To Test or Not?
NHSBT Regional Collaborative
13th November 2014
Roger Lightfoot
Objectives
• Generate Discussion
– Present 2 Cases
– Ask audience whether to confirm death by
completing Brain Stem Tests or not?
Curriculum Vitae
• Consultant – Neurointensive Care
– August 2004 – present
• Director of Neurointensive Care
– June 2014 - Present
• Clinical Lead Organ Donation Neurointensive Care
– November 2012 – present
My own views
“If a patient is close to death and their
views cannot be determined, you should be
prepared to explore with those close to
them whether they had expressed any
views about organ or tissue donation, if
GMC 2010
donation is likely to be a possibility.”
2008
Club 32 Meeting Sept ‘13
…it was important to
separate completely the diagnosis
and confirmation of death from anything
to do with the issues surrounding
organ donation and transplantation.
..Suggested practice could
involve testing before end-of-life discussions…
Neurointensive Care Data
NICU Trust Data
2013-2014
DBD
No.
BSD Tested Rate
100%
22
Referral Rate
100%
22
Neurointensive Care Data
NICU Trust Data
2014-2015
DBD
ND Tested Rate
Referral Rate
No.
55%
6/11
100%
11
Case 1
• 52 yr female
• Previous TIAs
• Occluded basilar artery
– Cerebellar infarct
• No interventions
Case 1
• 2 days after admission
• 14:00 my first involvement
– Dilated unreactive pupils from 02:00
– Cardiovascular instability
– Sedation stopped at 11:00 (fentanyl/propofol)
– Talk of “living will”
• In back of husbands car
• Caring and close family
Case 1
• Futility of continued treatment confirmed
• Influences on BS Testing:
– Timing
• Consensus was following morning
– Influence of “living will”
• No experience
Case 1
• Comprehensive
– Disability
– Prolongation of life
– Interventions
• Not for organ donation
• Signed by 3rd party
• Confirmed with NOK
Compassionindying.org.uk
To Test or Not?
Outcome
• I did not proceed to BSD testing
– Living Will facilitated wishes
– Insight into person
• Extubated in evening
• Family drinking champagne before extubation
Case 2
• 53 yr old female
• Previous Ca Breast
• Mastectomy and
radiotherapy
• ICH and MCA
aneurysm
Case 2
• Day 3 post op
– Worsening vasospasm
– Fixed Dilated pupils 04:00
– Sedation stopped 09:00
– Discussion with SNOD
• Cancer Hx contraindication to
organ donation
• My involvement 14:00
Case 2
• Futility of continued treatment confirmed
– Ancillary imaging techniques
• Factors influencing testing:
– Sedation
– PMHx contraindication to organ donation
To Brain Stem Test or Not?
Outcome
•
•
•
•
14:45 –Discussion with family
I did not proceed to BSD Testing
Withdrawal of care at 19:12
Verification of death at 19:36
Objectives
• Generate Discussion
– Present 2 Cases
– Ask audience whether to confirm death by
completing Brain Stem Tests or not?
Time Between Tests
“Confirming death using neurological criteria: are two sets of
tests better than one?”
Gardiner D, Danbury C & Manara A (2013) JICS 14(1):6-7.
• Patient not dead until second test is done
• Timing:
• No specified time delay in UK
• USA observation ~ 19 hrs
• ANZICS now no minimum time
•Time of first tests is the important decision
Ancillary Tests
• Clinical
– Dolls eyes movements
• Electrophysiological
– EEG
– AEP
• Cerebral Flow
– Cerebral angiography
– CTA, MRA, TCDs
• Cerebral Perfusion
– PET, Xenon CT, HMPAO SPECT
Ancillary Tests
A survey of current practice and attitudes surrounding the use of
ancillary tests in the diagnosis of brainstem death in neurocritical
care units in the UK
JICS Volume 14, Number 3, July 2013
• Variation in practice in neurocritical care units in UK
• Confidence
• Availability
• Timing after sedatives stopped
• Recommend guidance on use of tests.
Ancillary Testing - Angiography
•
•
•
•
•
19 yr Female
DKA
GCS 3/15
EVD inserted
Bilateral Fixed dilated
pupils
• Cerebral angiogram
• BSD Testing
• Central Line
✔
• Fluid resuscitation
• Vasopressors
• DDAVP