Predictors/Outcomes
Determination of death after circulatory arrest by intensive care physicians: A survey of current practice in the Netherlands

https://doi.org/10.1016/j.jcrc.2015.09.006Get rights and content

Abstract

Purpose

Determination of death is an essential part of donation after circulatory death (DCD). We studied the current practices of determination of death after circulatory arrest by intensive care physicians in the Netherlands, the availability of guidelines, and the occurrence of the phenomenon of autoresuscitation.

Methods

The Determination of Cardiac Death Practices in Intensive Care Survey was sent to all intensive care physicians.

Results

Fifty-five percent of 568 Dutch intensive care physicians responded. Most respondents learned death determination from clinical practice. The most commonly used tests for death determination were flat arterial line tracing, flat electrocardiogram (standard 3-lead electrocardiogram), and fixed and dilated pupils. Rarely used tests were absence pulse by echo Doppler, absent blood pressure by noninvasive monitoring, and unresponsiveness to painful stimulus. No diagnostic test or procedure was uniformly performed, but 80% of respondents perceived a need for standardization of death determination. Autoresuscitation was witnessed by 37%, after withdrawal of treatment or after unsuccessful resuscitation.

Conclusions

Extensive variability in the practice of determining death after circulatory arrest exists, and a need for guidelines and standardization, especially if organ donation follows death, is reported. Autoresuscitation is reported; this observation requires attention in further prospective observational studies.

Introduction

The use of organs from donation after circulatory death (DCD) donors is increasing in many countries. Donation after circulatory death, also known as donation after cardiac death or non–heart-beating donation, has become an established strategy to offer donation to more intensive care patients, expand the donor pool, and reduce the waiting list for transplantation [1]. Most DCD donors are patients admitted to the intensive care unit (ICU) who die after withdrawal of life-sustaining treatment (controlled DCD [cDCD]) [2]. Organs from cDCD donors are subjected to a period of warm ischemia, the period between the cessation of circulation and the initiation of preservation measures, which adversely affects transplant outcome [3]. To minimize the warm ischemic damage, it is paramount to initiate organ preservation as soon as possible after the patient's death. A fundamental principle within the context of organ donation is the “dead-donor rule”: organs cannot be removed until death has been declared [4]. The determination of circulatory death and a subsequent obligatory no-touch period to ensure the permanent death are an essential part of cDCD [5]. However, in contrast to the criteria for brain death, which are generally well defined and accepted with clear protocols, clearly defined criteria for determination of circulatory death are so far not available [6].

A review of contemporary international guidelines shows the currently existing variability in the determination of death after cardiac arrest [7], resulting in an ongoing discussion about the determination of cardiac death within the context of organ donation [8], [9], [10], [11]. The main issues identified relate to the irreversibility of the loss of cardiocirculatory function, the exact moment of death, and the concern about the possibility of spontaneous resumption of a cardiac rhythm after asystole with circulatory output, termed autoresuscitation (AR) [12], [13], [14].

The primary objective of this study was to describe the current practices of determination of death after cardiac arrest in adults in the Netherlands by intensive care physicians. Secondary objectives included to identify the policies and guidelines which are available to physicians, to determine the perceived need for standardization of practice, and to determine the reported occurrence of AR.

Section snippets

Materials and methods

All intensive care physicians caring for adult patients in the Netherlands were approached by mail using information from the Dutch Intensive Care Society, combined with information retrieved from Web sites of the hospitals. The medical manager of each department was contacted by telephone or by e-mail, to explain the study and ask permission to send the questionnaire to all staff intensivists.

To assess determination of death practice, the Determination of Cardiac Death Practices in Intensive

Demographics

All approached medical managers agreed to sending the questionnaire to their staff intensivists; 582 staff ICU physicians were approached.

The response rate was 55% (311/568); 14 were excluded (not practicing as intensivist, retired, or duplicated). The most frequent speciality training of participating intensivists included internal medicine and anesthesia. Most respondents (72%) were working in a university hospital, followed by a large teaching hospital (41%) and a district hospital (32%).

Discussion

This large national survey among all Dutch intensive care physicians caring for adult patients provides an in-depth insight in the practice of determination of death after circulatory arrest. The response rate was 55% representing the opinions of 311 intensive care physicians, from different backgrounds and different ICUs in the Netherlands, resulting in a reliable representation of common practice in the Netherlands.

The reported practice showed variability. No diagnostic test or procedure for

Conclusion

This large nationwide survey about the determination of death after cardiac arrest by intensive care physicians in the Netherlands shows an extensive variability in the practice of determining death after circulatory arrest. There is a need for guidelines and standardization of the determination of circulatory death, especially if organ donation follows death. The phenomenon of AR is reported, not only after unsuccessful resuscitation but also after withdrawal of life support, which requires

Competing interests

The authors declare that they have no conflict of interest.

Authors' contribution

JW, WvM, EvH, and SD: conception and design; JW: acquisition of data; JW, WvM, and EvH: data analysis; JW: first draft of manuscript; JW, WvM, SD, and EvH contributed to the interpretation of the data, revised the manuscript, and approved the final manuscript.

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