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Background: The global organ shortage is the biggest obstacle to expand urgently needed liver transplantation activities. In addition to donation after brain death (DBD), donation after primary circulatory death (DCD) has also been introduced in many European countries to increase the number of donated organs. Objective: This article summarizes the legal and ethical aspects of DCD, the practical donation process of DCD, the clinical results of DCD liver transplantation with a special focus on organ assessment before a planned DCD liver transplantation. Results: In Europe 11 countries have active DCD liver transplantation programs and a total of 1230 DCD liver transplantations were performed in Europe in 2023. The highest proportion of DCD liver transplantations were recorded in Belgium (52.8%), the Netherlands (42.8%) and Switzerland (32.1%). The adequate selection of donors and recipients is crucial in DCD transplantation and the use of DCD livers particularly depends on the preparedness of the healthcare system for routine machine perfusion. The leaders are Belgium, France and Italy which implant around 68–74% of DCD organs. With an adequate organ assessment, the long-term results of DBD and DCD liver transplantations are comparable. To assess mitochondrial damage and thus organ quality, hypothermic oxygenated machine perfusion (HOPE) was introduced and has the secondary benefit of mitochondrial protection through oxygenation. The establishment of aerobic metabolism in mitochondria under hypothermia leads to a reduction of toxic metabolites and the restoration of ATP storage, which subsequently leads to a reperfusion light during implantation. Conclusion: Expanding the donor pool with DCD donors can counteract the global organ shortage. With adequate patient selection and routine organ assessment short-term and also long-term outcomes of DBD and DCD liver transplantation are comparable. [ABSTRACT FROM AUTHOR]

The article discusses the causality between occupational activity and illness. It emphasizes that the prevalence within a professional group is only an indication of a medical causal relationship. It is also pointed out that an increased prevalence is not necessarily required to recognize an illness as an occupational disease. The text deals with legal aspects related to life-sustaining measures. It is noted that in urgent proceedings, new facts and evidence can be presented. The text deals with the definition of death in a legal context. It argues that it would be inconsistent to split the concept of death and reject the concept of brain death altogether. The present text deals with neurological examinations and guidelines for determining brain death. It is noted that a perfusion examination may be limited in its informative value when intracranial pressure decreases. It is also pointed out that movements within the context of brain death can be triggered by the spinal cord. There are doubts whether the observed body movements of the patient are compatible with a brainstem failure. The patient has a right to resume and continue tumor-specific therapy as well as receive vitamins and intestine-affecting medications due to contractual obligations. [Extracted from the article]

This contribution aims to understand whether it is possible to speak of a care relationship between a patient in ‘irreversible apneic coma’ and his relative, in order to demonstrate the illusory nature of the relationship, lacking the same prerequisites that characterize the care ethic: absence of reciprocity and the relative emotional and human enrichment of ‘giving’ for both. The conclusion will be reached that the emotional assistance of the relative towards the patient in brain death is dictated only by the personal selfishness of the former, convinced that the physical closeness to the loved one provides him with an emotional-psychological return to his personal advantage.

Background: A broader distribution of bedside color-coded duplex sonography (CCD) for detection of cerebral circulatory arrest (CCA) would be important to improve its use in the diagnosis of irreversible loss of brain function (ILBF-Dx). Question: Is extracranial compared to the commonly applied transcranial CCD of the brain-supplying vessels (ECCD vs. TCCD) equivalent for the detection of CCA in ILBF-Dx regarding specificity and sensitivity? Material and methods: Study period January 2019–June 2022, screening of 136 and inclusion of 114 patients with severe brain lesions > 24 h after onset of fixed and dilated pupils, apnea and completed ILBF-Dx. Exclusion of patients without brainstem areflexia and guideline-conform applicability of CCD. Complementary ECCD (and TCCD, if other method used for irreversibility detection). Results: Detection of ILBF (ILBF+) in 86.8% (99/114), no ILBF (ILBF−) in 13.2% (15/114). ECCD was fully feasible in all patients; findings matching CCA were found in 94/99 ILBF+ cases (ECCD+) and not in 5 patients (ECCD−). All 15 patients with ILBF− showed ECCD− findings. Thus, the specificity of ECCD was 1.0, and the sensitivity was 0.949. TCCD showed CCA in 56 patients (TCCD+), and ECCD+ was also found in all of them. An inconclusive result of TCCD in ILBF+ was found in 38 cases, with parallel ECCD+ in all of these patients. In 20 cases, TCCD did not show CCA (TCCD−), these also showed ECCD−. Of these patients 15 were ILBF− and 5 were ILBF+. Discussion: TCCD was not completely feasible or inconclusive in one third of the cases, whereas ECCD was always feasible. ECCD showed high validity with respect to the detection of CCA. Therefore, the possibility of using ECCD alone to detect CCA in ILBF-Dx should be discussed. [ABSTRACT FROM AUTHOR]

Background: The 4th update of the guidelines of the German Medical Association on the diagnosis of irreversible loss of brain function (brain death, BD) has introduced important new regulations regarding the required qualification of the examiners, approved procedures for ancillary testing, and a clarification regarding the sequencing of diagnostic steps. Objective: Investigation of the implementation and practical effects on the diagnosis of brain death. Method: Descriptive evaluation of the routine documentation of the German Organ Procurement Organization, comparing the periods July 2011–June 2015 (3rd update) and July 2015–June 2019 (4th update). Results: Patient numbers decreased from 6100 to 5403. The largest decrease affected hospitals without neurosurgery. Children were not affected. With the 4th update, clinical diagnostics were increasingly performed during on-call hours by external neurologists. Of the patients 83.8% now received ancillary tests compared to 80.1% previously. Computed tomography angiography (CTA), first introduced in the 4th update, was applied in 23.2% and established complete loss of cerebral circulation in 89.4%. The time between first documentation of the clinical signs of BD and certification of BD increased from 7.0 ± 12.7 h to 8.2 ± 14.2 h. The diagnosis was slightly less frequent with 95.3% compared to 96.6%. Conclusion: The updated standards were implemented in accordance with the guidelines. The demand for external consulting neurologists and neurosurgeons as well as the time required for BD assessment have increased. Negative effects on pediatric BD diagnostics were not apparent. CTA is widely and successfully used in adults as a new ancillary diagnostic procedure. [ABSTRACT FROM AUTHOR]

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The prerequisites for post-mortem organ donation in Germany include the determination of irreversible loss of brain function, consent to organ donation, and the exclusion of medical contraindications. In addition, mainly because of the shortage of donor organs in Germany and the sometimes controversial social and media discussions on the topic of organ donation, all physicians involved in the donation process must be familiar with the relevant laws, guidelines, and procedural instructions. This applies especially to those who are to carry out the verification of irreversible brain death. Only then, can they act safely in this challenging situation and serve as competent consultants for all involved. [ABSTRACT FROM AUTHOR]

Background: The number of organs donated after brain death in Germany is far lower than the demand. This underlines the importance of providing the brain-dead donor with optimal medical care throughout the donation process to decrease the risk of graft dysfunction. Several international guidelines and national recommendations guide the intensivists in organ-protective intensive care management of the brain-dead donor.Objective: The anesthetist is a key member during organ retrieval procedures and plays a crucial role in physiological donor management; however, evidence-based recommendations for the perioperative anesthetic management, drug treatment strategies and target values are lacking. Anesthesia literature about donor management is scarce and predominantly composed of reviews of practice, with little exploration of the scientific foundations. The aim of this review is to guide the anesthetist in the organ-protective perioperative therapy. The pathophysiological changes in patients who progress to brain death are briefly summarized. The available evidence, guidelines and expert opinions regarding medical treatment strategies and therapeutic goals in organ-protective therapy are reviewed. The ethical and pathophysiological considerations regarding the performance of anesthesia during organ retrieval are discussed.Methods: This review is based on a selective literature search in PubMed for publications regarding organ donation after brain death (keywords: "brain dead donor", "organ procurement", "organ protective therapy", "donor preconditioning", "perioperative donor management", "ethical considerations of brain dead donor"). International guidelines, national recommendations and expert opinions were given special consideration.Results: Overall, the evidence for optimal perioperative organ-protective care of the brain-dead donor is limited. Most elements in the current recommendations and guidelines are based on pathophysiological reasoning, epidemiological observations or extrapolations from general organ-protective management strategies, and not on evidence from randomized controlled trials. National and international recommendations on treatment goals and drug therapy differ considerably in some aspects. The therapy concepts applied are very heterogeneous. Apart from medical challenges, the ethical circumstances are an additional burden for the entire treatment team. Whether anesthesia is reasonable during organ retrieval remains unclear. There is uncertainty about possible organ-protective effects of anesthetic drugs. Furthermore, ethical considerations raise the question of whether the determination of brain death and the use of anesthetic drugs during the procedure of organ retrieval are compatible with each other.Conclusion: Due to the lack of evidence, perioperative treatment should be guided by intensive care therapy strategies. The discussion about using anesthetic drugs during organ retrieval remains controversial. Pathophysiological considerations support the use of volatile anesthetics because of possible organ-protective effects. The use of neuromuscular blocking is justified to control any possible motor response resulting from spinal cord reflexes, whereas there is no evidence for a benefit from using opioids. Apart from that, it seems ethically problematic to anesthetise a brain-dead donor. Consequently, knowledge about the pathophysiological processes caused by brain death and about organ-protective therapy concepts are just as much a basic requirement as the consideration of ethical problems in organ donation after brain death. Only then are the caregivers able to do justice to both the organ recipient and the organ donor, as well as their relatives in this challenging situation. [ABSTRACT FROM AUTHOR]

In 2019 a total of 756 people died in Germany while registered on the waiting list for an organ transplantation. With 10.8 organ donors/million inhabitants in 2019, Germany belongs to the bottom group in the Eurotransplant foundation as well as worldwide. All political attempts to increase the number of organ donations have so far been unsuccessful. Furthermore, the pandemic triggered by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to a further decline in organ donations. Critical care physicians play an important role in the identification of potential doners and are also the main point of contact for relatives; however, multiple uncertainties exist regarding the process of organ donation not only in discussions in the media and society but also among physicians involved in intensive care medicine. Many assumptions and hypotheses, which have been associated with the low number of donors, lack scientific evidence and are discussed in this article. [ABSTRACT FROM AUTHOR]

Spinal automatisms and reflexes, peripheral neurogenic and myogenic reactions are common in patients with irreversible brain death. They are therefore compatible and are even understood by experienced investigators as confirmation of irreversible brain death. This article provides an overview of the phenomenology of irreversible brain death and discusses it from a neuropathological perspective. Furthermore, irreversible brain death is described in order to distinguish it from pathological movements and motor reactions in comatose patients or patients with disturbed consciousness due to severe brain disorders. [ABSTRACT FROM AUTHOR]

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Copyright of Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The evaluation during the neurologic examination of hearing in horses generates only subjective values because the horse is turning the head and moves the ears towards the noise. Therefore the brainstem auditory evoked response (BAER) technique is very useful for evaluating the hearing in horses objectively. The aim of this study is to measure the BAER in horses with altered behaviour or lack of responsiveness to loud sounds. This has been effected on older horses, also on a horse with ceruminal occluded external ear canals and on a horse with colic surgery and bad prognosis during general anesthesia and euthanasia using T61®. Horses were sedated using detomidine (20 μg/kg bw i.v.) and placed in a stock or silent area. Needles were inserted subcutaneously on the median place of the vertex between the lateral canthus of the eyes, on the ventrocaudal area of the osseus part of the external ear canal on the top of Processus retrotympanicus on the left and right side, on the midline between the Os occipitale and Processus spinosus of the second cervical vertebra (ground). A click stimulus at 80 and 60 dB normal hearing level was applied ipsilateral and noise-masking sound at –35 dB normal hearing level was applied contralateral. An average of 2 000 responses of BAER was recorded over a 10 milliseconds epoch operated by the AEP-diagnostic system Corona. The latencies of peaks I, III and V were measured and the interpeak latencies between the waves I-III, III-V and I-V were calculated and saved by the AEP-diagnostic system. These measurements of five horses with altered behaviour and of one horse during euthanasia were compared with a control group of normal Warmblood horses (12 mares, 2 geldings, 2 stallions; mean age of 15 years, min 3 and max 19 years). The external ear canals were examined endoscopically before and they had normal findings (grade I) and the tympanic membranes were intact and transparent. The tympanohyoid and stylohyoid in the guttural pouches were normal too. The latencies in ms and interpeak latencies of the control group stimulated with 80 and 60 dB nHL ipsilateral are: peak I (left 1.49 ± 0.05, 1.79 ± 0.13; right 1.53 ± 0.09, 1.86 ± 0.11), III (left 2.81 ± 0.16, 3.27 ± 0.18; right 2.86 ± 0.20; 3.25 ± 0.18), V (left 4.60 ± 0.21, 5.05 ± 0.27; right 4.62 ± 023, 4.94 ± 0.26); I-III (left 1.32 ± 0.15, 1.48 ± 0.24; right 1.33 ± 0.15, 1.38 ± 0.20), III-V (left 1.79 ± 0.14, 1.78 ± 0.19; right 1.76 ± 0.24, 1.69 ± 0.28), I-V (left 3.11 ± 0.20, 3.26 ± 0.28; right 3.09 ± 0.19, 3.07 ± 0.27). A 20 years old Haflinger mare turned her head only to the left side when the owner called her. The peak amplitudes (I, III, V) and interpeak latencies (I-III, I-V) were reduced ipsilateral of the right ear. These are signs of a conductive hearing deficit and cochlear dysfunction or neural problem. The 25 years old Warmblood gelding which turned his head only towards very loud noises had reduced peak amplitudes and increased latencies (I, III, V) ipsilateral left and right. These are signs of conductive hearing deficit on both sides. No BAER (80 and 60 dB nHL) were detected ipsilateral on the left side on a 1.5 years old Warmblood mare which reacted only to very loud noises. These diagnostic findings explain deafness on the left ear. A five months old Warmblood stallion which responded only to very loud noises too, had prolonged latencies (I, III, V; 80 dB nHL) and unchanged interpeak latencies ipsilateral on the right ear. No peaks were detected stimulated by 60 dB. These are findings of a severe hearing deficit and cochlear dysfunction on the right ear. A five years old Warmblood mare had an altered behaviour with startling due to environmental noises. A complete obstructed osseous part of the right ear and a partial obstructed osseous part of the left external ear canal were seen endoscopically. Decreased peak amplitudes stimulated by 80 dB nHL and no peaks stimulated by 60 dB ipsilateral on the right side in comparison to the normal horse are findings with severe conductive hearing deficit on the right ear based on the complete obstruction. The applicated drug T61® used for euthanasia (30 ml/250 kg bw i.v.) under general anesthesia of a 19 years old Shetland pony gelding which had colic surgery and a very bad prognosis induced a complete loss of BAER which was a diagnostic finding of brain death within three minutes. In conclusion the testing of BAER in horses is an objective measurement of hearing and evaluates the physiology of the auditory pathway. The endoscopy of the external ear canal has to be done generally before BAER measurements! BEAR testing is indicated in horses with altered behaviour, head tilt, head shaking, temporohyoid osteoarthropathy, guttural pouch empyema, othematoma, melanoma, sarcoid or squamous cell carcinoma in the pinna or external ear canal, after surgery on the pinna or in the external ear canal, after treatment of Otitis purulenta externa or after surviving an encephalitis (West-Nile-Virus-, EHV-1-, Sarcocystis neurona-Infection). The BAER testing ought to be included into the pre-purchase exam plan/requirements! [ABSTRACT FROM AUTHOR]

A significant change in the fourth update of the German guidelines on determining brain death is that it includes an explicit profile of requirements on physicians involved in ILBF diagnosis. These requisite qualification criteria have also been formulated due to the fact that, in many hospitals, ILBF diagnosis is only rarely carried out and, as a result, uncertainty frequently arises. Typical difficulties emerge at all stages of ILBF diagnosis, and numerous relevant pitfalls arise that need to be taken into consideration and which might also be relevant in the selection of the method(s) to detect irreversibility. The approaches presented here are suited to achieving a valid result in the evaluation of equivocal ILBF. [ABSTRACT FROM AUTHOR]

Solid organ transplantation is frequently carried out in this society. Under these circumstances the basic principles are altruistic organ donation and abidance by the law, which are regulated by the German Transplantation Act and by directives of the Federal Medical Council from which process instructions of the German Organ Transplantation Foundation are derived. The organ allocation is carried out by the Eurotransplant International Foundation (ET) located in Leiden, the Netherlands. Organ procurement is an essential component of the process of organ donation. This article highlights the procedure for harvesting of abdominal organs and also nonsurgical issues in the process of organ donation. [ABSTRACT FROM AUTHOR]

The article provides information on the reform options in organ transplant law in Germany including discussion about living organ donation and its waiting lists, medical principles and healthy donor or the negative pathophysiological influences of brain death. Topics include implantation, health risk and medical assessment.

Background: The 4th update of the guidelines of the German Medical Association on the diagnosis of irreversible loss of brain function (brain death, BD) has introduced important new regulations regarding the required qualification of the examiners, approved procedures for ancillary testing, and a clarification regarding the sequencing of diagnostic steps., Objective: Investigation of the implementation and practical effects on the diagnosis of brain death., Method: Descriptive evaluation of the routine documentation of the German Organ Procurement Organization, comparing the periods July 2011-June 2015 (3rd update) and July 2015-June 2019 (4th update)., Results: Patient numbers decreased from 6100 to 5403. The largest decrease affected hospitals without neurosurgery. Children were not affected. With the 4th update, clinical diagnostics were increasingly performed during on-call hours by external neurologists. Of the patients 83.8% now received ancillary tests compared to 80.1% previously. Computed tomography angiography (CTA), first introduced in the 4th update, was applied in 23.2% and established complete loss of cerebral circulation in 89.4%. The time between first documentation of the clinical signs of BD and certification of BD increased from 7.0 ± 12.7 h to 8.2 ± 14.2 h. The diagnosis was slightly less frequent with 95.3% compared to 96.6%., Conclusion: The updated standards were implemented in accordance with the guidelines. The demand for external consulting neurologists and neurosurgeons as well as the time required for BD assessment have increased. Negative effects on pediatric BD diagnostics were not apparent. CTA is widely and successfully used in adults as a new ancillary diagnostic procedure., (© 2023. The Author(s).)

Background: No systematic study has previously been undertaken in Germany to ascertain why irreversible brain death determination (BDD) has not been carried out.Objective: A comprehensive analysis of reasons for unperformed BDD in deceased patients with acute, severe brain damage could improve the identification of potential organ donors.Method: Using the Transplantcheck program of the German Organ Transplantation Foundation (DSO) an analysis of the data from 2016 was undertaken in participating hospitals in Saxony, Saxony-Anhalt and Thuringia (Region East of the DSO), regarding why a BDD was not initiated in deceased patients with primary or secondary brain damage.Results: In 128 of the 144 Region East hospitals, 7889 deceased patients with primary or secondary brain damage were detected. In 7389 patients a BDD was out of the question for a variety of reasons. In 232 patients organ donation was not considered due to an advance directive. In 195 cases treatment was limited based on the patient's infaust neurological prognosis without the possibility of organ donation being discussed with relatives. In 73 cases initiation of BDD was indicated but not performed.Conclusion: The number of potential organ donors in Region East of the DSO could be significantly increased by identifying patients where BDD is indicated. By consistent evaluation of patients' wills in terms of organ donation before treatment is withdrawn in patients with poor neurological prognosis, additional potential organ donors could be identified. Furthermore, involving neurointensive care physicians in the care of all patients with brain damage could improve the prognostic assessment. [ABSTRACT FROM AUTHOR]

The article provides information on the legal regulation of post mortem organ donation in Germany with consent, focusing on organ transplant receivers, post mortem disposal of organs and willing to document organ donation. Topics include brain death of the donor, financial conditions improvement in organ removal hospitals and objection by the deceased in written.

Human death is challenging from both philosophical and medical points of view, because of a tension between the diagnosis of death of the organism as a whole and the declaration of death of a human person. BRAIN DEATH: CONTROVERSIES AND AGREEMENTS Human death is challenging from both philosophical and medical points of view, because of an apparent ontological discrepancy between the diagnosis of death of the organism as a whole and the declaration of death of a human person. In my paper I make an attempt to analyze the main controversies as well as agreements concerning ontological and medico-epistemological problems that have created the evolution of the definition of brain death, arguing that: 1. It is impossible to define death; 2. What functions as the definition of death is rather a set of criteria of death than a definition in a proper sense; 3. The debate concerning so-called definition of death refers not to death as such, universally conceptualized, but to a specific problem of death of a human being; 4. Analyzing the problem of human death it is impossible to make a clear distinction between biological and philosophical dimensions.

DONATION AFTER CIRCULATORY DETERMINATION OF DEATH. ABOUT THE PRECEDENCE OF NEUROLOGICAL CRITERION OF DEATH OVER CIRCULATORY CRITERION – REGULATORY ISSUES This two-part article concerns with bioethical issues associated with organ donation after circulatory determination of death (DCDD). Part 1 is devoted to legal and regulatory matters. Here I prove that in Poland organ retrieval from donors of all categories, specified in the modified Maastricht classification, is permissible. Particularly I argue that in our country there already is a legal basis for development of program of organ retrieval from donors in whom circulatory arrest have occurred after foregoing of life sustaining treatment. I also examine whether from the point of view of the law such donors might be considered dead when organ retrieval takes place.

DONATION AFTER CIRCULATORY DETERMINATION OF DEATH. ABOUT THE PRECEDENCE OF NEUROLOGICAL CRITERION OF DEATH OVER CIRCULATORY CRITERION – PHILOSOPHICAL ISSUES Summary This two-part article concerns with bioethical issues associated with organ donation after circulatory determination of death (DCDD). Part 2 is devoted to philosophical problems. I analyze three concepts of death, that identify the end of life with a) somatic disintegration of the organism, b) irreversible cessation of vital work of self-preservation and c) irreversible loss of patient’s moral status. By referring to these positions I argue that circulatory criterion of death is reliable only if cessation of circulation lasts long enough for brain death to occur. Taking this into account, it might be supposed that the 5 minutes period of observation of cessation of circulation is not enough for patient’s death to take place.

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Aim: The aim of the study was to examine how physicians experience caring for (potentially) brain-dead patients., Methods: Episodic interviews were conducted. Their evaluation was based on Benner's interpretative phenomenology., Results: Eleven physicians were interviewed. The following phenomena were extracted from the data: (1) encounter with the relatives, (2) making relatives understand brain death, (3) brain death is death, (4) experience of the nurses and (5) burdens., Conclusion: The results show the complexity that is perceived by physicians when caring for a (potentially) brain-dead patient. The transition from saving the patient's life to preserving organs or switching off the equipment and informing the relatives requires a high level of expertise on the part of the physicians. The patients' symptoms provide the physicians with clear diagnostic procedures and any remaining ambiguities in the (treatment) process should be resolved., (© 2022. The Author(s).)

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Background: According to the German Medical Council guidelines, the proof of irreversible brain death can be carried out using clinical investigations alone or can necessitate the use of ancillary tests (ATs), depending on the patient age and type of brain injury. Methods: Retrospective evaluation of the diagnostics of irreversible brain death, which were carried out using ATs according to the third edition of the guidelines between January 2001 and December 2010 in Berlin, Brandenburg and Mecklenburg-Western Pomerania and were registered at the German National Foundation for Organ Transplantation. Results: In 1401 patients (aged 0-94 years) a total of 1636 ATs were carried out. The most frequently used additional procedure for the first AT was an electroencephalogram (EEG) in 71.7 %. Confirmatory results regarding irreversibility were reported for 93.6 % of the initial ATs. Negative results of ATs were less common with primary supratentorial brain lesions (2.9 %) compared to infratentorial lesions (13.7 %), secondary hypoxic brain damage (8.1 %) and children younger than 2 years old (18.5 %). Regardless of the AT results, a return of clinical brain function was never documented. The timing, type and repetition of ATs were variable. In most cases the diagnostic process was clearly accelerated by the use of ATs but was significantly delayed in 10.1 % compared to a purely clinical proof of irreversible brain death. Conclusion: ATs by themselves do not provide evidence of the cessation of all brain functions. Instead, they are used to prove the irreversibility of the clinically defined syndrome. For patients over 2 years old and in the absence of primary brainstem lesions, clinical re-assessment and ATs are considered to be equally accurate in demonstrating irreversibility. A standardization of diagnostic procedures between hospitals would be desirable. [ABSTRACT FROM AUTHOR]

The death of the donor is a mandatory prerequisite for organ transplantation (dead donor rule) worldwide. It is a medical, legal and ethical consensus to accept the concept of brain death, as first proposed in 1968 by the ad hoc committee of the Harvard Medical School, as a certain criterion of death. In isolated cases where the diagnosis of brain death was claimed to be wrong, it could be demonstrated that the diagnostic procedure for brain death had not been correctly performed. In March 2014 a joint statement by the German neuromedical societies emphasized that 1) the diagnosis of brain death is one of the safest diagnoses in medicine if performed according to accepted medical standards and criteria and 2) the concept of non-heart-beating donors (NHBD, i. e. organ donation after an arbitrarily defined duration of circulatory and cardiac arrest) practiced in some European countries must be absolutely rejected because it implicates a high risk of diagnostic error. According to the current literature it is unclear at what time cardiac and circulatory arrest is irreversible and leads to irreversible cessation of all functions of the entire brain including the brainstem, even though clinical signs of cessation of brain functions are always found after 10 min. Furthermore, is it often an arbitrary decision to exactly define the duration of cardiac arrest if continuous echocardiographic monitoring has not been carried out from the very beginning. Last but not least there are ethical concerns against the concept of NHBD because it might influence therapeutic efforts to resuscitate a patient with cardiac arrest. Therefore, the German Medical Council (BÄK) has repeatedly rejected the concept of NHBD for organ transplantation since 1995. [ABSTRACT FROM AUTHOR]

In several European countries catheter angiography is permitted as a confirmatory procedure for the determination of irreversible loss of brain function (brain death). In Germany catheter angiography requires the possibility of a therapeutic implication as a prerequisite. In the updated German guidelines computed tomography angiography (CTA) has been accredited as a new confirmatory procedure if a standardized protocol and predefined assessment parameters are adhered to. The CTA can be performed within a few minutes, even in situations with unstable intensive care patients. Magnetic resonance (MR) angiography has not yet been adequately validated and is not permitted in Germany as a confirmatory procedure for the determination of irreversible loss of brain function. [ABSTRACT FROM AUTHOR]

Principally, in the fourth update of the rules for the procedure to finally determine the irreversible cessation of function of the cerebrum, the cerebellum and the brainstem, the importance of an electroencephalogram (EEG), somatosensory evoked potentials (SEP) and brainstem auditory evoked potentials (BAEP) are confirmed. This paper presents the reliability and validity of the electrophysiological diagnosis, discusses the amendments in the fourth version of the guidelines and introduces the practical application, problems and sources of error. An EEG is the best established supplementary diagnostic method for determining the irreversibility of clinical brain death syndrome. It should be noted that residual brain activity can often persist for many hours after the onset of brain death syndrome, particularly in patients with primary brainstem lesions. The derivation and analysis of an EEG requires a high level of expertise to be able to safely distinguish artefacts from primary brain activity. The registration of EEGs to demonstrate the irreversibility of clinical brain death syndrome is extremely time consuming. The BAEPs can only be used to confirm the irreversibility of brain death syndrome in serial examinations or in the rare cases of a sustained wave I or sustained waves I and II. Very often, an investigation cannot be reliably performed because of existing sound conduction disturbances or failure of all potentials even before the onset of clinical brain death syndrome. This explains why BAEPs are only used in exceptional cases. The SEPs of the median nerve can be very reliably derived, are technically simple and with few sources of error. A serial investigation is not required and the time needed for examination is short. For these reasons SEPs are given preference over EEGs and BAEPs for establishing the irreversibility of clinical brain death syndrome. [ABSTRACT FROM AUTHOR]

Approximately 17 million inhabitants live in the Netherlands. The number of potential organ donors in 1999 was the lowest in Europe with only 10 donors per million inhabitants. Medical associations, public health services, health insurance companies and the government had to find common solutions in order to improve organ allocation, logistics of donations and to increase the number of transplantations. After a prolonged debate on medical ethical issues of organ transplantation, all participants were able to agree on socio-medico-legal regulations for organ donation and transplantation. In addition to improving the procedure for organ donation after brain death (DBD) the most important step was the introduction of organ donation after circulatory death (DCD). Measures such as the introduction of a national organ donor database, improved information to the public, further education on intensive care units (ICU), guidelines for end of life care on the ICU, establishment of transplantation coordinators on site, introduction of autonomous explantation teams and strict procedures on the course of organ donations, answered many practical issues about logistics and responsibilities for DBD and DCD. In 2014 the number of postmortem organ donations rose to 16.4 per million inhabitants. Meanwhile, up to 60 % of organ donations in the Netherlands originate from a DCD procedure compared to approximately 10 % in the USA. This overview article discusses the developments and processes of deceased donation in the Netherlands after 15 years of experience with DCD. [ABSTRACT FROM AUTHOR]