (physicians, nurses, and organ donation coordinators) in intensive care units (hospitals) and organ donation organizations across Canada. Results Interviews were analyzed using a 6-step systematic approach: coding, generation of specific beliefs, identification of themes, aggregation of themes into categories, assignment of barrier or enabler and analysis for shared and unique discipline barriers and enablers. Seven broad categories encompassing 29 themes of barriers (n = 21) and enablers (n = 4) to DCDD u...
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Objectives: Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada. Methods: We followed a process of clinical practice guideline... more
Objectives: Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada. Methods: We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and...
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The purpose of this survey was to determine how Canadian healthcare professionals perceive their deficiencies and educational requirements related to organ and tissue donation. We surveyed 641 intensive care unit (ICU) physicians, 1,349... more
The purpose of this survey was to determine how Canadian healthcare professionals perceive their deficiencies and educational requirements related to organ and tissue donation. We surveyed 641 intensive care unit (ICU) physicians, 1,349 ICU nurses, 1,561 emergency room (ER) physicians, and 1,873 ER nurses. The survey was distributed by the national organization for each profession (the Canadian Association of Emergency Physicians, the Canadian Association of Critical Care Nurses, and the National Emergency Nurses Association). Canadian Blood Services developed the critical care physician list in collaboration with the Canadian Critical Care Society. Survey development included questions related to comfort with, and knowledge of, key competencies in organ and tissue donation. Eight hundred thirty-one (15.3%) of a possible 5,424 respondents participated in the survey. Over 50% of respondents rated the following topics as highly important: knowledge of general organ and tissue donation...
Research Interests: Death, Family Medicine, Organ Donation, Medicine, Curriculum, and 13 moreCanada, Continuing Medical Education, Humans, Physicians, Nurses, Clinical Sciences, Intensive Care Unit, Tissue donation, Clinical Competence, Intensive Care Units, Surveys and Questionnaires, Specialty, and Tissue and organ procurement
The timing of the circulatory determination of death for organ donation presents a medical and ethical challenge. Concerns have been raised about the timing of electrocerebral inactivity in relation to the cessation of circulatory... more
The timing of the circulatory determination of death for organ donation presents a medical and ethical challenge. Concerns have been raised about the timing of electrocerebral inactivity in relation to the cessation of circulatory function in organ donation after cardio-circulatory death. Nonprocessed electroencephalographic (EEG) measures have not been characterized and may provide insight into neurological function during this process. We assessed electrocortical data in relation to cardiac function after withdrawal of life-sustaining therapy and in the postmortem period after cardiac arrest for four patients in a Canadian intensive care unit. Subhairline EEG and cardio-circulatory monitoring including electrocardiogram, arterial blood pressure (ABP), and oxygen saturation were captured. Electrocerebral inactivity preceded the cessation of the cardiac rhythm and ABP in three patients. In one patient, single delta wave bursts persisted following the cessation of both the cardiac rh...
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Decompressive craniectomy (DC) after devastating brain injury (DBI) may influence the manner in which patients die, having implications for end-of-life care and organ donation. We performed a retrospective review of deaths following a... more
Decompressive craniectomy (DC) after devastating brain injury (DBI) may influence the manner in which patients die, having implications for end-of-life care and organ donation. We performed a retrospective review of deaths following a non-traumatic DBI between 2008 and 2012. 160 patients were reviewed; 26 were treated with DC and 134 received standard care. There was no relationship between DC and mechanism of death, (OR 1.18, 95% CI 0.44-3.17). Prospective studies are required to confirm these preliminary finding. DC studies should report the mechanism of death.
Research Interests: Cognitive Science, Nonparametric Statistics, Traumatic Brain Injury, Medicine, Humans, and 15 moreFemale, Male, Young Adult, Clinical Sciences, Aged, Middle Aged, Adult, Intensive Care Units, Mechanism in Biology, Neurosciences, Decompressive Craniectomy, Cohort Studies, Brain injuries, Randomized Controlled Trials as Topic, and glasgow outcome scale
The neurological determination of death (NDD, brain death) is principally a clinical evaluation. However, ancillary testing is required when there are factors confounding the clinical determination or when it is impossible to complete the... more
The neurological determination of death (NDD, brain death) is principally a clinical evaluation. However, ancillary testing is required when there are factors confounding the clinical determination or when it is impossible to complete the minimum clinical criteria. At the time of the 2003 Canadian Forum clarifying the criteria for brain death, 4-vessel cerebral angiography or radionuclide angiography were the recommended tests and the electroencephalogram was no longer supported. At the request of practitioners in the field, the Canadian Council for Donation and Transplantation sponsored the assembly of neuroradiology and neurocritical care experts to make further recommendations regarding the use of ancillary testing. At minimum, patients referred for ancillary testing should be in a deep unresponsive coma with an established etiology, in the absence of reversible conditions accounting for the unresponsiveness and the clinical examination should be performed to the fullest extent p...
Research Interests: Cognitive Science, Death, Neuroimaging, Expert testimony, Organ Donation, and 15 moreMedicine, Brain Death, Canada, Brain, Hemodynamics, Neuroradiology, Clinical Sciences, Angiography, Blood Flow, Intensive Care Medicine, X ray Computed Tomography, Cerebral Blood Flow, Neurosciences, Magnetic resonance angiography, and guidelines as topic
Brain death is defined as the complete and irreversible absence of all brain function. It is diagnosed by means of rigorous testing at the bedside. The advent of neurologic or brain death criteria to establish the death of a person was a... more
Brain death is defined as the complete and irreversible absence of all brain function. It is diagnosed by means of rigorous testing at the bedside. The advent of neurologic or brain death criteria to establish the death of a person was a significant departure from the traditional way of defining death and remains ethically challenging to some. We review the ethical, cultural, religious and legal issues surrounding brain death and outline an approach to establishing a diagnosis of brain death in clinical practice.
Research Interests: Bioethics, Medical Ethics, Religion and medicine, Medicine, Brain Death, and 15 moreClinical Practice, Canada, Humans, Pubmed, Male, Subarachnoid hemorrhage, Legal Issues, Ct Scan, Intensive Care Unit, Social Values, Adult, Brain Function, Emergency Department, Child preschool, and Medical and Health Sciences
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Research Interests: Anesthesiology, Death, Quality of life, Organ Donation, Medicine, and 12 moreTransplantation, Humans, Donation, Organ Transplantation, Pain Medicine, Clinical Sciences, Public health systems and services research, DDC, Intensive Care Medicine, Medizin, Determination of Death, and Tissue and organ procurement
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For a French translation of the executive summary, please see the Supplementary Material at DOI: 10.1017/cem.2017.429.
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Technological advances, particularly in the capacity to support, replace or transplant failing organs, continue to challenge and refine our understanding of human death. Given the ability to reanimate organs before and after death, both... more
Technological advances, particularly in the capacity to support, replace or transplant failing organs, continue to challenge and refine our understanding of human death. Given the ability to reanimate organs before and after death, both inside and outside of the body, through reinstitution of oxygenated circulation, concepts related to death of organs (e.g. cardiac death) are no longer valid. This paper advances the rationale for a single conceptual determination of death related to permanent brain arrest, resulting from primary brain injury or secondary to circulatory arrest. The clinical characteristics of brain arrest are the permanent loss of capacity for consciousness and loss of all brainstem functions. In the setting of circulatory arrest, death occurs after the arrest of circulation to the brain rather than death of the heart. Correspondingly, any intervention that resumes oxygenated circulation to the brain after circulatory arrest would invalidate the determination of death.