Je cite un extrait du livre du Dr. Marc Andronikof, "Médecin aux Urgences", écrit avec Jacqueline Dauxois (Editions du Rocher, 2005, pages 127-131) :
Jacqueline Dauxois (JD) : "- Mais pourquoi affirme-t-on que c'est le cerveau qui détermine la mort ?
Marc Andronikof (MA) : - Les dégâts occasionnés au cerveau sont irréversibles.
JD : - Pas ceux occasionnés au coeur ?
MA : - Pour le coeur, vous pouvez essayer la réanimation, le massage cardiaque, vous avez un moyen pour revenir en arrière. Même chose pour les poumons, s'ils ne fonctionnent plus dans le cas d'une noyade par exemple, avec mise sous respiration artificielle, tout l'organisme peut repartir. Mais lorsque le cerveau cesse de fonctionner, assez rapidement le poumon s'arrête si vous ne suppléez pas par une machine et, au bout de quelques jours, quelques heures, quelques semaines, le coeur s'arrête aussi, quoi que vous fassiez. Autrement dit, on ne sait pas réactiver le cerveau. Puisqu'on ne sait pas, on affirme : 'ça va être fini', et comme ça va être fini, autant dire que c'est fini tout de suite, c'est ça, la supercherie ! Et de prétendre que le cerveau est le plus indispensable des organes n'est pas vrai non plus ! Quand il cesse de fonctionner et qu'on supplée à tous les autres organes par la réanimation, tout peut continuer pendant des jours et des jours. En revanche, si c'est le coeur qui s'arrête de fonctionner, même si vous suppléez à toutes les autres fonctions, la mort vient en quelques minutes, quoi que vous fassiez ! Pareil pour les poumons, le foie. Alors dans ces conditions, dites-moi quel est l'organe le plus indispensable ? Celui sans lequel tout peut fonctionner pendant de nombreux jours ou celui sans lequel tout s'arrête en quelques minutes ? Un arrêt cardiaque non réanimé dans les cinq minutes provoque des lésions irréversibles. Donc, le coeur est plus vital et le cerveau moins vital.. Mais on nous dit que le cerveau est plus vital que les autres organes, non pas tellement pour faire fonctionner l'organisme que parce qu'on ne peut pas suppléer à ses fonctions. [...]La mort est un processus au cours duquel vient le moment où il est impossible de revenir en arrière. Dans ce continuum arrive un moment où le processus de mort est tellement avancé qu'il n'est plus possible de prélever, on nous affirme donc qu'il faut prélever avant !
JD : - Pourquoi ne pas attendre ?
MA : - Parce que les organes commencent à se décomposer, alors on prélève avant ! [...]
JD : - Les chrétiens sont d'accord ?
MA : - Tout le monde est d'accord. Cependant les Américains, sous pression juive je suppose car les juifs, vous le savez, se tiennent mieux que les chrétiens, ont créé des centres où ils prélèvent sur coeur arrêté, sur coeur non-battant, c'est-à-dire lorsque le processus de mort est un peu plus avancé. A la seconde après l'arrêt du coeur, ils prélèvent les organes en toute hâte".
© Editions du Rocher, 2005
==> "Non heart-beating donation": in the Wikipedia Encyclopedia: click here.
Décret n° 2005-949 du 2 août 2005 relatif aux conditions de prélèvement des organes, des tissus et des cellules et modifiant le livre II de la première partie du code de la santé publique (dispositions réglementaires):
"Les établissements conventionnés pourront désormais prélever des reins et des foies sur des personnes 'décédées présentant un arrêt cardiaque et respiratoire persistant'. Précédemment, ces prélèvements étaient réalisés sur des donneurs en état de mort encéphalique et dont l’activité cardio-respiratoire était maintenue artificiellement. Cette disposition devrait augmenter le nombre de prélèvements".
==> Les textes officiels : cliquer ici.
==> "Le prélèvement sur donneurs à coeur arrêté va enfin pouvoir démarrer en France. Le 2 août 2005, un décret paru au Journal Officiel autorise ce type de prélèvements". Lire les informations à ce sujet sur le site Renaloo.com : ces informations sont très complètes et actualisées.
Controversies and updates in Donation after Cardiac Death (DCD)
Review
Pro/con ethics debate: When is dead really dead?
Abstract
"Contemporary intensive care unit (ICU) medicine has complicated the issue of what constitutes death in a life support environment. Not only is the distinction between sapient life and prolongation of vital signs blurred but the concept of death itself has been made more complex. The demand for organs to facilitate transplantation promotes a strong incentive to define clinical death in a manner that most effectively supplies that demand. We consider the problem of defining death in the ICU as a function of viable organ availability for transplantation.
The scenario
A 45 year old female patient arrives in the emergency department after having complained of a headache and progresses to unresponsiveness. She is placed on mechanical ventilation and a CAT scan of her brain shows massive intracranial bleed. The family is assured she will probably progress to brain death but she doesn't. After two days in the intensive care unit she continues with gasping ventilations and some flexion to pain in one arm. All other brain functions are absent. Her hemodynamics and other organ function are stable. The family desires the patient to be an organ donor but she is clearly not brain dead. It is suggested to the family that the patient can still donate under the 'Donation after Cardiac Death' (DCD) rules. Life support can be withdrawn and she can be pronounced dead using asystole as a criterion rather than brain death, following which organs can be taken for transplantation after a variable period of time to rule out 'auto-resuscitation'. Would you recommend this procedure? "
Various points of view are represented in this review. Here is the big picture:
- Death is a process and not an event.
- Brain-dead patients are dead ; patients who wish to become organ donors after their cardiac death (Donation after Cardiac Death) may not be dead at this stage.
- Stick to the Dead Donor Rule.
==> Read the full Review: click here.
Article by Leslie Whetstine, Health Care Ethics Center, Duquesne University, Pittsburgh, PA, USA.
"The question that arises from this case is: Is the DCD donor truly dead at the moment of organ recovery? The answer depends on two things: first, on what concept of death we are using; and second, what version of irreversibility we find most compelling. It is beyond the scope of this analysis to examine the appropriate conceptual definition of death, but suffice to say that the traditional concept of death is the irreversible cessation of the integrated functioning of the organism as a whole. I will argue that DCD does not fulfil this definition.
The Uniform Determination of Death Act (UDDA) [1] established that death could be declared by either the irreversible cessation of circulatory functions or the irreversible cessation of the entire brain, including the brain stem [2]. DCD advocates cite this statute as evidence that DCD is a legitimate practice using the circulatory criterion. The UDDA may appear to support DCD but only if we construe a bifurcated rather than a unitary definition of death that does not require the permanent cessation of the organism as a whole but only of certain parts of it. The UDDA claimed it did not suggest two different types of death but that either of the two criteria were necessary and sufficient conditions for death. We cannot embark on a critical analysis of this legislation here but it has three primary shortcomings: First, it failed to define the critical term 'irreversible'; second, irreversible absence of circulation is sufficient for death but not necessary; and third, irreversible absence of circulation may be a mechanism of death, but it is not death itself, which has always been regarded as brain death. As quoted from the New England Journal of Medicine [3], 'It is clear that a person is not dead until his brain is dead. The time honoured criteria of the stoppage of the heart beat and circulation are indicative of death only when they persist long enough for the brain to die.'
Advocates of DCD take a soft-line interpretation of irreversibility. They argue that if resuscitation has been proscribed and if the person cannot spontaneously resuscitate (auto-resuscitation), the person is irreversibly dead as a practical matter. But a moral decision to not restore function does not ensure the clinical state of death has been fulfilled. Moreover, inability to auto-resuscitate cannot be used to determine when death has occurred as many people who cannot auto-resuscitate can be resuscitated with an intervention. Finally, the time period in which auto-resuscitation may occur has not been sufficiently studied to make a determination that two or five minutes of asystole will preclude it. The fact that a person proscribes resuscitation or cannot auto-resuscitate does not make one dead at that precise moment, but prognosticates death and suggests one has entered a dying process that may ultimately lead to irreversible death.
Organ donation operates under the dead donor rule (DDR), which stipulates that organs may not be removed prior to death nor may organ procurement cause or hasten death. DCD fails to satisfy the DDR on three counts: First, it manipulates the definition of irreversibility based on a moral position not to resuscitate; second, it appeals to fallacious logic that because one cannot auto-resuscitate then one is dead; and third, it focuses solely on the circulatory criterion endorsed by the UDDA, which does not immediately correlate with brain status. Generally speaking, using the circulatory criterion would not be problematic as its absence will inevitably cause total brain failure. In DCD, however, the need for speed becomes a factor such that organs will be removed before the requisite time it takes for the brain to die as cessation of cardio-respiratory functions does not cause the brain to die immediately.
If the body can be resuscitated, we have to question if it was ever really dead given our conventional notion of death as a finality from which one cannot be returned or resurrected from under any circumstances. DCD protocols remove organs from a donor who is not irreversibly dead; if the whole brain is not yet dead, the patient cannot be dead."
Stephan Streat, Department of Critical Care Medicine, Auckland Hospital, Auckland, New Zealand.
"The issue of how death is certified, if this is 'according to good medical practice', does not determine my approach to organ donation. Whetstine, however, finds this 'the question' for non-heart-beating donation and advances three arguments why this should be so. First, I am unconvinced that death hasn't occurred because 'irreversibility' hasn't been established. Strictly speaking, no prospective definition of 'irreversibility' is possible. Only after all possible reversal strategies have failed can a situation truly be said to have been, in retrospect, 'irreversible'. In the circumstance of possible non-heart-beating donation, such strategies would be morally repugnant and contrary to acceptable clinical practice. I agree with Cole [4] that inclusion of the concept of 'irreversibility' is a deficiency of the Uniform Determination of Death Act (UDDA) [1]. But this semantic difficulty does not arise in many countries, including my own, that do not have a statutory definition of death.
Second, I understand how Whetstine's concern with 'irreversibility' has led her to consider the concept of auto-resuscitation but the UDDA is silent on this concept, as it is on the means by which death should be determined, requiring only that it must be "in accordance with accepted medical standards" [1]. Although 'lack of auto-resuscitation after a certain time interval' might be a reasonable 'accepted medical standard', there is no general consensus on whether this is an appropriate operational approach to 'irreversibility' or on what that 'certain time interval' might be and a dearth of reported evidence to inform that discussion.
The phenomenon of return of spontaneous circulation (ROSC) after discontinuation of cardiopulmonary resuscitation (CPR) was first reported in 1982 [5] and later termed the 'Lazarus phenomenon' [6]. A more recent review of 25 reported cases found that the exact timing after stopping CPR until the detection of ROSC was usually uncertain but could have been as long as 20 minutes in one case [7]. These authors suggested, 'after cessation of CPR, each patient should be further monitored (at least clinically and with an ECG) for at least 10 minutes (the typical time interval for a Lazarus phenomenon).' However, the phenomenology of similar events after circulatory arrest following extubation in the presence of severe brain damage may or may not be the same as those occurring after discontinuation of CPR (which has usually included, for example, several doses of adrenaline and other therapies).
In most jurisdictions where non-heart-beating organ donation occurs, a 10 minute period of circulatory arrest (asystole on ECG and no pulsatility by arterial line) has been accepted as sufficient to determine that 'death has occurred' [8], whereas the US Institute of Medicine recommended that a five minute period was sufficient [9]. Dutch law requires a further five minute 'no touch' period after death has been declared before any measures to procure organs can begin, similar to recommendations by the US Institute of Medicine.
Finally, Whetstine suggests that non-heart-beating donation springs solely from the circulatory criterion endorsed by the UDDA and, because the cessation of circulation does not cause the brain to die immediately, that the brain, and thereby the patient, might still be alive at the time that organ procurement begins. Although I agree that some parts of the previously severely damaged brain might be able to function if oxygen transport was immediately restored (even after perhaps 10 minutes of circulatory arrest), I see this concern as similar to her concern with irreversibility of circulatory arrest. There is no way to tell if the brain is dead after such a period of circulatory arrest, other than by restoring and maintaining oxygen transport and determining whether any signs of brain activity return. Such an operational approach to 'brain death' is not required by the UDDA or good clinical practice.
My own concerns in non-heart-beating organ donation are for the medical acceptability of the methods used to certify death, the independence of this process from the organ retrieval process, the manner in which the option of organ donation is discussed with the family and the acceptability of all of these processes to everyone involved. I do not believe that organ donation should ever be 'recommended' to families, only that under appropriate clinical circumstances, perhaps including this one, it is an 'option' that should be 'sensitively offered'."
Mike Darwin, Independent Critical Care Consultant, Arizona, USA.
"The fundamental questions are, simply, what and when is death? This problem is not new: In the seventh century, Celsus wrote, 'Democritus, a man of well merited celebrity, has asserted that there are in reality, no characteristics of death sufficiently certain for physicians to rely upon' [10].
Both Streat and Whetstine essentially concede defeat in dealing with these two pivotal questions in the first paragraph of their respective analyses. While sidestepping the core issue of what is the 'appropriate conceptual definition of death', Whetstine then argues compellingly that DCD does not meet either the intent or the criteria set forth in the UDDA. Streat argues compellingly that the issue of irreversibility is a practical impossibility to determine, and that because of this, utilitarian criteria should prevail in determining when death is pronounced and when organs may be retrieved.
The earliest definitions of death are arguably religious and largely binary; a person is either clearly dead or alive on the basis of whether a metaphysical spirit, soul, or life force continues to animate the physical body. The departure of the soul is synonymous with unequivocal death of the person and the only obligations that remain are ritually appropriate corpse disposal. This worldview is extremely valuable as it satisfies the practical and emotional needs of people for certainty, closure and clarity. With the advent of CPR and life support systems, the formerly binary status of life and death became increasingly analogue. The advent of transplantation served only to further degrade the binary view of death by allowing the continued 'survival' of the organism in a fragmented way in the bodies of others.
Because all other functions of human life could be medically enabled to persist after the loss of personal identity, the Harvard Committee properly focused its attention on the sole organ that enables or produces this property; the brain. As both Streat and Whetstine agree, however, the problem of what constitutes 'irreversible' was left unaddressed, and this is a critical flaw in any absolute definition of death. It is obvious that a solid majority of patients dying today could be resuscitated and supported artificially with intact mentation, albeit only at tremendous cost, both in terms of resources and suffering.
The brain is a discrete pattern of atoms, each as effective as the next as long as the unique pattern of their arrangement persists. Presumably all of the attributes of personhood are encoded in this lattice. This view allows us to view the person as 'information beings', defined by the arrangement of particular atoms that comprise our brains at any moment. So long as that pattern of information can be recovered, the person is not dead. If a cookbook is ripped to pieces it is no longer functional; it is impossible to read or use. The torn pages still contain all the information required, however, to allow for the book to be pieced back together and restored to a functional, useful state. By contrast, if the book is burned and the ashes stirred, the loss is irreversible given our current understanding of physical law (the limitations imposed by both the laws of thermodynamics and information theory). This approach to defining death, which is rooted not in relative, changing technology and vitalistic worldviews, but rather in the fundamentals of physical law, is known as the information theoretic criterion of death [11]. [...]
Both medicine and the law should respond to this problem with common sense, compassion and flexibility. It is only the ideologue or the fool who acknowledges noon and midnight, but denies all the states of light and darkness that smoothly shade together in the real world to create day and night. Patients who are not candidates for further medical intervention to save or prolong their lives should be pronounced dead based not on the absolute or theoretical irreversibility of their pathology, but rather on the basis of the permanence of this condition; namely, that there will be no attempt to resuscitate, revive, or otherwise seek to continue the patient's life. In the current milieu, this means the use of whatever clinical criteria under the law are appropriate at a time when further therapeutic interventions are medically ineffective, or are rejected by the patient, or his duly authorized medical surrogate.
Streat summarizes the course physicians should follow succinctly:
'My own concerns in non-heart-beating organ donation are for the medical acceptability of the methods used to certify death, the independence of this process from the organ retrieval process, the manner in which the option of organ donation is discussed with the family and the acceptability of all of these processes to everyone involved. I do not believe that organ donation should ever be recommended to families, only that under appropriate clinical circumstances, perhaps including this one, it is an option that should be sensitively offered.' [...]
Defining death in morally absolute terms is technologically, if not scientifically, impossible at this time. Attempts to use rigid, binary, black or white, all or none approaches will only serve to recreate the bitter futility of similarly barren arguments that have characterized the debate over when life begins (and the attendant social and medical issue of abortion). In the real world, death is a continuum, and it should be dealt with as such. That means thoughtful judgment on the part of patients, physicians and lawmakers as to where to draw lines in that shifting sand. If the informed consent of the patient is the foremost value, there will be little moral risk in deciding just how dark it must be before night has fallen."
David Crippen, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
"The rules for the interpretation of death by whole brain death (WBD) criteria were formulated over 20 years ago in an age of only moderate technological innovation. In 2005, it may be that modern critical care medicine has modified the entire concept of WBD, mandating replacement by a new paradigm taking into account our ability to discern shades of grey in brain function. Those shades of grey have become the focus of much debate as we try to find the line separating 'alive enough to donate' and 'dead enough to bury'.
These paradigm shifts not withstanding, the rules set out for the determination of death as it pertains to organ donation are very clear even in 2005. Patients must be dead before organs can be taken for transplantation. Traditionally, 'brain death' has been necessary for a patient to be declared legally dead for procurement of organs for transplantation [3]. The concept of DCD is a creative interpretation of the DDR [12], equating the aftermath of cardiac death with the presence of brain death. Many more patients could be used for donorship using cardiac death criteria.
But these concepts are not synonymous. Brain death is a diagnosis that death has occurred. Cardiac death is a prognosis that death is inevitable (using WBD criteria). The rules set down by the UDDA [1] suggest that death must be irreversible. Patients with cardiac standstill may not necessarily be brain dead, and may actually be resuscitatable if anyone chose to do it [13]. The criteria to make that determination must be both necessary and sufficient for death. It is necessary and sufficient that the entire brain has irreversibly ceased to function. Loss of a heartbeat is sufficient but not necessary in the presence of WBD. In this regard, DCD is a very creative interpretation of the DDR using utilitarian criteria. Patients may not be necessarily 'dead' by the rules, but they're 'dead enough' after cardiac standstill if death is inevitable. A seemingly small issue, but with big picture implications.
The big picture of all workarounds and creative interpretation of the rules is more daunting than the short-term benefits. The rules for organ donation are poorly amenable to bending, lest we find ourselves bidding for organs on eBay or harvesting suspicious operating room deaths as in Coma [14]. Enthusiasm and aggressive marketing techniques to raise public consciousness about organ donation are not necessarily compatible with rules in place to protect public rights.
Now that this workaround has been popularized, further creative interpretations of the rules are inevitable. Anything that increases the desired supply of organs could be fair game. Why not allow families to simply authorize mining for paired organs from incompetent relatives before death, and then withdraw life support on the basis of futility? Further, why not mandate that everyone is a donor unless they sign up with an 'I don't want to donate' registry? Now that the foot is in the door, and not much cry of foul has been forthcoming, more workarounds are on the way and each one will be an escalation of creative interpretation slanted toward increasing demand, perhaps at the cost of individual rights. This is the major reason why a very public discourse must continue on the subject of how we interpret the rules for organ donation."
Competing interests:
The author(s) declare that they have no competing interests.
References
[1] Uniform Determination of Death Act
http://www.law.upenn.edu/bll/ulc/fnact99/1980s/udda80.htm
[2] Joynt RJ: A new look at death.J Am Med Assoc 1984, 252:681.
[3] Sweet WH: Brain death, New England Journal of Medicine 1978, N°299, pages 410-412.
[4] Cole D: Statutory definitions of death and the management of terminally ill patients who may become organ donors after death. Kennedy Inst Ethics Journal 1993, N°3, pages 145-155.
[5] Linko K, Honkavaara P, Salmenperä M: Recovery after discontinued cardiopulmonary resuscitation. Lancet 1982, N°1, pages 106-107.
[6] Bray JG: The Lazarus phenomenon revisited. Anesthesiology 1993, N°78, page 991.
[7] Maleck WH, Piper SN, Triem J, Boldt J, Zittel FU: Unexpected return of spontaneous circulation after cessation of resuscitation (Lazarus phenomenon).
In: Resuscitation 1998, N°39, pages 125-128.
[8] Bos MA: Ethical and legal issues in non-heart-beating organ donation.
In: Transplantation 2005, N°79, pages 1143-1147.
[9] Institute of Medicine, National Academy of Sciences: Non-heartbeating Organ Transplantation: Medical and Ethical Issues in Procurement. Washington, DC: National Academy Press; 1997.
[10] Walker AE: Cerebral Death. 2nd edition. Baltimore-Munich: Urban and Schwarzenberg; 1981, pages 166.
[11] Merkle RC: The technical feasibility of cryonics. Med Hypotheses 1992, N° 39, pages 6-16.
[12] Veatch RM: The dead donor rule: true by definition. In: American Journal of Bioethics 2003, N°3, pages 10-11.
[13] Bernat JL: A defense of the Whole Brain concept of death. In: Hastings Center Report 1998, N°28, pages 14-23.
[14] Cook R: Coma. London: Macmillan Publishers; 1977.
Source:
Leslie Whetstine (1), Stephen Streat (2), Mike Darwin (3) and David Crippen (4)
(1) Health Care Ethics Center, Duquesne University, Pittsburgh, PA 15282, USA
(2) Department of Critical Care Medicine, Auckland Hospital, Auckland, New Zealand
(3) Independent Critical Care Consultant, Arizona, USA
(4) Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
In: Critical Care October 31, 2005.
==> Download the PDF Version of this review (Full text): click here.
==> Critical Care Medicine-L: www.ccm-l.org
An interdisciplinary Forum for the discussion of topics germane to the specialty of Critical Care Medicine. Medical Director: David Crippen, MD, Associate Professor, Department of Critical Care Medicine, Neurovascular Intensive Care Unit, University of Pittsburgh Medical Center, USA:
==> Access the CCM-L Editorial: click here.
Pro/con ethics debate: When is dead really dead?
Abstract
"Contemporary intensive care unit (ICU) medicine has complicated the issue of what constitutes death in a life support environment. Not only is the distinction between sapient life and prolongation of vital signs blurred but the concept of death itself has been made more complex. The demand for organs to facilitate transplantation promotes a strong incentive to define clinical death in a manner that most effectively supplies that demand. We consider the problem of defining death in the ICU as a function of viable organ availability for transplantation.
The scenario
A 45 year old female patient arrives in the emergency department after having complained of a headache and progresses to unresponsiveness. She is placed on mechanical ventilation and a CAT scan of her brain shows massive intracranial bleed. The family is assured she will probably progress to brain death but she doesn't. After two days in the intensive care unit she continues with gasping ventilations and some flexion to pain in one arm. All other brain functions are absent. Her hemodynamics and other organ function are stable. The family desires the patient to be an organ donor but she is clearly not brain dead. It is suggested to the family that the patient can still donate under the 'Donation after Cardiac Death' (DCD) rules. Life support can be withdrawn and she can be pronounced dead using asystole as a criterion rather than brain death, following which organs can be taken for transplantation after a variable period of time to rule out 'auto-resuscitation'. Would you recommend this procedure? "
Various points of view are represented in this review. Here is the big picture:
- Death is a process and not an event.
- Brain-dead patients are dead ; patients who wish to become organ donors after their cardiac death (Donation after Cardiac Death) may not be dead at this stage.
- Stick to the Dead Donor Rule.
==> Read the full Review: click here.
Patients cannot donate organs until they are dead
Article by Leslie Whetstine, Health Care Ethics Center, Duquesne University, Pittsburgh, PA, USA.
"The question that arises from this case is: Is the DCD donor truly dead at the moment of organ recovery? The answer depends on two things: first, on what concept of death we are using; and second, what version of irreversibility we find most compelling. It is beyond the scope of this analysis to examine the appropriate conceptual definition of death, but suffice to say that the traditional concept of death is the irreversible cessation of the integrated functioning of the organism as a whole. I will argue that DCD does not fulfil this definition.
The Uniform Determination of Death Act (UDDA) [1] established that death could be declared by either the irreversible cessation of circulatory functions or the irreversible cessation of the entire brain, including the brain stem [2]. DCD advocates cite this statute as evidence that DCD is a legitimate practice using the circulatory criterion. The UDDA may appear to support DCD but only if we construe a bifurcated rather than a unitary definition of death that does not require the permanent cessation of the organism as a whole but only of certain parts of it. The UDDA claimed it did not suggest two different types of death but that either of the two criteria were necessary and sufficient conditions for death. We cannot embark on a critical analysis of this legislation here but it has three primary shortcomings: First, it failed to define the critical term 'irreversible'; second, irreversible absence of circulation is sufficient for death but not necessary; and third, irreversible absence of circulation may be a mechanism of death, but it is not death itself, which has always been regarded as brain death. As quoted from the New England Journal of Medicine [3], 'It is clear that a person is not dead until his brain is dead. The time honoured criteria of the stoppage of the heart beat and circulation are indicative of death only when they persist long enough for the brain to die.'
Advocates of DCD take a soft-line interpretation of irreversibility. They argue that if resuscitation has been proscribed and if the person cannot spontaneously resuscitate (auto-resuscitation), the person is irreversibly dead as a practical matter. But a moral decision to not restore function does not ensure the clinical state of death has been fulfilled. Moreover, inability to auto-resuscitate cannot be used to determine when death has occurred as many people who cannot auto-resuscitate can be resuscitated with an intervention. Finally, the time period in which auto-resuscitation may occur has not been sufficiently studied to make a determination that two or five minutes of asystole will preclude it. The fact that a person proscribes resuscitation or cannot auto-resuscitate does not make one dead at that precise moment, but prognosticates death and suggests one has entered a dying process that may ultimately lead to irreversible death.
Organ donation operates under the dead donor rule (DDR), which stipulates that organs may not be removed prior to death nor may organ procurement cause or hasten death. DCD fails to satisfy the DDR on three counts: First, it manipulates the definition of irreversibility based on a moral position not to resuscitate; second, it appeals to fallacious logic that because one cannot auto-resuscitate then one is dead; and third, it focuses solely on the circulatory criterion endorsed by the UDDA, which does not immediately correlate with brain status. Generally speaking, using the circulatory criterion would not be problematic as its absence will inevitably cause total brain failure. In DCD, however, the need for speed becomes a factor such that organs will be removed before the requisite time it takes for the brain to die as cessation of cardio-respiratory functions does not cause the brain to die immediately.
If the body can be resuscitated, we have to question if it was ever really dead given our conventional notion of death as a finality from which one cannot be returned or resurrected from under any circumstances. DCD protocols remove organs from a donor who is not irreversibly dead; if the whole brain is not yet dead, the patient cannot be dead."
Donation after cardiac death is consistent with good medical practice
Stephan Streat, Department of Critical Care Medicine, Auckland Hospital, Auckland, New Zealand.
"The issue of how death is certified, if this is 'according to good medical practice', does not determine my approach to organ donation. Whetstine, however, finds this 'the question' for non-heart-beating donation and advances three arguments why this should be so. First, I am unconvinced that death hasn't occurred because 'irreversibility' hasn't been established. Strictly speaking, no prospective definition of 'irreversibility' is possible. Only after all possible reversal strategies have failed can a situation truly be said to have been, in retrospect, 'irreversible'. In the circumstance of possible non-heart-beating donation, such strategies would be morally repugnant and contrary to acceptable clinical practice. I agree with Cole [4] that inclusion of the concept of 'irreversibility' is a deficiency of the Uniform Determination of Death Act (UDDA) [1]. But this semantic difficulty does not arise in many countries, including my own, that do not have a statutory definition of death.
Second, I understand how Whetstine's concern with 'irreversibility' has led her to consider the concept of auto-resuscitation but the UDDA is silent on this concept, as it is on the means by which death should be determined, requiring only that it must be "in accordance with accepted medical standards" [1]. Although 'lack of auto-resuscitation after a certain time interval' might be a reasonable 'accepted medical standard', there is no general consensus on whether this is an appropriate operational approach to 'irreversibility' or on what that 'certain time interval' might be and a dearth of reported evidence to inform that discussion.
The phenomenon of return of spontaneous circulation (ROSC) after discontinuation of cardiopulmonary resuscitation (CPR) was first reported in 1982 [5] and later termed the 'Lazarus phenomenon' [6]. A more recent review of 25 reported cases found that the exact timing after stopping CPR until the detection of ROSC was usually uncertain but could have been as long as 20 minutes in one case [7]. These authors suggested, 'after cessation of CPR, each patient should be further monitored (at least clinically and with an ECG) for at least 10 minutes (the typical time interval for a Lazarus phenomenon).' However, the phenomenology of similar events after circulatory arrest following extubation in the presence of severe brain damage may or may not be the same as those occurring after discontinuation of CPR (which has usually included, for example, several doses of adrenaline and other therapies).
In most jurisdictions where non-heart-beating organ donation occurs, a 10 minute period of circulatory arrest (asystole on ECG and no pulsatility by arterial line) has been accepted as sufficient to determine that 'death has occurred' [8], whereas the US Institute of Medicine recommended that a five minute period was sufficient [9]. Dutch law requires a further five minute 'no touch' period after death has been declared before any measures to procure organs can begin, similar to recommendations by the US Institute of Medicine.
Finally, Whetstine suggests that non-heart-beating donation springs solely from the circulatory criterion endorsed by the UDDA and, because the cessation of circulation does not cause the brain to die immediately, that the brain, and thereby the patient, might still be alive at the time that organ procurement begins. Although I agree that some parts of the previously severely damaged brain might be able to function if oxygen transport was immediately restored (even after perhaps 10 minutes of circulatory arrest), I see this concern as similar to her concern with irreversibility of circulatory arrest. There is no way to tell if the brain is dead after such a period of circulatory arrest, other than by restoring and maintaining oxygen transport and determining whether any signs of brain activity return. Such an operational approach to 'brain death' is not required by the UDDA or good clinical practice.
My own concerns in non-heart-beating organ donation are for the medical acceptability of the methods used to certify death, the independence of this process from the organ retrieval process, the manner in which the option of organ donation is discussed with the family and the acceptability of all of these processes to everyone involved. I do not believe that organ donation should ever be 'recommended' to families, only that under appropriate clinical circumstances, perhaps including this one, it is an 'option' that should be 'sensitively offered'."
A thoughtful analysis of death in the ICU
Mike Darwin, Independent Critical Care Consultant, Arizona, USA.
"The fundamental questions are, simply, what and when is death? This problem is not new: In the seventh century, Celsus wrote, 'Democritus, a man of well merited celebrity, has asserted that there are in reality, no characteristics of death sufficiently certain for physicians to rely upon' [10].
Both Streat and Whetstine essentially concede defeat in dealing with these two pivotal questions in the first paragraph of their respective analyses. While sidestepping the core issue of what is the 'appropriate conceptual definition of death', Whetstine then argues compellingly that DCD does not meet either the intent or the criteria set forth in the UDDA. Streat argues compellingly that the issue of irreversibility is a practical impossibility to determine, and that because of this, utilitarian criteria should prevail in determining when death is pronounced and when organs may be retrieved.
The earliest definitions of death are arguably religious and largely binary; a person is either clearly dead or alive on the basis of whether a metaphysical spirit, soul, or life force continues to animate the physical body. The departure of the soul is synonymous with unequivocal death of the person and the only obligations that remain are ritually appropriate corpse disposal. This worldview is extremely valuable as it satisfies the practical and emotional needs of people for certainty, closure and clarity. With the advent of CPR and life support systems, the formerly binary status of life and death became increasingly analogue. The advent of transplantation served only to further degrade the binary view of death by allowing the continued 'survival' of the organism in a fragmented way in the bodies of others.
Because all other functions of human life could be medically enabled to persist after the loss of personal identity, the Harvard Committee properly focused its attention on the sole organ that enables or produces this property; the brain. As both Streat and Whetstine agree, however, the problem of what constitutes 'irreversible' was left unaddressed, and this is a critical flaw in any absolute definition of death. It is obvious that a solid majority of patients dying today could be resuscitated and supported artificially with intact mentation, albeit only at tremendous cost, both in terms of resources and suffering.
The brain is a discrete pattern of atoms, each as effective as the next as long as the unique pattern of their arrangement persists. Presumably all of the attributes of personhood are encoded in this lattice. This view allows us to view the person as 'information beings', defined by the arrangement of particular atoms that comprise our brains at any moment. So long as that pattern of information can be recovered, the person is not dead. If a cookbook is ripped to pieces it is no longer functional; it is impossible to read or use. The torn pages still contain all the information required, however, to allow for the book to be pieced back together and restored to a functional, useful state. By contrast, if the book is burned and the ashes stirred, the loss is irreversible given our current understanding of physical law (the limitations imposed by both the laws of thermodynamics and information theory). This approach to defining death, which is rooted not in relative, changing technology and vitalistic worldviews, but rather in the fundamentals of physical law, is known as the information theoretic criterion of death [11]. [...]
Both medicine and the law should respond to this problem with common sense, compassion and flexibility. It is only the ideologue or the fool who acknowledges noon and midnight, but denies all the states of light and darkness that smoothly shade together in the real world to create day and night. Patients who are not candidates for further medical intervention to save or prolong their lives should be pronounced dead based not on the absolute or theoretical irreversibility of their pathology, but rather on the basis of the permanence of this condition; namely, that there will be no attempt to resuscitate, revive, or otherwise seek to continue the patient's life. In the current milieu, this means the use of whatever clinical criteria under the law are appropriate at a time when further therapeutic interventions are medically ineffective, or are rejected by the patient, or his duly authorized medical surrogate.
Streat summarizes the course physicians should follow succinctly:
'My own concerns in non-heart-beating organ donation are for the medical acceptability of the methods used to certify death, the independence of this process from the organ retrieval process, the manner in which the option of organ donation is discussed with the family and the acceptability of all of these processes to everyone involved. I do not believe that organ donation should ever be recommended to families, only that under appropriate clinical circumstances, perhaps including this one, it is an option that should be sensitively offered.' [...]
Defining death in morally absolute terms is technologically, if not scientifically, impossible at this time. Attempts to use rigid, binary, black or white, all or none approaches will only serve to recreate the bitter futility of similarly barren arguments that have characterized the debate over when life begins (and the attendant social and medical issue of abortion). In the real world, death is a continuum, and it should be dealt with as such. That means thoughtful judgment on the part of patients, physicians and lawmakers as to where to draw lines in that shifting sand. If the informed consent of the patient is the foremost value, there will be little moral risk in deciding just how dark it must be before night has fallen."
DCD: a work-around of the rules we need to consider carefully
David Crippen, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
"The rules for the interpretation of death by whole brain death (WBD) criteria were formulated over 20 years ago in an age of only moderate technological innovation. In 2005, it may be that modern critical care medicine has modified the entire concept of WBD, mandating replacement by a new paradigm taking into account our ability to discern shades of grey in brain function. Those shades of grey have become the focus of much debate as we try to find the line separating 'alive enough to donate' and 'dead enough to bury'.
These paradigm shifts not withstanding, the rules set out for the determination of death as it pertains to organ donation are very clear even in 2005. Patients must be dead before organs can be taken for transplantation. Traditionally, 'brain death' has been necessary for a patient to be declared legally dead for procurement of organs for transplantation [3]. The concept of DCD is a creative interpretation of the DDR [12], equating the aftermath of cardiac death with the presence of brain death. Many more patients could be used for donorship using cardiac death criteria.
But these concepts are not synonymous. Brain death is a diagnosis that death has occurred. Cardiac death is a prognosis that death is inevitable (using WBD criteria). The rules set down by the UDDA [1] suggest that death must be irreversible. Patients with cardiac standstill may not necessarily be brain dead, and may actually be resuscitatable if anyone chose to do it [13]. The criteria to make that determination must be both necessary and sufficient for death. It is necessary and sufficient that the entire brain has irreversibly ceased to function. Loss of a heartbeat is sufficient but not necessary in the presence of WBD. In this regard, DCD is a very creative interpretation of the DDR using utilitarian criteria. Patients may not be necessarily 'dead' by the rules, but they're 'dead enough' after cardiac standstill if death is inevitable. A seemingly small issue, but with big picture implications.
The big picture of all workarounds and creative interpretation of the rules is more daunting than the short-term benefits. The rules for organ donation are poorly amenable to bending, lest we find ourselves bidding for organs on eBay or harvesting suspicious operating room deaths as in Coma [14]. Enthusiasm and aggressive marketing techniques to raise public consciousness about organ donation are not necessarily compatible with rules in place to protect public rights.
Now that this workaround has been popularized, further creative interpretations of the rules are inevitable. Anything that increases the desired supply of organs could be fair game. Why not allow families to simply authorize mining for paired organs from incompetent relatives before death, and then withdraw life support on the basis of futility? Further, why not mandate that everyone is a donor unless they sign up with an 'I don't want to donate' registry? Now that the foot is in the door, and not much cry of foul has been forthcoming, more workarounds are on the way and each one will be an escalation of creative interpretation slanted toward increasing demand, perhaps at the cost of individual rights. This is the major reason why a very public discourse must continue on the subject of how we interpret the rules for organ donation."
Competing interests:
The author(s) declare that they have no competing interests.
References
[1] Uniform Determination of Death Act
http://www.law.upenn.edu/bll/ulc/fnact99/1980s/udda80.htm
[2] Joynt RJ: A new look at death.J Am Med Assoc 1984, 252:681.
[3] Sweet WH: Brain death, New England Journal of Medicine 1978, N°299, pages 410-412.
[4] Cole D: Statutory definitions of death and the management of terminally ill patients who may become organ donors after death. Kennedy Inst Ethics Journal 1993, N°3, pages 145-155.
[5] Linko K, Honkavaara P, Salmenperä M: Recovery after discontinued cardiopulmonary resuscitation. Lancet 1982, N°1, pages 106-107.
[6] Bray JG: The Lazarus phenomenon revisited. Anesthesiology 1993, N°78, page 991.
[7] Maleck WH, Piper SN, Triem J, Boldt J, Zittel FU: Unexpected return of spontaneous circulation after cessation of resuscitation (Lazarus phenomenon).
In: Resuscitation 1998, N°39, pages 125-128.
[8] Bos MA: Ethical and legal issues in non-heart-beating organ donation.
In: Transplantation 2005, N°79, pages 1143-1147.
[9] Institute of Medicine, National Academy of Sciences: Non-heartbeating Organ Transplantation: Medical and Ethical Issues in Procurement. Washington, DC: National Academy Press; 1997.
[10] Walker AE: Cerebral Death. 2nd edition. Baltimore-Munich: Urban and Schwarzenberg; 1981, pages 166.
[11] Merkle RC: The technical feasibility of cryonics. Med Hypotheses 1992, N° 39, pages 6-16.
[12] Veatch RM: The dead donor rule: true by definition. In: American Journal of Bioethics 2003, N°3, pages 10-11.
[13] Bernat JL: A defense of the Whole Brain concept of death. In: Hastings Center Report 1998, N°28, pages 14-23.
[14] Cook R: Coma. London: Macmillan Publishers; 1977.
Source:
Leslie Whetstine (1), Stephen Streat (2), Mike Darwin (3) and David Crippen (4)
(1) Health Care Ethics Center, Duquesne University, Pittsburgh, PA 15282, USA
(2) Department of Critical Care Medicine, Auckland Hospital, Auckland, New Zealand
(3) Independent Critical Care Consultant, Arizona, USA
(4) Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
In: Critical Care October 31, 2005.
==> Download the PDF Version of this review (Full text): click here.
==> Critical Care Medicine-L: www.ccm-l.org
An interdisciplinary Forum for the discussion of topics germane to the specialty of Critical Care Medicine. Medical Director: David Crippen, MD, Associate Professor, Department of Critical Care Medicine, Neurovascular Intensive Care Unit, University of Pittsburgh Medical Center, USA:
==> Access the CCM-L Editorial: click here.
"Science And Society: Death, Unconsciousness And The Brain"
Abstract:
"The concept of death has evolved as technology has progressed. This has forced medicine and society to redefine its ancient cardiorespiratory centred diagnosis to a neurocentric diagnosis of death. The apparent consensus about the definition of death has not yet appeased all controversy. Ethical, moral and religious concerns continue to surface and include a prevailing malaise about possible expansions of the definition of death to encompass the vegetative state or about the feared bias of formulating criteria so as to facilitate organ transplantation."
Says Steven Laureys, Neurology Department, University of Liège, Belgium:
"As mentioned in the paper my opinion is: death is an event and not a process ; brain dead patients are dead ; stick to the dead-donor rule. The situation in Belgium I believe is similar to France, with the exception that all citizens are donors unless one actively and explicitly objects during life."
==>Full article (PDF Form): click here.
Source:
National Review of Neurosciences, 2005 Nov;6(11):899-909.
Author: Steven Laureys, Cyclotron Research Centre and Neurology Department, Université de Liège, Sart Tilman-B30, 4000 Liege, Belgium.
NCBI-PubMed
Other article by Steven Laureys, Neurology Department, University of Liège, Belgium: The locked-in syndrome: what is it like to be conscious but paralyzed and voiceless?
==> click here.
"The concept of death has evolved as technology has progressed. This has forced medicine and society to redefine its ancient cardiorespiratory centred diagnosis to a neurocentric diagnosis of death. The apparent consensus about the definition of death has not yet appeased all controversy. Ethical, moral and religious concerns continue to surface and include a prevailing malaise about possible expansions of the definition of death to encompass the vegetative state or about the feared bias of formulating criteria so as to facilitate organ transplantation."
Says Steven Laureys, Neurology Department, University of Liège, Belgium:
"As mentioned in the paper my opinion is: death is an event and not a process ; brain dead patients are dead ; stick to the dead-donor rule. The situation in Belgium I believe is similar to France, with the exception that all citizens are donors unless one actively and explicitly objects during life."
==>Full article (PDF Form): click here.
Source:
National Review of Neurosciences, 2005 Nov;6(11):899-909.
Author: Steven Laureys, Cyclotron Research Centre and Neurology Department, Université de Liège, Sart Tilman-B30, 4000 Liege, Belgium.
NCBI-PubMed
Other article by Steven Laureys, Neurology Department, University of Liège, Belgium: The locked-in syndrome: what is it like to be conscious but paralyzed and voiceless?
==> click here.
La valise diplomatique. Une fiction médicale
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Je me suis décidée à écrire sur ce sujet aux frontières entre la vie et la mort, la mort et la vie, un no man’s land où nous, chirurgiens et chirurgiennes, procédons en passeurs anonymes à des échanges clandestins. Nous passons ces frontières en clandestins : «Non, je n’ai rien à déclarer» (ce territoire ne fait pas encore partie de l’espace Schengen). «Valise diplomatique !». Je brandis mon I.D. justifiant mon Immunité Diplomatique, et je franchis sans histoire les frontières successives, avec ma précieuse valise, que personne ne m’a demandé d’ouvrir. En général, à ce moment là, des images m’accompagnent : un ange aux ailes de sang. Pourquoi du sang ? J’ai dû essayer de faire rentrer mes ailes dans les gants chirurgicaux. Pas précisément adaptés. Je saigne, je sais, ça fait partie du métier. «Le sang coule, c’est le métier qui rentre». «Ce qui ne détruit pas rend plus fort». Ces phrases reviennent souvent dans la bouche de mes collègues. Des phrases pour cimenter les briques des épreuves.
Quand j’étais étudiante en première année de médecine, l’année du redoutable concours, l’amphi était bondé en début d’année. Un de nos profs procéda à un écrémage selon une recette maison, sans attendre le concours : «En choisissant médecine, vous vous préparez à passer votre vie dans le sang, l’urine, la merde et le vomi. Ceux que ça gêne, il faut qu’ils partent à côté : ils apprendront à vendre des savonnettes». Trois cours plus tard, un bon quart des étudiants avait déserté l’amphi pour de bon. A la grande satisfaction du prof. En même temps que le sang et compagnie, il aurait dû mentionner le manque de sommeil. Parler du sommeil à un «chir.» (c’est comme ça qu’on nous appelle dans le métier) équivaut à parler du sucre à un diabétique. Orgie de douceur vengeresse qui me traverse, dans le sillage de l’ange aux ailes de sang.
Depuis 5 ans, je supervise les internes dans le service de chirurgie pédiatrique d’un grand hôpital parisien. Les usagers de la santé nous tiennent pour des scientifiques, des grands prêtres de la Science Exacte : chirurgie assistée par ordinateur pour opérer les organes mous en endoscopie, chirurgie au laser, robot pour opérer la cataracte, système high-tech de chirurgie assistée par ordinateur pour la pose de prothèses de genoux : la précision chirurgicale est devenue numérique. La chirurgie, c’est Matrix ; le chirurgien, c’est James Bond. Comme l’espion britannique de Sa Majesté, j’utilise la technologie de pointe en m’efforçant de ne pas faire de vagues. «Painless civilization ¹». C’est le package que l’hôpital vend à l’usager de la santé. Un ami qui est comptable dans une clinique privée m'a repris l’autre jour : «Tu ne dois plus parler de malade ou de patient. Il faut parler de client». Je lui ai répondu : «Pour une fois que la compta et le marketing s’entendent !... D’habitude, le marketing dépense des sous et la compta râle».
«On va opérer votre petite Mélanie en chirurgie mini invasive, à cœur battant. Pas besoin de lui ouvrir la cage thoracique, il suffira de pratiquer quelques incisions minimes. Pas besoin de lui casser les côtes, pas besoin non plus d’utiliser le CEC (Système de Circulation Extracorporelle) qui gère l’arrêt temporaire du cœur et des poumons, la circulation du sang s’effectuant en 'itinéraire bis' pendant ce temps, grâce à une machine qui relaye les fonctions cardio-pulmonaires, tout ceci après ouverture de la cage thoracique et écartement des côtes. Lorsqu’on utilise cette méthode de chirurgie traditionnelle invasive, on opère ‘à ciel ouvert’, comme disent les chirurgiens. Pour Mélanie, plus besoin de tout ça. Par les toutes petites incisions qu’on pratiquera sur son thorax, on entrera les instruments destinés à opérer. Un chirurgien assis à une console équipée d’une image en 3D et d’un système infrarouge commandera, ou téléguidera, si vous voulez, les mouvements des instruments opérant à cœur battant. Vous voyez, ce n’est pas le robot qui opère, c’est le chirurgien, pour autant plus besoin d’ouvrir le thorax et d’utiliser la CEC. Rassurez-vous, c’est une opération pratiquée couramment aujourd’hui, votre petite fille sera sortie de l’hôpital et totalement rétablie en 3 jours». Tandis que je parle ainsi à la mère de ma petite patiente de 6 ans, l’ange aux ailes de sang me traverse à nouveau, cette fois-ci, il opère à ciel ouvert. Le fruit de vos entrailles est béni !
Chirurgie mini invasive, coelioscopie, etc. : je suis une chirurgienne informatisée, et je veille à avoir les derniers logiciels. Ils viennent de Californie. Silicon Valley, l’université de Stanford, l’UCLA (University of California, Los Angeles), etc. Le progrès est relégué au grenier. Nous sommes à l’ère des technologies, biotechnologies, bioéthique, éthique médicale. L’autre jour j’ai lu un article dans le NEJM, le très sérieux «New England Journal of Medicine», écrit par un «Medical Bioethicist PHD». J’ai mis un moment avant de déchiffrer ce que recouvrait exactement ce terme barbare. C’est dans la langue de Shakespeare, mais ce n’est pas du Shakespeare ! En salle de garde, un interne résume la situation : «La biotechnologie, c’est de la technologie bio. Et la bioéthique, c’est pour réfléchir là-dessus. Internet ; l’intranet et l’extranet, tout ça c’est bio, comme la Vie Claire. Puisqu’on nous promet des écrans organiques pour nos ordinateurs de demain… Jamais entendu parler des écrans OLED ?»
¹- Titre d'un essai du philosophe Japonais Masahiro Morioka, Professeur à l'université d'Osaka. Lien vers cet essai (version anglaise) : "Painless Civilization: A Philosophical Critique of Desire" (2003) ==> cliquer ici.
==> Lire la suite de La Valise Diplomatique (Format PDF) :
cliquer ici.
A lire également :
==> Des chirurgiens et des robots : cliquer ici.
==> Des chirurgiens et des robots (suite) : cliquer ici.
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