Alex Manara

International perspective on the diagnosis of death

There is growing medical consensus in a unifying concept of human death. All human death involves the irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breathe. Death then is a result of the irreversible loss of these functions in the brain. This paper outlines three sets of criteria to diagnose human death. Each set of criteria clearly establishes the irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breathe. The most appropriate set of criteria to use is determined by the circumstances in which the medical practitioner is called upon to diagnose death. The three criteria sets are somatic (features visible on external inspection of the corpse), circulatory (after cardiorespiratory arrest), and neurological (in patients in coma on mechanical ventilation); and represent a diagnostic standard in which the medical profession and the public can have complete confidence. This review unites authors from Australia, Canada, and the UK and examines the medical criteria that we should use in 2012 to diagnose human death.

Organ donation in adults: a critical care perspective

PurposeThe shortage of organs for transplantation is an important medical and societal problem because transplantation is often the best therapeutic option for end-stage organ failure.MethodsWe review the potential deceased organ donation pathways in adult ICU practice, i.e. donation after brain death (DBD) and controlled donation after circulatory death (cDCD), which follows the planned withdrawal of life-sustaining treatments (WLST) and subsequent confirmation of death using cardiorespiratory criteria.ResultsStrategies in the ICU to increase the number of organs available for transplantation are discussed. These include timely identification of the potential organ donor, optimization of the brain-dead donor by aggressive management of the physiological consequence of brain death, implementation of cDCD protocols, and the potential for ex vivo perfusion techniques.ConclusionsOrgan donation should be offered as a routine component of the end-of-life care plan of every patient dying in the ICU where appropriate, and intensivists are the key professional in this process.

A Donation After Circulatory Death Program Has the Potential to Increase the Number of Donors After Brain Death.

Objectives:Donation after circulatory death has been responsible for 75% of the increase in the numbers of deceased organ donors in the United Kingdom. There has been concern that the success of the donation after circulatory death program has been at the expense of donation after brain death. The objective of the study was to ascertain the impact of the donation after circulatory death program on donation after brain death in the United Kingdom. Design:Retrospective cohort study. Setting:A national organ procurement organization. Patients:Patients referred and assessed as donation after circulatory death donors in the United Kingdom between October and December 2013. Interventions:None. Measurements and Main Results:A total of 257 patients were assessed for donation after circulatory death. Of these, 193 were eligible donors. Three patients were deemed medically unsuitable following surgical inspection, 56 patients did not proceed due to asystole, and 134 proceeded to donation. Four donors had insufficient data available for analysis. Therefore, 186 cases were analyzed in total. Organ donation would not have been possible in 79 of the 130 actual donors if donation after circulatory death was not available. Thirty-six donation after circulatory death donors (28% of actual donors) were judged to have the potential to progress to brain death if withdrawal of life-sustaining treatment had been delayed by up to a further 36 hours. A further 15 donation after circulatory death donors had brain death confirmed or had clinical indications of brain death with clear mitigating circumstances in all but three cases. We determined that the maximum potential donation after brain death to donation after circulatory death substitution rate observed was 8%; however due to mitigating circumstances, only three patients (2%) could have undergone brain death testing. Conclusions:The development of a national donation after circulatory death program has had minimal impact on the number of donation after brain death donors. The number of donation after brain death donors could increase with changes in end-of-life care practices to allow the evolution of brain death and increasing the availability of ancillary testing.

Microendoscopic nasointestinal feeding tube placement in mechanically ventilated patients with gastroparesis.

Gastroparesis often precludes gastric enteral nutrition (EN) in critically ill patients. Our aim was to determine the feasibility of bedside microendoscopic placement of nasointestinal feeding tubes to facilitate enteral nutrition in critically ill patients with poor gastric emptying. Nine mechanically ventilated patients with proven gastroparesis underwent 10 nasointestinal intubations using a microendoscope. These were compared with 35 patients who underwent pH sensor-guided intubation. Blind pH-guided intubation was faster than microendoscopic placement (21.4 ± 10.7 v 32 ± 11.6 min, P = 0.016) and cheaper in terms of disposables [£87 (

A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries

132) vs £222 (

In-hospital logistics: what are the key aspects for succeeding in each of the steps of the process of controlled donation after circulatory death?

337) per intubation, P < 0.0001]. Depth of placement (postpyloric: 64% vs 50% including 32% vs 50% reaching duodenum part 3, 4, or jejunum, both NS) was similar. We conclude that microendoscopy failed to improve transpyloric intubation due to poor visualization of gastrointestinal anatomy and difficulty maneuvering the tube–endoscope ensemble. However, when successful, transpyloric placement was always deep, permitting immediate and full EN. To date, the technique and equipment is not superior to pH-guided placement and is not suitable for use by personnel with minimal training.

Outcomes of the first full year of implementing a devastating brain injury pathway

Early prognostication in patients with a devastating brain injury is not always accurate and can lead to inappropriate decisions. We present case histories to support the recent recommendations of the Neurocritical Care Society that treatment withdrawal decisions should be delayed by up to 72 h in these patients. Development of pathways incorporating these recommendations can improve prognostication, enhance end of life care given to these patients and their families, and increase the opportunities to explore the donation wishes of more patients. They may also standardise the approach to decision making in the same way as the recommendations for management of patients after out of hospital cardiac arrest have done.

Admission to bed 13 in the ICU does not reduce the chance of survival

Donation after circulatory death (DCD) donors are becoming an increasingly important population of organ donors in Europe and worldwide. We report the state of the art regarding controlled DCD donation describing the organizational and technical aspects of establishing a controlled DCD programme and provide recommendations regarding the introduction and development of this type of programme.

Confirming nasogastric tube position with electromagnetic tracking versus pH or X-ray and tube radio-opacity

. 21 patients were admitted to the intensive care unit (ICU) instead of undergoing withdrawal of lifesustaining treatment (WLST) in emergency department; . Five patients had the treatment limitation decision reversed and treated actively; . Three patients survived – two cognitively intact and one still in rehabilitation; . Other 16 patients died, all within 48 h of admission; . End-of-life care enhanced in all patients; . Thirteen relatives approached for organ donation; twelve consented (92%); . Five became actual donation after brain death donors and two actual donation after cardiac death donors.

Management of perceived devastating brain injury after hospital admission: a consensus statement from stakeholder professional organizations

Purpose: To examine whether admission to bed number 13 on our intensive care unit has any negative impact on the patients hospital mortality. Materials and methods: We conducted a retrospective cohort study of 1568 patients admitted to our ICU over a two‐year period. Observed hospital mortality, predicted mortality using the ICNARC and APACHE II scoring systems and standardised mortality ratios were used to compared patients admitted to bed number 13 with those admitted to beds number 14–24. Results: Of the 1568 patients admitted to ICU, 110 were placed in bed number 13 and 1458 into bed numbers 14–24. Demographics and ICNARC and APACHE II scores were similar between the two groups. There was no significant difference in the ICNARC predicted hospital mortality (mean 21.0%, median8.5% in bed 13 compared with a mean 17.5%, median 6.4% in beds 14–24, p = 0.33), APACHE II predicted hospital mortality (mean 18.4%, median 9.9% in bed 13 compared with mean 18.7%, median 8.9% in beds 14–24, p = 0.74), or observed hospital mortality (20.2% compared with 15.2%, OR 1.41 (CI 0.87 to 2.30), p = 0.17). Conclusions: Admission to bed number 13 was not associated with a significant increase in hospital mortality when compared to admission to other bed numbers.