When is dead really dead?

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The death prediction and physiology after removal of therapy study (DePPaRT study)

Dr. Sam Shemie, Professor in the Department of Pediatrics at McGill University is the senior investigative researcher on a new international study documenting the physiology of the dying process, led by Dr. Sonny Dhanani of the Children’s Hospital of Eastern Ontario (CHEO) Research Institute, and published in the January 28 issue of the New England Journal of Medicine. Working closely with the Canadian Donation and Transplantation Research Program, the research team asked over 600 families to allow their loved ones in the ICU to have their vital signs monitored during the dying process. This is the largest international study of its kind.

Why is a study like this important?

For families to choose organ donation when a loved one has died, they must be able to trust that death has really happened and that it is irreversible. Trust allows people to decide to donate at a time of grief and allows the medical community to feel comfortable opening a dialogue about donation. For donation after circulatory-determined death to be medically possible, death must be declared within a window of time after life sustaining measures are withdrawn. Yet, stories persist about people “coming back to life” following a declaration of death, and there was little evidence to inform the medical understanding of dying.

What did the study find?

The team found that the classic “flatline” of death is not so straightforward. The study showed that cardiac activity often stops and re-starts several times during the dying process before it finally stops completely – but no one regained sustained circulation or consciousness. The study provides evidence to support the current standard to wait for 5 minutes after the heart stops before determining death and proceeding to organ donation.

“This is the largest study to date seeking to better understand and characterize the dying process,” says Dr. Shemie, who is also a physician at in the critical care division of the Montreal Children’s Hospital and an associate investigator at the Research Institute of the McGill University Health Centre. “These findings are critical to maintaining trust with families in the organ donation process.”

How do you ask a family whose loved one is dying in the ICU to participate in a research study on organ donation? DePPaRT was empowered by the support and perspectives of a family partner, Ms. Heather Talbot, a woman whose son became a donor after dying in a car accident. The Canadian Donation and Transplantation Research Program’s Patient, Family and Donor Partnership Platform connected Heather with the DePPaRT team in 2015, and she took on the emotional challenges of joining as a consultant. Heather provided feedback from a family’s perspective, contributing ideas on how to appropriately approach families of dying patients. Her ability to reflect on her experiences and apply them to the study was pivotal for the project’s success. Her contributions helped achieve a family consent rate of 93% and dampened the team’s fears of overstepping boundaries. Her son’s gift of organ donation saved at least four lives and her involvement in DePPaRT is multiplying those gifts.

“To do this, we had to go into ICUs and monitor people as they were dying,” notes Dr. Dhanani. “This is a very personal experience. And here we were collecting data, sending it to a server, downloading it and having people review the vital signs … how things stopped and if they restarted. People were worried. Some physicians didn’t want to do it. Some researchers felt uncomfortable. But we knew we should keep going when we met Heather.”

What is the take away for the public?

Families and health care teams can trust that when death is determined, it is safe to begin the organ donation process. DePPaRT study data can now be used to inform policy and guidelines for determining death for organ donation both nationally and internationally. Further work using the study data will allow donation and transplant teams to predict how long it will take patients to die after removing life-sustaining measures. Predicting a time of death would be immensely useful to coordinate a donation and improve how organs are allocated.

This research was supported by the Canadian Institutes of Health Research as part of the Canadian Donation and Transplantation Research Program, the CHEO Research Institute, and Karel Pavlík Foundation.

Further background: CDTRP Fast Facts on Death Determination https://cdtrp.ca/wp-content/uploads/2021/01/Fast-Facts-Death-Determination-FEB2021.pdf

With source files from the CHEO

February 4, 2021

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