Table 4.
Clinical Practice Guideline recommendations
| Foundational medical principles | |
| DCC is made based on the absence of extracranial circulation that leads to the permanent absence of intracranial (brain) circulation. | |
| The following prerequisites must be met before conducting a valid clinical assessment for DNC: there must be an established cause of devastating brain injury severe enough to cause death and supported by neuroimaging evidence, and potential confounders of an accurate clinical assessment must have been considered and excluded. | |
| DNC is primarily a clinical assessment that requires all three of the following: 1) absence of consciousness shown by a lack of wakefulness and awareness in response to stimuli, 2) absence of brainstem function as shown by cranial nerve testing, and 3) absence of the capacity to breathe shown by formal apnea testing. | |
| All components of the clinical assessment for DNC must be performed to the fullest extent possible. If a valid clinical assessment is fully performed, complete, and consistent with death, then this is sufficient for death determination. Ancillary investigation alone is not sufficient to determine death and will not override a clinical assessment that is inconsistent with death. | |
| A clinical assessment is necessary but not sufficient for DNC in patients with isolated infratentorial brain injury without supratentorial involvement. Ancillary investigation is required to determine death in this scenario. | |
| Death determination by circulatory criteria | |
| We recommend that continuous invasive arterial blood pressure monitoring be used to confirm permanent cessation of circulation for patients who are potential organ donors undergoing DCC (strong recommendation, moderate certainty in evidence). | |
| We suggest that continuous electrocardiogram monitoring be used to confirm of permanent cessation of circulation in situations where the use of invasive arterial blood pressure monitoring is not possible for patients who are potential organ donors undergoing DCC (weak recommendation, moderate certainty in evidence). | |
| We recommend that an arterial pulse pressure of ≤ 5 mm Hg and within the error of measurement of clinical monitoring equipment be used to confirm permanent cessation of circulation for patients with an indwelling arterial cathether who are potential organ donors undergoing DCC (strong recommendation, very low certainty in evidence). | |
| We recommend a that minimum of five minutes observation be used to confirm permanent cessation of circulation for patients who are potential organ donors undergoing controlled donation after DCC (strong recommendation, moderate certainty in evidence). | |
| We recommend that a minimum of ten minutes of observation time be used to confirm permanent cessation of circulation for patients who are potential organ donors undergoing uncontrolled donation after DCC (strong recommendation, low certainty in evidence). | |
| Death determination by neurologic criteria | |
| We suggest delaying the clinical assessment for at least 48 hr from the time of return of spontaneous circulation post-cardiac arrest for patients with hypoxic-ischemic injury who do not have imaging evidence consistent with devastating brain injury undergoing DNC (weak recommendation, low certainty in evidence). | |
| We suggest ensuring a core body temperature of ≥ 36 °C for patients undergoing DNC (weak recommendation, very low certainty in evidence). | |
| We suggest using either quantitative pupillometry or clinical pupil assessment for patients undergoing DNC (weak recommendation, low certainty in evidence). | |
| We recommend against the addition of oculocephalic reflex testing to vestibulo-ocular reflex testing as part of the clinical assessment for patients undergoing DNC (strong recommendation, moderate certainty in evidence). | |
| We recommend that one complete clinical assessment is sufficient for patients one year of age or older who are undergoing DNC (strong recommendation, moderate certainty in evidence). | |
| We suggest that two complete clinical assessments separated in time are sufficient for patients less than one-year corrected gestational age who are undergoing DNC (weak recommendation, very low certainty in evidence). | |
| Apnea testing | |
| We suggest using a PaCO2 threshold of ≥ 60 mm Hg (and ≥ 20 mm Hg above baseline) when performing apnea testing for patients undergoing DNC (weak recommendation, very low certainty of evidence). | |
| We suggest using either positive pressure (continuous positive airway pressure) or passive oxygenation when performing the apnea test for patients undergoing DNC (weak recommendation, low certainty in evidence). | |
| We suggest using exogenously administered CO2 for patients undergoing DNC who have a high pre-test probability for cardiorespiratory instability that could prevent successful completion of the apnea test or who fail to complete the apnea test because of cardiorespiratory instability (weak recommendation, low certainty in evidence). | |
| Ancillary investigation—adults | |
| We suggest performing CT perfusion, CT angiography, transcranial Doppler, or a radionuclide brain perfusion study employing a lipophilic radiopharmaceutical (with or without tomographic imaging) in adult patients who require ancillary investigation for DNC (weak recommendation, very low to moderate certainty in evidence). | |
| We suggest against performing EEG, BAEP, SSEP, a radionuclide brain flow only study employing a lipophobic radiopharmaceutical, four-vessel cerebral angiography, or magnetic resonance imaging in adult patients who require ancillary investigation for DNC (weak recommendation, very low certainty in evidence). | |
| Ancillary investigation—pediatrics | |
| We suggest performing a radionuclide brain perfusion study employing a lipophilic radiopharmaceutical such as 99mTc-HMPAO or equivalent (which incorporates both a flow and parenchymal phase) with or without tomographic imaging in pediatric patients who require ancillary investigation for DNC (weak recommendation, low certainty in evidence). | |
| We suggest performing a radionuclide brain perfusion study employing a lipophobic radiopharmaceutical such as 99mTc-DTPA, 99mTc-GHA, 99mTc-pertechnetate or equivalent (which incorporate only a flow phase) when a study employing a lipophilic radiopharmaceutical cannot be performed in pediatric patients who require ancillary investigation for DNC (weak recommendation, low certainty in evidence). | |
| We suggest against performing EEG, transcranial Doppler, BAEP, SSEP, CT angiography, and four-vessel angiography in pediatric patients who require ancillary investigation for DNC (weak recommendation, very low certainty in evidence). | |
| We suggest against performing ancillary investigation in infants under 2 months corrected gestational age who require ancillary investigation for DNC (weak recommendation, very low certainty in evidence). | |
| Good practice statements | |
| A multidisciplinary support team (e.g., nurses, social workers, psychologists, spiritual carers, religious officials, and donor coordinators where applicable) should be included in care discussions as early as possible when it is suspected that a patient may progress to death. | |
| Any clinician participating in death determination must have the requisite skills, training, and knowledge of death determination processes and procedures. | |
| In all cases of potential organ donation, clinicians determining death must not have an association or active involvement in transplant procedures, organ allocation, or care of the intended transplant recipients. | |
| Where appropriate, assessment for DNC should be made in all persons with devastating brain injuries who are believed to meet these criteria, regardless of organ donation potential. | |
| The cause of devastating brain injury should be supported by neuroimaging evidence consistent with the established cause. | |
| A standardized checklist should be used for death determination and documentation. | |
| Fulfillment of all phases of death determination must be clearly documented by the most responsible physician in the patient’s medical record. | |
| Physicians supervising and interpreting radiologic ancillary investigation for DNC should be trained in neuroradiology with experience in the performance and interpretation of the specific examination being conducted. For CT angiography, radiologists should have required experience in using the correct protocol and scale. For CT perfusion, radiologists should have requisite training in performance and interpretation of this investigation. | |
| Physicians supervising and interpreting radionuclide ancillary investigation for DNC should be residency trained in nuclear medicine with experience in the performance and interpretation of the specific examination being conducted. | |
| Physicians supervising and interpreting transcranial Doppler testing for DNC should be adequately trained in neurosonography with experience in the performance and interpretation of the specific examination being conducted. |
BAEP = brainstem auditory evoked potentials; CT = computer tomography; DCC = death determination by circulatory criteria; DNC = death determination by neurologic criteria; EEG = electroencephalography; SSEP = somatosensory evoked potentials; DTPA = diethylene-triamine-pentaacetate acid; GHA = glucoheptonate; HMPAO = hexamethyl propylenamine oxime