Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR

1. 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

2. Timing in Death declaration ICU Admission Vegetative Storm Brain Death Declaration Organ Retrieval BD criteria observation 3 4 1 2 Treatment of the patient F Procaccio 2012

4. Flow chart for decisions regarding patients with devastating neurological injuries End-of-life in ICU DCD DBD

5. Death in ICU • New clinicalscenarios: • Death under ECMO • Artificialcirculation • (before or afterdeath) • Withdrawalof ventilator • Beforedeath • In BD withoutdeclaration • AfterBD declaration • Never

6. Aims of death declarationby neurological criteria • Clinical and legal definition that the patient is dead • Ethical aim • Avoid treatment of cadavers • Organ donation

7. April 1975 American BAR Association

8. After brain deathdeclaration • Legal time of death must be clear • Time of deathshouldnotdepend on organretrieval or not • Any treatment afterdeathis inappropriate • Practiceshould be uniformaspossible

9. Timing in Death declaration Family opposition To organ donation ICU Admission Vegetative Storm Brain Death Declaration ? BD criteria observation 3 1 2 Treatment of the patient

10. Ventilatorwithdrawalafter BD • Physiciansdoubts • Unawarenessof clearprinciples and rules • Family opposition • External (social – religious) objections

11. After BD declaration in non donors In Spain: withdrawal of • allsupportventilationincluded 75% • onlyvasoactivedrugs 8% • progressive decrease of support 9% • allmaintained 1% • unknown 7% ONT & D Escudero & B Dominguez-Gil, 2012 personal communication

12. 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’sCommission,1981

13. Longestduration of successfulmaternalsomaticsupport following BD : more than 100 days

14. In Oakland, a family refused to acceptJM’sdeath and went to court to preventventilatorwithdrawal • In Texas MM body wasmaintained on MV for 8 weeks after BD in an attempt to «rescue» herfetuswithout family consent.

15. BMJ 2000 Theseactions are for the family, not the patient

16. BMJ, 6 May 2000 Continued treatment mayoffend the dignity of the individual, By usinghim or heras a means to achieve the ends of others. Itis a medical and social nonsense

17. In Poland BD declaration isnotobligatory if the donation isnotexpected.

18. 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

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

20. Timing in Death declaration Family opposition To organ donation ICU Admission Immediate Stop ventilation Vegetative Storm Brain Death Declaration BD criteria observation 4 3 1 2 Treatment of the patient Patient recovery Death

21. The neurologicaldetermination of deathhasensured theutmostrespect for the dignity of deathfor patients and theirrelativesin thesecureknowledgethatthereis no possible chance of recovery.At the same time in some casesithasallowed thedonation of organsasone of the finestgestures for the benefit of humankind. Organs, Tissues & Cells, (13), 179-189, 2010

23. Suggestions • Clear National (supra-national) principles(rules) • ICU personnel ad hoc education • Ad hoc procedures and transparency • Family understanding and support • Communication & conflictsolvingskills