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• W4221001429 abstract "To the Editor: The Uniform Determination of Death Act (UDDA) recognizes two different clinical situations that permit the determination of death: (1) the irreversible cessation of circulatory and respiratory functions and (2) the irreversible cessation of all functions of the entire brain, including the brain stem. Contrary to a recent claim by Parent et al. in the Journal,1Parent B, Caplan A, Moazami N, et al. Response to American College of Physician’s statement on the ethics of transplant after normothermic regional perfusion. Am J Transplant. 2022.Google Scholar controlled donation after circulatory determination of death (cDCDD) programs that use thoracoabdominal-normothermic regional perfusion (TA-NRP)2Manara A Shemie SD Large S et al.Maintaining the permanence principle for death during in situ normothermic regional perfusion for donation after circulatory death organ recovery: a United Kingdom and Canadian proposal.Am J Transplant. 2020; 20: 2017-2025Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar challenge the UDDA criteria of death.3Glazier AK, Capron AM. NRP and US legal standards for determining death are not aligned. Am J Transplant. 2020.Google Scholar TA-NRP protocols, which have been developed to improve heart DCDD transplant outcomes, involve rapidly re-initiating circulation to the heart and permitting its functionality to be assessed in situ.2Manara A Shemie SD Large S et al.Maintaining the permanence principle for death during in situ normothermic regional perfusion for donation after circulatory death organ recovery: a United Kingdom and Canadian proposal.Am J Transplant. 2020; 20: 2017-2025Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar After death has been determined, medical personnel clamp the vessels of the aortic arch to exclude brain circulation, and extracorporeal membrane oxygenation (ECMO) is used to restore bodily circulation. In cDCDD programs, death is determined before the irreversible cessation of circulatory and brain functions have occurred,4Dalle Ave AL Bernat JL. Using the brain criterion in organ donation after the circulatory determination of death.J Crit Care. 2016; 33: 114-118Crossref PubMed Google Scholar at a time when circulatory and brain functions have ceased permanently. The irreversible cessation of circulatory and brain functions means that no medical measures can resume those functions, while their permanent cessation means that medical measures could resume those functions, but will not be attempted. There are two conditions to be fulfilled if death is determined as permanent: (1) the possibility of auto-resuscitation has elapsed, and (2) circulation will not be resumed after the determination of death.5Bernat JL. How the distinction between irreversible and permanent illuminates circulatory-respiratory death determination.J Med Philos. 2010; 35: 242-255Crossref PubMed Scopus (0) Google Scholar By resuming bodily circulation after the determination of death, TA-NRP does not respect the second condition, and consequently invalidates the determination of death based on the permanent cessation of circulation. Moreover, TA-NRP creates a new clinical state, where circulation has resumed yet brain functions are assumed to have ceased irreversibly because of the exclusion of brain circulation. The medical community has had more than 50 years of experience in determining death in such a clinical state, using brain death tests to determine whether the brain criterion of death has been met. Physicians first correct any medical conditions that produce a reversible absence of brain functions, such as hypothermia or hypotension. But determining death in a patient under TA-NRP is more difficult than an ordinary determination. Any attempt to restore brain circulation so as to confirm that the loss of functions is indeed irreversible would risk harming patients and would violate their autonomy. Finally, since “TA-NRP currently cannot categorically confirm or refute the absence of some brain blood flow” (2, p. 2024), one is left with a confounding condition that may require one performing ancillary tests (such as brain angiography or perfusion techniques), although it is not clear that any known ancillary tests have sufficient sensitivity to confirm the absence of brain circulation in the context of TA-NRP. The medical community is thus left in a predicament. Once bodily circulation has been restored under a TA-NRP protocol, a formal determination of death by brain criterion seems either impossible or undesirable (time-consuming). But the alternative—merely assuming death—would amount to a departure from standard medical practice. Is society ready to accept such “assumability” of death, were this practice clearly and transparently presented to the public?" @default.
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• W4221001429 date "2022-06-01" @default.
• W4221001429 modified "2023-09-24" @default.
• W4221001429 title "Determination of death: From irreversibility to assumability" @default.
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• W4221001429 doi "https://doi.org/10.1111/ajt.17030" @default.
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