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A Brief History of Death - 2020-11-10 - AAGBI

I attended AAGBI and NHS Blood and Organ Transplant Webinar

They point out in catastrophic brain injury that respiratory arrest leading to cardiac arrest is interrupted, as we stop the respiratory arrest happening with ventilators.

1968 bring in irreversible coma of ad hoc committee as death

2008 UK Criteria for Circulatory Criteria brings in asytole for five minutes.

UK Code of Practice of Death Diagnosis

Irreversible loss of the capacity for consciousness combined with irreversible loss of the capacity to breathe.

UK Case Law

Re A (A minor) 1992 - brainstem death is death Bland 1993 TOny Bland is alive as brainstem no destroyed.

Death is a brainstem

Reticular activating system - for consciousness

Medulla Oblongata - for respiratory control

Death can be diagnosed through

Circulatory Criteria - 99% of deaths in UK First is a clear intention not to attempt or continue CPR An examination and observation period

Continuous apnoea, mechanical asystole for five minues
Neurological examination after the five minutes
Neuro exam is pupil, cornea, supraorbital pressure

Five minutes is because the heart won't restart spontaneously after that.

Other parts of world 2 minutes is used. But hearts have restarted spont at that time

Probition is any intervention that might restore cerebral blood flow by any means.

But how can you give early inflation of lungs with oxygen to allow for lung donation.

There is a 2010 doc to show how to do that safely.

To allow for this in the lung donation. You can intubate after five minutes. But you need to wait another five minutes before the single inflation breath. There isn't any risk of the heart restarting if you follow this.

Neurological Criteria

Irreversible loss of capacity of consciousness, and capacity to breathe.

You need an established aetiology first. SOmething that makes sense to cause brainstem death.

You need to exclude confounding conditions.

Clinical exam demonstrating profound coma, brain stem reflexes (additional reflexes in comparison to cardiac.)

Apnoea test is mapleson C circuit, which allows you to see breathes, observe for five minutes. looking for a paCO2 rise in >0.5. The apnoea test is only performed twice.

Somatic Criteria - Recognition of Life Extinct for paramedics

International Criteria

Canada pretty similar.

US talks about needing Total Brain Failure rather than brain stem.

However the World Brain Death project is trying to clarify this and is moving towards brainstem rather than whole brain.

Challenges of Brain Stem Death Criteria

  • "Self Fulfilling Prophecy"
  • Explaining spinal reflexes to family

There has never been a case of someone who has appropriate death diagnosed by neurological criteria who has woken up.

Talking to relatives

We shouldn't talk about brain stem death, we should talk about how we are "concerned that they have already died"

The confirmation of death.

Dying is a process, as clinicians we have had to decide where along that process we are happy to confirm that someone has died.

www.odt.nhs.uk <- Look at these videos about organ donation