Ethical care in the ICU – daily issues: Symposium organised by the European Society of Intensive Care Medicine (ESICM)

Saturday 3 June, 14h00-15h30, Room W

Will all the modern technology that exists today, one would think that determination of death should be a straightforward matter. But in the first talk in this session, Giuseppe Citerio, Professor of Anesthesia and Intensive Care at the Milano Bicocca University, School of Medicine and Surgery will discuss the problems and international variability around determining brain death in a person.

Prof Citerio says: “Despite it being more than 40 years since the concept of ‘brain death’ was first introduced into clinical practice, many of the controversies that surround the determination of death by neurological criteria (DNC) —a more focused and accurate description of the process — have not been settled, and present an opportunity for future research and education to clarify outstanding issues in order to reduce professional and public disquiet.”

“There is broad consensus, at least in the Western world, that human death is ultimately death of the brain, but debate continues over the extent of brain functions that must cease in order to satisfy a definition of DNC,” he adds. “Confusingly DNC can be defined in two different ways based on ‘whole’ brain and ‘brainstem’ formulations.”

Furthermore, the clinical determination of whole brain and brainstem death is identical, requiring confirmation of the absence of brainstem function by identification of unresponsive coma and absence of brainstem reflexes including the capacity to breathe.

Prof Citerio will argue that since it is the brainstem that is responsible for consciousness, breathing and circulatory regulation, and conducting virtually all throughput to and from the brain, then if there is brainstem death, the person is dead, without all the other parts of the brain having to be dead at that moment. Some countries, including Italy, also insist that other ancillary tests be carried out (such as EEG) but Prof Citerio says this causes confusion as they suggest the determination of brain stem death alone is not enough to determine death.

He says the international community must work together to establish a universal definition of DNC, and a universal procedure to diagnose DNC. He says: “At the same time, critical care physicians must unite with other professional colleagues and public policymakers to engage local communities and national governments in DNC-related issues. Only in this way will it be possible to achieve equivalence of DNC and cardiorespiratory death in the minds of the public and professionals. As Dr. Panayiotis Varelas* so eloquently stated in 2014, the time has come when the determination of DNC should be as easy and accepted as placing a stethoscope on a deceased patient’s chest to search for a heartbeat and breath that will never come.”

Prof Citerio will also emphasise that timely definition of DNC and improved maintenance of potential organ donors in the ICU after death determined by neurologic criteria might help, along with other strategies, to reduce the huge gap between organ availability and organ requirements for transplantation that remains a major healthcare issue worldwide.

The second talk on this session on the cost-effectiveness of Extracorporeal Life Support will be given by Jozef Kesecioglu, Professor of Intensive Care Medicine and the chair of the Division of Anaesthesiology, Intensive Care and Emergency Medicine at University Medical Center, Utrecht, the Netherlands.

Early reports on Extracorporeal Membrane Oxygenation (ECMO) showed that the procedure had mortality higher than 90%. However, development of specialised ECMO referral centres, technology advancements and clearer patient selection criteria have dramatically improved outcomes and acceptance over the past 4 decades.  Increased reports of ECMO survival rates to hospital discharge that exceed 50% have established ECMO as a valuable “rescue strategy” for severe respiratory failure refractory to conventional medical management.

“The number of physicians, patients, and families who consider ECMO as a treatment option have all expanded considerably in recent years,” says Prof Kesecioglu, who is President Elect of European Society of Intensive Care Medicine.  “The ability of ECMO to replace the function of the heart or lungs for prolonged periods of time, allows ECMO to be used as a bridge to healing, transplant or ventricular assist devices.”

Prof Kesecioglu will also point out that randomised controlled trials may not always be suitable to determine the efficacy of ECMO. He says: “ECMO utilisation and patient selection criteria have been developed during the last few years but decisions as to whether and when to initiate and discontinue ECMO are not always clear-cut either clinically or ethically. A limited number of trials suggest that ECMO is cost effective and cheaper than certain other treatments. However, declining health care resources seem to be an obstacle for the reimbursement of ECMO costs.”

The final presentation in this session, on variation in end-of-life care (EOLC), will be given by Dr Andrej Michalsen, Department of Anaesthesiology and Intensive Care Medicine, Tettnang Hospital, Tettnang, Germany.

EOLC is a complex task that physicians taking care of critically ill patients are usually confronted with, once life-prolonging measures are not (or no longer) indicated for an individual patient; or not (or no longer) in agreement with a patient’s wishes. This task comprises, but is not limited to, reaching a joint decision amongst the treating team as well as a shared decision with the patient and/or his/her legal representative regarding the possible change of the treatment goal(s) and the ensuing limitation of life-sustaining therapies, whilst ensuring an adequate symptom control and finally a “good death”.

“Over the last years, several studies have shown that a wide variation exists as to the decision-making towards and implementation of EOLC — not only between world-regions or countries — but also within countries and even hospitals,” explains Dr Michalsen. “Various reasons may be behind this variation, among them cultural norms and values, religious beliefs, legal stipulations, different levels of experience, and different levels of knowledge about ethical principles.”

He concludes: “One important question to be answered in light of such variation is, whether in order to harmonise EOLC we need to strive for more standard operating procedures, more laws – or more moral courage, based on evidence and experience. My plea is for the latter.”

*Varelas P (2014) Brain death determination: still a lot to learn, still a lot to do. Neurocrit Care 21:373–375. doi:10.1007/s12028-014-0075-8