brain death medical pro (vs con) - critical care canada forum · 1.brain death is the unintended...
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McGill University Health Centre, Montreal Children’s Hospital, MUHC Research Institute
Division of Critical Care
McGill UniversityProfessor of Pediatrics
Canadian Blood ServicesMedical Director, Deceased Donation
Brain DeathMedical Pro (vs Con)
Sam D. Shemie
Critical Care Canada ForumToronto Nov 7th 2018
Disclosures & Influences
1. Full time pediatric med/surg/cardiac ICU physician
2. ECMO specialist & former ECMO team medical director
3. Trauma team leader
4. Research and health policy program in organ replacement during critical illness, deceased organ donation and death determination
5. Medical advisor for deceased donation at Canadian Blood Services, a non-profit, government funded organization to help coordinate the donation & transplant system in Canada
6. No industry funding
7. No transplant funding
Death: Heart or Brain?
Summary1. Fascinating & challenging advances in technology & in
the ability to support & replace organ failure.
2. Brain death was discovered, not invented.
3. 2 concepts of ‘heart’ & ‘brain’ death are no longer relevant
4. It is inevitable that all death will become brain-based.
8. Canadian Association of Transplantation9. Canadian Society of Transplantation10. Quebec Transplant11. Trillium Gift of Life Network12. Alberta HOPE Programs13. Newfoundland OPEN Program14. Transplant Atlantic15. New Brunswick Transplant 16. Canadian Council for Donation and
Transplantation.
Endorsed by 16 Organization in Canada:1. Canadian Critical Care Society2. Canadian Neurological Society3. Canadian Neurosurgical Society 4. Canadian Neurocritical Care Group5. Conference of Chief Coroners and Medical
Examiners of Canada6. Canadian Association of Critical Care Nurses7. Canadian Association of Emergency
Physicians
Can J Anes 2006
Major differences diagnostic procedures:• apnea testing• observation time• age related criteria• required expertise of physicians• provisions for anoxic BD• confirmatory lab tests• legal standards & time of death
1. Clear medical standards for NDD & defining qualifications of physicians augment quality & rigour of the determination.
2. Protect dying patients and minimize risk of diagnostic error
Bank Vault Cranial Vault
Intelligent Design or Evolution
86 Billion Neurons & 100 Trillion Interconnections
Human Connectome ProjectGE Healthcare
• Senses - vision, smell, touch, pain, hearing• Movement - voluntary, purposeful, involuntary brain mediated• Autonomic functions- breathing, airway control, brainstem reflexes• Consciousness
- awake, thinking, feeling, doing, reacting, planning, memory• Need driven commercial exchange with environment
- sensory, energy/nutrition, O2/CO2
NY Times
No Brain Function Some Brain Function
Brain Death: Refractory Intracranial PressureDownward Herniation of Brainstem
No blood flow, no function
How Can Someone Be Dead?With a heartbeat, pulse, lungs moving, skin warm, growth, strange
movements?Able sustain a fetus & give life to a baby???
“Dead”
“Cadaver”
“Corpse”
“Irreversible Apneic Coma”
“Loss of capacity for consciousness”
“As good as dead”
“Death by Neurological Criteria”“Brain Death”
“Integration/disintegration”
“Whole Brain”
“Deceased”
“Passing away”
“Deep unresponsive coma”
“Heart beating death” “Cessation of brain function”
“Menstruating Resurrected Corpse”Alan Shewmon, Harvard Brain Death, April 2018
The Difference Between Life and DeathOxygen & Nutrient Delivery
Monolayer cell culture Mitochondria
Human Cellular Respiration Consumes Oxygen
To Create Energy Required for Cell Life
Monolayer cell culture
37 Trillion Cells(Smithsonian)
Biology of Life = Oxygen & Nutrient DeliveryOxygenated Circulation
Organs as Functioning PartsBrian drives the lung to bring in O2
Lungs load O2Red blood cells carry O2
Heart circulatesLiver metabolizes, Kidney filters
86 Billion Neurons & 100 Trillion Interconnections
Biology of Life = Oxygen & Nutrient Delivery
If oxygenated circulation stopsto the body or an individual organ, and does not resume within a finite periodthe body/organ will never function again.
Two Concepts of Death1. Heart and circulation stops2. Brain stops
Shemie, Gardiner Frontiers CV Medicine, 2018
All Death Occurs This WaySaving Life Interrupts this Process
What is the purpose of Critical Care?
Resuscitation of heart & lung is notthe purpose, it’s the method.
The purpose is to resuscitate the brain.
Inference = resuscitate heart & lung?
Living patients 1. Intrinsic cardiopulmonary support• mechanical ventilation, hemodynamic support, cardiac compressions
2. Extrinsic extracorporeal support • ventricular assist devices, ECMO
Dead people1. Intrinsic cardiopulmonary support • somatic support after brain death• mechanical ventilation/cardiac compressions in uDCD
2. Extrinsic extracorporeal support • normothermic regional perfusion=donor ECMO
Individual organs • ex-vivo organ support
Options for Oxygenated Circulation
Shemie, Gardiner FCVM 2018
Via Ivan Ortega Deballon, with thanks
O2 Circulation: Intrinsic Cardiopulmonary SupportMechanical Ventilation, Cardiac Compressions
ECMO/Extracorporeal Oxygenated CirculationOutside the Body, but into the Patient
PICU Montreal Children’s Hospital, McGill UniversityECMO
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Artificial Heart Artificial KidneyArtificial Lung
Is not death if you have a machineto provide oxygenated circulation.
Complete and Irreversible Arrest of Heart Function
PICU, Montreal Children’s Hospital, McGill University
Oxygenated Circulation
Reviving Organs Outside the Body
Toronto Ex Vivo Lung Program
Keshavjee, Cypel with thanks
Edmonton Ex-situ Cardiac Program
D Freed with thanks
NRP/Normothermic Regional Perfusion after DeathReviving Organs Inside the Body
= Donor ECMO after deathReperfusion of abdomen +/- chest/heart
Oxygenated Circulation to the BrainNo blood flow, no function
No Brain Function But……
As long as oxygen & nutrients are delivered artificially
the body, organs, intestines, & spinal cord still work.
Growth occurs, & a mother’s body can support a fetus.
Thought Experiment
1.Intubate and ventilate
2.Control bleeding
3.Somatic support in ICU
Monolayer cell culture
The Ability to Sustain the Function of Cells,
Individual Organs or a Body
1.Brain death is the unintended consequence of
the attempt to save life
2.It is the final expression of irreversible
cessation of brain function
3.We are our brains- when our brain is no
longer, we are no longer
4.It extinguishes personhood
5.The person has died, but not the body parts
Summary1. Fascinating & challenging advances in technology & in
the ability to support & replace organ failure.
2. Brain death was discovered, not invented.
3. 2 concepts of‘heart’ & ‘brain’ death are no longer
relevant
4. It is inevitable that all death will become brain-based.
Register todaycampus.blood.ca
This curriculum is an accredited learning activity
(Sections 1 and 3) as defined by the
Maintenance of Certification program of
The Royal College of Physicians and Surgeons
of Canada.
The Canadian Clinical Guide to Organ Donation is
a free self-directed, interactive, online
e-learning course featuring case scenarios.
First module available
Neurological Determination of
Death (NDD)
Canadian Clinical Guide to Organ Donation
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