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Acknowledging this variation in the recognition, diagnosis and documentation of neurological death, the Canadian Council for Donation and Transplantation sponsored a national forum of experts to create a set of recommendations that will have significant implications for organ donation in Canada. Severe brain injury is a prerequisite for neurological determination of death (NDD); and NDD, commonly referred to as brain death, is a prerequisite for cadaveric organ donation. The right to entertain the option of organ and tissue donation is increasingly supported by society and will become legislated in some Canadian jurisdictions. Collaborative efforts are required to optimize the care of patients who may become eligible for donation and to ensure consistent and ethical conduct in care. This comprehensive national collaboration is the first of its kind in Canada in this domain. Each of the 3 main areas of focus - recommendations for a Canadian definition, criteria and minimum testing requirements for NDD; recommendations concerning the incidence and reporting of NDD and legal issues; and recommendations associated with the management of patients with severe brain injury from the emergency department to the intensive care unit - was addressed using the following process. Presentations by experts were followed by plenary discussions supported by fact sheets that summarized preceding American8 and Canadian guidelines7 and by substantial background papers9-11 and surveys12 provided by the planning committee in advance of the forum. Small-group discussions then focused on specific questions related to the processes of care. The Forum Recommendations Group (FRG) and the Pediatric Reference Group (PRG) reviewed the results of the small-group discussions, developed unanimous recommendations for adults and children and returned these for plenary discussion. A Neonatal Reference Group met subsequent to the forum to develop neonatal age-adjusted recommendations. (See Appendix 1 for a list of members of these groups.) Clinical checklists are included in Appendix 4. From Division of Pediatric Critical Care, Montreal Children's Hospital, McGill University Health Centre, Montréal, Que. (Shemie), Adult Critical Care, Foothills Hospital, University of Calgary, Calgary, Alta. (Doig), Faculty of Law, Joint Centre for Bioethics, University of Toronto, Toronto, Ont. ([Bernard Dickens]), John Dossetor, Health Ethics Centre and Department of Pediatrics, University of Alberta, Edmonton, Alta. ([Paul Byrne]), Neonatal Intensive Care Unit, Stollery Children's Hospital (Byrne), Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, NS (Rocker), Trauma and Neurosurgery Intensive Care Unit, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Baker), Department of Critical Care Medicine, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Ont. (Guest), Emergency Medicine, St. Michael's Hospital, Toronto, Ont. ([Dan Cass]), ICU, Children's and Women's Health Centre of British Columbia, Vancouver, BC ([Rosella Jefferson]), Montreal Neurological Institute and Hospital, McGill University, Montréal, Que. (Teitelbaum), Maisonneuve-Rosemount Hospital, University of Montreal, Montréal, Que. (Teitelbaum), Trillium Gift of Life Network (Baker, Guest), Canadian Critical Care Society (Shemie, Doig, Rocker, Baker), Canadian Council for Donation and Transplantation (Shemie, Doig, Young), Canadian Neurosurgical Society ([Brian Wheelock]), Canadian Anesthesiologists' Society (Baker), College of Physicians and Surgeons of British Columbia (Seland), Canadian Association of Emergency Physicians (Cass), Canadian Association of Critical Care Nurses (Jefferson), Canadian Association of Transplantation (Young), Canadian Neurocritical Care Group ([Jeanne Teitelbaum]).

This thematic issue in Intensive Care Medicine subscribes to a fundamental medical principle: Brain death is death, and organ and tissue donation must be a priority. For all involved in declaring brain death, there is acceptance, resignation, compassion, support, and a deep humanistic appreciation that lives can be saved. Intensivists (with their respective academies and societies) have defined the practice, proposed clinical pathways, and introduced safeguards. After much reflection in the 1960s–1980s, brain death determination has been medically settled for most nations worldwide.

In collaboration with the Canadian Critical Care Society, the Canadian Association of Transplantation and the Canadian Society of Transplantation, the Canadian Council for Donation and Transplantation (CCDT) sponsored a forum entitled \"Medical Management to Optimize Donor Organ Potential,\" 23-25 Feb. 2004, to develop guidelines and recommendations for organ donor management in Canada. Discussions were restricted to the interval of care that begins with neurological determination of death (NDD), commonly called \"brain death,\" and consent to organ donation, and culminates in surgical organ procurement. This period presents a significant opportunity to enhance multi-organ function and improve organ utilization. From Division of Pediatric Critical Care, Montreal Children's Hospital, McGill University Health Centre, Montréal, Que. (Shemie), Cardiac Transplant Program, Toronto General Hospital, University Health Network ([Heather Ross]), GI Transplant Program, Toronto General Hospital, University Health Network ([Paul D. Greig]), General Surgery, ICU and Organ and Tissue Donation Program, The Ottawa Hospital ([Joe Pagliarello]), Trauma and Neurosurgery Intensive Care Unit, St. Michael's Hospital, University of Toronto, Toronto, Ont. ([Andrew J. Baker]), Adult Critical Care, Foothills Hospital, Calgary, Alta. ([Christopher Doig]), Trillium Gift of Life Network (Baker), Canadian Critical Care Society ([Sam D. Shemie], Pagliarello, Baker, Doig, Guest), Canadian Anesthesiologists' Society (Baker), Canadian Organ Replacement Register (Greig), Canadian Society of Transplantation (Greig, Ross, [Sandra Cockfield], Keshavjee, [Vivek Rao], [Peter Nickerson]), Canadian Association of Transplantation ([Tracy Brand], [Kimberly Young]), Kidney Transplant Program, University of Alberta Hospital, Edmonton, Alta. (Cockfield), Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ont. (Keshavjee), Immunogenetics Laboratory, University of Manitoba Health Services Centre, Winnipeg, Man. (Nickerson), Cardiac Transplant Program, University Health Network, University of Toronto, Toronto, Ont. (Rao), Department of Critical Care Medicine, Sunnybrooke and Women's College Hospital, Toronto, Ont. (Guest), Canadian Council for Donation and Transplantation (Shemie, Young, Doig), Saskatchewan Transplant Program (Brand).

Dalle Ave et al (2016) provide a valuable overview of several protocols for heart transplantation after circulatory death. However, their analysis of the compatibility of heart donation after circulatory death (DCD) with the dead donor rule (DDR) is flawed. Their permanence-based criteria for death, which depart substantially from established law and bioethics, are ad hoc and unfounded. Furthermore, their analysis is self-defeating, because it undercuts the central motivation for DDR as both a legal and a moral constraint, rendering the DDR vacuous and trivial. Rather than devise new and ad hoc criteria for death for the purpose of rendering DCD nominally consistent with DDR, we contend that the best approach is to explicitly abandon DDR.

Abstract OBJECTIVE To determine the understanding of the conceptual basis and diagnostic tests used for brain death (BD) by neurosurgeons in Canada. METHODS Between February and June 2006, a previously developed survey was mailed to every neurosurgeon in Canada. RESULTS Of 223 surveys mailed, 147 (66%) were returned; of these, 128 (87%) were completed and analyzed. When asked to choose a conceptual reason to explain why BD is equivalent to death, 50 (39%) chose a higher brain concept, 50 (39%) chose a prognosis concept, and 33 (26%) chose a loss of integration of the organism concept. More than half of respondents answered that BD is not compatible with electroencephalographic activity or brainstem evoked potential activity. More than one-third of respondents answered that some cerebral blood flow or a brainstem with minimal microscopic damage was not compatible with BD. Of the 90 respondents who answered that they were comfortable diagnosing BD because the conceptual basis of BD makes it equivalent to death of the patient, in their own words, 14 (16%) used a loss of integration concept, 20 (22%) used a prognosis concept, 25 (28%) used a higher brain concept, and 39 (43%) did not articulate a concept. When asked, “Are brain death and cardiac death the same state (i.e., are both death of the patient)?,” 57 (45%) answered “No.” CONCLUSION Within the neurosurgical community, a stand-alone concept of BD does not exist. There is also significant variability in the understanding of the tests that are compatible with the criterion of BD.

On 5 August 1968, publication of the Harvard Committee’s report on the subject of “irreversible coma” established a standard for diagnosing death on neurological grounds. On the same day, the 22nd World Medical Assembly met in Sydney, Australia, and announced the Declaration of Sydney, a pronouncement on death, which is less often quoted because it was overshadowed by the impact of the Harvard Report. To put those events into present-day perspective, the authors reviewed all papers published on this subject and the World Medical Association web page and documents, and corresponded with Dr A G Romualdez, the son of Dr A Z Romualdez. There was vast neurological expertise among some of the Harvard Committee members, leading to a comprehensible and practical clinical description of the brain death syndrome and the way to diagnose it. This landmark account had a global medical and social impact on the issue of human death, which simultaneously lessened reception of the Declaration of Sydney. Nonetheless, the Declaration of Sydney faced the main conceptual and philosophical issues on human death in a bold and forthright manner. This statement differentiated the meaning of death at the cellular and tissue levels from the death of the person. This was a pioneering view on the discussion of human death, published as early as in 1968, that should be recognised by current and future generations.

In 1968, the Harvard criteria equated irreversible coma and apnea (i.e., brain death) with human death and later, the Uniform Determination of Death Act was enacted permitting organ procurement from heart-beating donors. Since then, clinical studies have defined a spectrum of states of impaired consciousness in human beings: coma, akinetic mutism (locked-in syndrome), minimally conscious state, vegetative state and brain death. In this article, we argue against the validity of the Harvard criteria for equating brain death with human death. (1) Brain death does not disrupt somatic integrative unity and coordinated biological functioning of a living organism. (2) Neurological criteria of human death fail to determine the precise moment of an organism’s death when death is established by circulatory criterion in other states of impaired consciousness for organ procurement with non-heart-beating donation protocols. The criterion of circulatory arrest 75 s to 5 min is too short for irreversible cessation of whole brain functions and respiration controlled by the brain stem. (3) Brain-based criteria for determining death with a beating heart exclude relevant anthropologic, psychosocial, cultural, and religious aspects of death and dying in society. (4) Clinical guidelines for determining brain death are not consistently validated by the presence of irreversible brain stem ischemic injury or necrosis on autopsy; therefore, they do not completely exclude reversible loss of integrated neurological functions in donors. The questionable reliability and varying compliance with these guidelines among institutions amplify the risk of determining reversible states of impaired consciousness as irreversible brain death. (5) The scientific uncertainty of defining and determining states of impaired consciousness including brain death have been neither disclosed to the general public nor broadly debated by the medical community or by legal and religious scholars. Heart-beating or non-heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients. Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness within the context of the perceived need to enhance the supply of transplantable organs.

Assessing brain death may sometimes be difficult, with isoelectric EEG following psychotrope overdoses or normal cerebral blood flow (CBF) persisting despite brain death in the case of ventricular drainage or craniotomy. A 42-year-old man, resuscitated after cardiac arrest following a suicidal ingestion of ethanol, bromazepam and zopiclone, was admitted in deep coma. On day 4, his brainstem reflexes and EEG activity disappeared. On day 5, his serum bromazepam concentration was 817 ng/ml (therapeutic: 80-150). The patient was unresponsive to 1 mg of flumazenil. MRI showed diffuse cerebral swelling. CBF assessed by angiography and Doppler remained normal and EEG isoelectric until he died on day 8 with multiorgan failure. There was a discrepancy between the clinically and EEG-assessed brain death, and CBF persistence. We hypothesized that brain death, resulting from diffuse anoxic injury, may lead, in the absence of major intracranial hypertension, to angiographic misdiagnoses. Therefore, EEG remains useful to assess diagnosis in such unusual cases.

There is no definitive answer to the question of how long one must wait, after a person's heart stops beating, before concluding that the person meets the heart-lung criteria for death. This question has assumed new importance with attempts to remove transplantable organs from people declared dead using those criteria. An examination of the legal definition of death suggests that organs are indeed being procured from some of these people prior to their being legally dead. Moreover, the fact that the donors have consented to these procedures does not eliminate reason for concern regarding this state of affairs, since patient autonomy must at times be overridden in pursuance of important social goals.