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The Unified Brain-Based Determination of Death Conceptually Justifies Death Determination in DCDD and NRP Protocols
1Dartmouth Geisel School of Medicine.
Insights
Organ donation after circulatory death requires permanent cessation of circulation, while brain death requires irreversible cessation of brain function. A unified approach links these, but remains inconsistent with the Uniform Determination of Death Act.
Area of Science:
- Medical Ethics
- Organ Transplantation
- Neurology
Background:
- Organ donation protocols differentiate between circulatory determination of death (DCD) and brain determination of death (DBD).
- Current DCD criteria require permanent cessation of all circulation.
- DBD criteria mandate irreversible cessation of all brain functions.
Purpose of the Study:
- To explore the concept of a unified brain-based determination of death for organ donation.
- To evaluate the compatibility of this unified approach with existing organ donation protocols, specifically thoracoabdominal NRP protocols using ECMO.
- To assess the alignment of the unified brain-based determination of death with the Uniform Determination of Death Act (UDDA).
Main Methods:
- Conceptual analysis of the physiological link between circulatory and brain death.
- Examination of organ perfusion circuits, particularly extracorporeal membrane oxygenation (ECMO), in non-heart-beating donor (NRP) protocols.
- Comparison of the proposed unified criteria with the legal framework established by the UDDA.
Main Results:
- Permanent cessation of systemic circulation leads to permanent cessation of brain circulation, perfusion, and function.
- Excluding brain circulation from ECMO circuits in NRP protocols can satisfy the unified brain-based determination of death, provided complete cessation is verifiable.
- The unified brain-based determination of death, despite its physiological basis, is currently inconsistent with the UDDA.
Conclusions:
- The unified brain-based determination of death offers a physiologically coherent framework for organ donation.
- Verification of complete cessation of brain circulation is crucial for implementing this unified approach in ECMO-assisted NRP protocols.
- Legislative and legal reform is necessary to reconcile the unified brain-based determination of death with the UDDA for broader application in organ transplantation.
Abstract:
Organ donation after the circulatory determination of death requires the permanent cessation of circulation while organ donation after the brain determination of death requires the irreversible cessation of brain functions. The unified brain-based determination of death connects the brain and circulatory death criteria for circulatory death determination in organ donation as follows: permanent cessation of systemic circulation causes permanent cessation of brain circulation which causes permanent cessation of brain perfusion which causes permanent cessation of brain function. The relevant circulation that must cease in circulatory death determination is that to the brain. Eliminating brain circulation from the donor ECMO organ perfusion circuit in thoracoabdominal NRP protocols satisfies the unified brain-based determination of death but only if the complete cessation of brain circulation can be proved. Despite its medical and physiologic rationale, the unified brain-based determination of death remains inconsistent with the Uniform Determination of Death Act.
