Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR Ventilator withdrawal in case of DBD refusal Francesco Procaccio ISS – CNT - Rome Neuro Intensive Care Unit University City Hospital, Verona - Italy University City Hospital, Verona - Italy

F Procaccio 2012 ICUAdmission VegetativeStorm Brain Death Declaration OrganRetrieval Treatment of the patient Timing in Death declaration BDcriteria observation

Flow chart for decisions regarding patients with devastating neurological injuries with devastating neurological injuries End-of-life in ICU DCDDBD

Death in ICU Death in ICU New clinical scenarios: Death under ECMO Artificial circulation Artificial circulation (before or after death) (before or after death) Withdrawal of ventilator Before death In BD without declaration In BD without declaration After BD declaration After BD declaration Never Never

Aims of death declaration by neurological criteria 1)Clinical and legal definition that the patient is dead 2)Ethical aim 3)Avoid treatment of cadavers 4)Organ donation

April 1975 American BAR Association

After brain death declaration Legal time of death must be clear Legal time of death must be clear Time of death should not depend on organ retrieval or not Time of death should not depend on organ retrieval or not Any treatment after death is inappropriate Any treatment after death is inappropriate Practice should be uniform as possible Practice should be uniform as possible

ICUAdmission VegetativeStorm Brain Death Declaration 12 3 Treatment of the patient Timing in Death declaration BDcriteria observation Family opposition To organ donation

Ventilator withdrawal after BD Physicians doubts Physicians doubts Unawareness of clear principles and rules Unawareness of clear principles and rules Family opposition Family opposition External (social – religious) objections External (social – religious) objections

After BD declaration in non donors In Spain: withdrawal of  all support ventilation included75%  only vasoactive drugs 8%  progressive decrease of support9%  all maintained1%  unknown7% ONT & D Escudero & B Dominguez-Gil, 2012 personal communication

In adults who have experienced irreversible cessation of the functions of the entire brain… …the heart usually stops beating within two to ten days. USA - The President’s Commission,1981

Longest duration of successful maternal somatic support following BD : more than 100 days 13

 In Oakland, a family refused to accept JM’s death and went to court to prevent ventilator withdrawal  In Texas MM body was maintained on MV for 8 weeks after BD in an attempt to «rescue» her fetus without family consent.

These actions are for the family, not the patient BMJ 2000

Continued treatment may offend the dignity of the individual, By using him or her as a means to achieve the ends of others. It is a medical and social nonsense BMJ, 6 May 2000

In Poland BD declaration is not obligatory is not obligatory if the donation is not expected.

Social confidence in BD diagnosis and family trust in the dead donor rule would take advantage from BD declaration in all the subjects who fulfill BD criteria This medical practice could support the fundamental idea that all the citizens must be equal in death, that is not different in potential donors from other patients. Thuong, Procaccio et al. VI Ed. COI Guide, in preparation

F Procaccio in M Thuong et al. COE Guide VI Ed., in preparation Brain Death Algorithm

ICUAdmission VegetativeStorm Brain Death Declaration Treatment of the patient Patient recovery Timing in Death declaration BDcriteria observation ImmediateStopventilation Death 20 Family opposition To organ donation

The neurological determination of death has ensured the utmost respect for the dignity of death for patients and their relatives in the secure knowledge that there is no possible chance of recovery. At the same time in some cases it has allowed the donation of organs as one of the finest gestures for the benefit of humankind. Organs, Tissues & Cells, (13), , 2010

Suggestions 1.Clear National (supra-national) principles (rules) 2.ICU personnel ad hoc education 3.Ad hoc procedures and transparency 4.Family understanding and support 5.Communication & conflict solving skills