Barbara J. Russell

Seeking to increase beneficial ethics consultations in the ICU and beyond.

Critical Care Medicine www.ccmjournal.org e683 of the short-lived nature of these returns by reemphasizing the fact that the longest period of return we measured was within 89 seconds of our defined cessation time point that corresponded to 60 seconds without activity. This is consistent with current nonheart beating or donation after circulatory death (DCD) protocols in North America that demand a minimum of a 2-minute waiting period. Our study is the first stage of documenting and describing the activity rather than overinterpreting the meaning of that activity by irresponsibly labeling it as autoresuscitation. We agree that any sustained resumption of cardiac or neurologic function would be relevant to DCD processes. To this, where short-lived resumption of arterial waveform function was noted, it was within the current 2to 5-minute practice of “hands off” time before a second declaration. We documented three subjects where EEG ceased several minutes prior to cessation of arterial waveform activity, which is consistent with evidence that a minimal arterial perfusion pressure is required to maintain cerebral perfusion and thus consciousness. The pressure of 12–27/11–15 mm Hg would not have been sufficient to perfuse capillary beds in most organs, certainly not the brain. Since this occurred with absent palpable pulse, the perfusion pressure was too low for brain perfusion. We feel that it is not appropriate to overinterpret these cases of activity ceasing well before the cessation of arterial waveform as having the potential for awareness. Literature has shown that mean arterial blood pressures of 30–40 mm Hg are required for neuronal function (2). The authors suggest that electrical surges may represent near-death experience. We did not document any electrical surges and thus are unable to comment on near-death experiences. We did document one case out of four with EEG activity persisting to well after (26 min) the cessation of arterial waveform activity. We could not interpret this activity as anything other than artifact as this persisted so far in time after the cessation of clinical circulation. Previous literature has shown that EEG activity ceases within 15 seconds of cardiac arrest (3). We agree that EEG monitoring only reflects cortical activity and has been shown to have continuing subcortical activity; however, this has not been reported to have occurred in the context of absence of arterial waveform activity as in this case. We look forward to future studies that will investigate cessation of circulatory as well as subcortical and brainstem functions during withdrawal of life-sustaining therapy or arrest of circulation. We appreciate that the determination of death for the purposes of organ donation can be controversial. We feel strongly that it is irresponsible to overinterpret pilot feasibility data. In this limited dataset, we observed short-lived events of spontaneous return of arterial pressure waveform within 89 seconds after 60 seconds of cessation of activity. We chose not to call these events autoresuscitation, given their questionable clinical significance. Artifactual activity on EEG or persistent activity on electrocardiograms after death declaration should not be interpreted as clinically meaningful signs of the maintenance of circulatory or neurologic function. Importantly, within the context of current guidelines for donation after circulatory determined death, the wait period for determining death is 2–5 minutes, and therefore, any return of activity within this time period would result in a restarting of the clock for the wait period. Findings of measured returns of activity such as recorded in our study are within the current 2to 5-minute window. Our study aims to reinforce safe and transparent practice for DCD. In plan is a larger study documenting cardiovascular and neurologic activity and function will help to reinforce public and professional trust in donation practices. Dr. Dhanani consulted for Trillium Gift of Life Network (chief medical officer, donation). His institution received grant support from Physicians Service Incorporated. Dr. Young consulted for GE Healthcare (developing electroencephalogram and impedance measurements for ICU recordings), has patents with GE Healthcare (patent pending for stimulating device for testing electroencephalogram reactivity), and received support for travel from GE Healthcare (travel to ICU meetings in Europe). Dr. Shemie is employed by Canadian Blood Services.

On Purpose: Four Concerns

We welcome Pickard’s article (2012) for helping to enliven ongoing inquiry and for increasing debate regarding the nature, causes, and remedies of addictions. She displaces the hegemonic view that considers addictions to be chronic, relapsing diseases by positing that they are purposive behaviors. Her article explains important implications of her position vis-à-vis diagnosis, prognosis, prevention, and treatment. While we support the critique of the prevailing tendency to biological reductionism, we see Pickard as introducing a not-so-new binary argument that fails to appreciate the full dimensionality of addiction. The lived reality of individuals and communities experiencing substance misuse and abuse problems is more complex than Pickard allows. Four points in Pickard’s analysis and recommendations reflect worrisome simplifications of addiction and its remedies.

Review of The Ethics of Autism: Among Them, but Not of Them by Deborah R. Barnbaum 1

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