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Park S, Ha J, Kim L. Event-related pupillary response-based authentication system using eye-tracker add-on augmented reality glasses for individual identification. Front Physiol 2024; 15:1325784. [PMID: 39193438 PMCID: PMC11347300 DOI: 10.3389/fphys.2024.1325784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 08/05/2024] [Indexed: 08/29/2024] Open
Abstract
This study aimed at developing a noncontact authentication system using event-related pupillary response (ErPR) epochs in an augmented reality (AR) environment. Thirty participants were shown in a rapid serial visual presentation consisting of familiar and unknown human photographs. ErPR was compared with event-related potential (ERP). ERP and ErPR amplitudes for familiar faces were significantly larger compared with those for stranger faces. The ERP-based authentication system exhibited perfect accuracy using a linear support vector machine classifier. A quadratic discriminant analysis classifier trained using ErPR features achieved high accuracy (97%) and low false acceptance (0.03) and false rejection (0.03) rates. The correlation coefficients between ERP and ErPR amplitudes were 0.452-0.829, and the corresponding Bland-Altman plots showed a fairly good agreement between them. The ErPR-based authentication system allows noncontact authentication of persons without the burden of sensor attachment via low-cost, noninvasive, and easily implemented technology in an AR environment.
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Affiliation(s)
- Sangin Park
- Industry-Academy Cooperation Team, Hanyang University, Seoul, Republic of Korea
| | - Jihyeon Ha
- Bionics Research Center, Korea Institute of Science and Technology, Seoul, Republic of Korea
| | - Laehyun Kim
- Bionics Research Center, Korea Institute of Science and Technology, Seoul, Republic of Korea
- Department of HY-KIST Bio-Convergence, Hanyang University, Seoul, Republic of Korea
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2
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Sdobnov A, Tsytsarev V, Piavchenko G, Bykov A, Meglinski I. Beyond life: Exploring hemodynamic patterns in postmortem mice brains. JOURNAL OF BIOPHOTONICS 2024; 17:e202400017. [PMID: 38714530 DOI: 10.1002/jbio.202400017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/14/2024] [Accepted: 04/09/2024] [Indexed: 05/10/2024]
Abstract
We utilize Laser Speckle Contrast Imaging (LSCI) for visualizing cerebral blood flow in mice during and post-cardiac arrest. Analyzing LSCI images, we noted temporal blood flow variations across the brain surface for hours postmortem. Fast Fourier Transform (FFT) analysis depicted blood flow and microcirculation decay post-death. Continuous Wavelet Transform (CWT) identified potential cerebral hemodynamic synchronization patterns. Additionally, non-negative matrix factorization (NMF) with four components segmented LSCI images, revealing structural subcomponent alterations over time. This integrated approach of LSCI, FFT, CWT, and NMF offers a comprehensive tool for studying cerebral blood flow dynamics, metaphorically capturing the 'end of the tunnel' experience. Results showed primary postmortem hemodynamic activity in the olfactory bulbs, followed by blood microflow relocations between somatosensory and visual cortical regions via the superior sagittal sinus. This method opens new avenues for exploring these phenomena, potentially linking neuroscientific insights with mysteries surrounding consciousness and perception at life's end.
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Affiliation(s)
- Anton Sdobnov
- Optoelectronics and Measurement Techniques, University of Oulu, Oulu, Finland
| | - Vassiliy Tsytsarev
- Department of Neurobiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gennadi Piavchenko
- Department of Human Anatomy and Histology, Institute of Clinical Medicine N.V. Sklifosovsky, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Alexander Bykov
- Optoelectronics and Measurement Techniques, University of Oulu, Oulu, Finland
| | - Igor Meglinski
- Department of Human Anatomy and Histology, Institute of Clinical Medicine N.V. Sklifosovsky, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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3
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Mahon S. Variation and convergence in the morpho-functional properties of the mammalian neocortex. Front Syst Neurosci 2024; 18:1413780. [PMID: 38966330 PMCID: PMC11222651 DOI: 10.3389/fnsys.2024.1413780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 06/03/2024] [Indexed: 07/06/2024] Open
Abstract
Man's natural inclination to classify and hierarchize the living world has prompted neurophysiologists to explore possible differences in brain organisation between mammals, with the aim of understanding the diversity of their behavioural repertoires. But what really distinguishes the human brain from that of a platypus, an opossum or a rodent? In this review, we compare the structural and electrical properties of neocortical neurons in the main mammalian radiations and examine their impact on the functioning of the networks they form. We discuss variations in overall brain size, number of neurons, length of their dendritic trees and density of spines, acknowledging their increase in humans as in most large-brained species. Our comparative analysis also highlights a remarkable consistency, particularly pronounced in marsupial and placental mammals, in the cell typology, intrinsic and synaptic electrical properties of pyramidal neuron subtypes, and in their organisation into functional circuits. These shared cellular and network characteristics contribute to the emergence of strikingly similar large-scale physiological and pathological brain dynamics across a wide range of species. These findings support the existence of a core set of neural principles and processes conserved throughout mammalian evolution, from which a number of species-specific adaptations appear, likely allowing distinct functional needs to be met in a variety of environmental contexts.
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Affiliation(s)
- Séverine Mahon
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, APHP, Hôpital de la Pitié Salpêtrière, Paris, France
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4
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Kirschen MP, Lewis A, Rubin MA, Varelas PN, Greer DM. Beyond the Final Heartbeat: Neurological Perspectives on Normothermic Regional Perfusion for Organ Donation after Circulatory Death. Ann Neurol 2024; 95:1035-1039. [PMID: 38501716 DOI: 10.1002/ana.26926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/28/2024] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
Normothermic regional perfusion (NRP) has recently been used to augment organ donation after circulatory death (DCD) to improve the quantity and quality of transplantable organs. In DCD-NRP, after withdrawal of life-sustaining therapies and cardiopulmonary arrest, patients are cannulated onto extracorporeal membrane oxygenation to reestablish blood flow to targeted organs including the heart. During this process, aortic arch vessels are ligated to restrict cerebral blood flow. We review ethical challenges including whether the brain is sufficiently reperfused through collateral circulation to allow reemergence of consciousness or pain perception, whether resumption of cardiac activity nullifies the patient's prior death determination, and whether specific authorization for DCD-NRP is required. ANN NEUROL 2024;95:1035-1039.
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Affiliation(s)
- Matthew P Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ariane Lewis
- Departments of Neurology and Neurosurgery, New York University, Langone Medical Center, New York, NY, USA
| | - Michael A Rubin
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - David M Greer
- Department of Neurology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
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5
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Kovoor JG, Santhosh S, Stretton B, Tan S, Gouldooz H, Moorthy S, Pietris J, Hannemann C, Yu LK, Johnson R, Reddi BA, Gupta AK, Wagner M, Page GJ, Kovoor P, Bastiampillai T, Maddocks I, Perry SW, Wong ML, Licinio J, Bacchi S. Near-death experiences after cardiac arrest: a scoping review. DISCOVER MENTAL HEALTH 2024; 4:19. [PMID: 38806961 PMCID: PMC11133272 DOI: 10.1007/s44192-024-00072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 05/24/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND This scoping review aimed to characterise near-death experiences in the setting of cardiac arrest, a phenomenon that is poorly understood and may have clinical consequences. METHOD PubMed/MEDLINE was searched to 23 July 2023 for prospective studies describing near-death experiences in cardiac arrest. PRISMA-ScR guidelines were adhered to. Qualitative and quantitative data were synthesised. Meta-analysis was precluded due to data heterogeneity. RESULTS 60 records were identified, of which 11 studies involving interviews were included from various countries. Sample size ranged from 28-344, and proportion of female patients (when reported) was 0-50%, with mean age (when reported) ranging 54-64 years. Comorbidities and reasons for cardiac arrest were heterogeneously reported. Incidence of near-death experiences in the included studies varied from 6.3% to 39.3%; with variation between in-hospital (6.3-39.3%) versus out-of-hospital (18.9-21.2%) cardiac arrest. Individual variables regarding patient characteristics demonstrated statistically significant association with propensity for near-death experiences. Reported content of near-death experiences tended to reflect the language of the questionnaires used, rather than the true language used by individual study participants. Three studies conducted follow-up, and all suggested a positive life attitude change, however one found significantly higher 30-day all-cause mortality in patients with near-death experiences versus those without, in non-controlled analysis. CONCLUSIONS From prospective studies that have investigated the phenomenon, near-death experiences may occur in as frequent as over one-third of patients with cardiac arrest. Lasting effects may follow these events, however these could also be confounded by clinical characteristics.
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Affiliation(s)
- Joshua G Kovoor
- University of Adelaide, Adelaide, South Australia, Australia
- Ballarat Base Hospital, Ballarat, VIC, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- Heart of the Nation, Sydney, NSW, Australia
| | | | - Brandon Stretton
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
| | - Sheryn Tan
- University of Adelaide, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
| | - Hasti Gouldooz
- Gold Coast University Hospital, Gold Coast, QLD, Australia
| | | | | | - Christopher Hannemann
- Ballarat Base Hospital, Ballarat, VIC, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Long Kiu Yu
- University of Adelaide, Adelaide, South Australia, Australia
| | - Rhys Johnson
- University of Adelaide, Adelaide, South Australia, Australia
| | - Benjamin A Reddi
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- University of Adelaide, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Morganne Wagner
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | | | - Pramesh Kovoor
- Heart of the Nation, Sydney, NSW, Australia
- Westmead Hospital, Sydney, NSW, Australia
- University of Sydney, Sydney, NSW, Australia
| | - Tarun Bastiampillai
- Flinders University, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Ian Maddocks
- Australasian Chapter of Palliative Medicine, Royal Australasian College of Physicians, Adelaide, South Australia, Australia
| | - Seth W Perry
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Ma-Li Wong
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Julio Licinio
- State University of New York Upstate Medical University, Syracuse, NY, USA
- Flinders University, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Health and Information, Adelaide, South Australia, Australia.
- Flinders University, Adelaide, South Australia, Australia.
- Lyell McEwin Hospital, Adelaide, South Australia, Australia.
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6
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Murphy NB, Shemie SD, Capron A, Truog RD, Nakagawa T, Healey A, Gofton T, Bernat JL, Fenton K, Khush KK, Schwartz B, Wall SP. Advancing the Scientific Basis for Determining Death in Controlled Organ Donation After Circulatory Determination of Death. Transplantation 2024:00007890-990000000-00733. [PMID: 38637919 DOI: 10.1097/tp.0000000000005002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
In controlled organ donation after circulatory determination of death (cDCDD), accurate and timely death determination is critical, yet knowledge gaps persist. Further research to improve the science of defining and determining death by circulatory criteria is therefore warranted. In a workshop sponsored by the National Heart, Lung, and Blood Institute, experts identified research opportunities pertaining to scientific, conceptual, and ethical understandings of DCDD and associated technologies. This article identifies a research strategy to inform the biomedical definition of death, the criteria for its determination, and circulatory death determination in cDCDD. Highlighting knowledge gaps, we propose that further research is needed to inform the observation period following cessation of circulation in pediatric and neonatal populations, the temporal relationship between the cessation of brain and circulatory function after the withdrawal of life-sustaining measures in all patient populations, and the minimal pulse pressures that sustain brain blood flow, perfusion, activity, and function. Additionally, accurate predictive tools to estimate time to asystole following the withdrawal of treatment and alternative monitoring modalities to establish the cessation of circulatory, brainstem, and brain function are needed. The physiologic and conceptual implications of postmortem interventions that resume circulation in cDCDD donors likewise demand attention to inform organ recovery practices. Finally, because jurisdictionally variable definitions of death and the criteria for its determination may impede collaborative research efforts, further work is required to achieve consensus on the physiologic and conceptual rationale for defining and determining death after circulatory arrest.
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Affiliation(s)
- Nicholas B Murphy
- Departments of Medicine and Philosophy, Western University, London, ON, Canada
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
- System Development, Canadian Blood Services, Ottawa, ON, Canada
| | - Alex Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | - Thomas Nakagawa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Divisions of Emergency and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Kathleen Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bryanna Schwartz
- Heart Development and Structural Diseases Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
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7
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Tidwell TL. Life in Suspension with Death: Biocultural Ontologies, Perceptual Cues, and Biomarkers for the Tibetan Tukdam Postmortem Meditative State. Cult Med Psychiatry 2024:10.1007/s11013-023-09844-2. [PMID: 38393648 DOI: 10.1007/s11013-023-09844-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 02/25/2024]
Abstract
This article presents two cases from a collaborative study among Tibetan monastic populations in India on the postdeath meditative state called tukdam (thugs dam). Entered by advanced Tibetan Buddhist practitioners through a variety of different practices, this state provides an ontological frame that is investigated by two distinct intellectual traditions-the Tibetan Buddhist and medical tradition on one hand and the Euroamerican biomedical and scientific tradition on the other-using their respective means of inquiry. Through the investigation, the traditions enact two paradigms of the body at the time of death alongside attendant conceptualizations of what constitutes life itself. This work examines when epistemologies of these two traditions might converge, under what ontological contexts, and through which correlated indicators of evidence. In doing so, this work explores how these two intellectual traditions might answer how the time course and characteristics of physiological changes during the postmortem period might exhibit variation across individuals. Centrally, this piece presents an epistemological inquiry delineating the types of valid evidence that constitute exceptional processes post-clinical death and their potential ontological implications.
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Affiliation(s)
- Tawni L Tidwell
- Center for Healthy Minds, University of Wisconsin-Madison, 625 W. Washington Ave., Madison, WI, 53703, USA.
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8
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Candia-Rivera D, Machado C. Reduced Heartbeat-Evoked Responses in a Near-Death Case Report. J Clin Neurol 2023; 19:581-588. [PMID: 37455508 PMCID: PMC10622722 DOI: 10.3988/jcn.2022.0415] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/30/2022] [Accepted: 01/25/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND AND PURPOSE Whether brain-heart communication continues under ventricular fibrillation (VF) remains to be determined. There is weak evidence of physiological changes in cortical activity under VF. Moreover, brain-heart communication has not previously been studied in this condition. We aimed to measure parallel changes in heart-rate variability (HRV), cortical activity, and brain-heart interactions in a patient who experienced VF. METHODS The EEG and EKG signals for the case report were acquired for approximately 20 h. We selected different 1-min-long segments based on the changes in the EKG waveform. We present the changes in heartbeat-evoked responses (HERs), HRV, and EEG power for each selected segment. RESULTS The overall physiological activity appeared to deteriorate as VF proceeded. Brain-heart interactions measured using HERs disappeared, with a few aberrant amplitudes appearing occasionally. The parallel changes in EEG and HRV were not pronounced, suggesting the absence of bidirectional neural control. CONCLUSIONS Our measurements of brain-heart interactions suggested that the evolving VF impairs communication between the central and autonomic nervous systems. These results may support that reduced brain-heart interactions reflect loss of consciousness and deterioration in the overall health state.
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Affiliation(s)
| | - Calixto Machado
- Department of Clinical Neurophysiology, Institute of Neurology and Neurosurgery, Havana, Cuba
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9
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Wang T, Raman VK, Motamedi GK. Continuous EEG Characteristics in Critically ill Patients Presenting With Seizures Prior to Death From Cardiac Arrest. Neurohospitalist 2023; 13:371-375. [PMID: 37701258 PMCID: PMC10494811 DOI: 10.1177/19418744231174950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Background: There have been limited reports about brain activity during cardiac arrest. Here we report 4 patients presenting with seizure who had cardiac arrest leading to their deaths while being on continuous video-EEG (cVEEG) monitoring and one-lead cardiac telemetry. Purpose: We illustrate characteristic stepwise EEG and EKG changes in these critically ill patients prior to their death. Research Design/Study Sample: All patients showed progressive broad spectrum of cardiac arrhythmias at or before the beginning of EEG suppression while there were no such changes seen in a control group of 4 randomly selected patients without cardiac arrest who had seizure on presentation and underwent cVEEG monitoring. Data Collection and Results: There was a progressive decline in EEG potentials associated with decreasing heart rate starting from the posterior region, more pronounced on the left, progressing to complete unilateral deactivation of the left fronto-central head regions while the right-sided networks became hyperactive before bilateral deactivation by the time of asystole. Conclusions: This case series provides a rare opportunity to compare EEG and EKG changes in patients who died while being on continuous EEG and EKG monitoring from hours to minutes prior to cardiac arrest and death.
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Affiliation(s)
- Tian Wang
- Department of Neurology, Georgetown University Hospital, Washington, DC, USA
| | - Venkatesh K. Raman
- Division of Cardiology, Veterans Affairs Medical Center, Washington, DC, USA
| | - Gholam K. Motamedi
- Department of Neurology, Georgetown University Hospital, Washington, DC, USA
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10
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Bernat JL, Domínguez-Gil B, Glazier AK, Gardiner D, Manara AR, Shemie S, Porte RJ, Martin DE, Opdam H, McGee A, López Fraga M, Rayar M, Kerforne T, Bušić M, Romagnoli R, Zanierato M, Tullius SG, Miñambres E, Royo-Villanova M, Delmonico FL. Understanding the Brain-based Determination of Death When Organ Recovery Is Performed With DCDD In Situ Normothermic Regional Perfusion. Transplantation 2023; 107:1650-1654. [PMID: 37170405 DOI: 10.1097/tp.0000000000004642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
| | | | - Alexandra K Glazier
- New England Donor Services, Waltham, MA. Health Services, Policy and Practice, Brown University, Providence, RI
| | - Dale Gardiner
- Medical Directorate, Deceased Organ Donation for NHS Blood and Transplant, Nottingham, United Kingdom
| | - Alexander R Manara
- Intensive Care Medicine, The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Sam Shemie
- Pediatric Critical Care Medicine, McGill University Health Centre, Montreal, QB, Canada
| | - Robert J Porte
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Dominique E Martin
- Health Ethics and Professionalism School of Medicine, Faculty of Health Deakin University, Geelong, VIC, Australia
| | - Helen Opdam
- Australian Organ and Tissue Authority, Austin Hospital, and Warringal Private Hospital Intensive Care Unit, Melbourne, VIC, Australia
| | - Andrew McGee
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane City, QLD, Australia
| | - Marta López Fraga
- Quality of Medicines and Healthcare, Council of Europe, European Committee on Organ Transplantation (CD-P-TO), Strasbourg, France
| | - Michel Rayar
- Service de chirurgie Hépatobiliaire et Digestif CHU Pontchaillou, Rennes, France
| | - Thomas Kerforne
- Service d'Anesthésie-Réanimation et Médecine Périopératoire-CHU de Poitiers, Poitiers, France
| | - Mirela Bušić
- SoHO Standards Department of Biological Standardisation, OMCL Network and HealthCare (DBO) EDQM, Council of Europe, Strasbourg, France
| | - Renato Romagnoli
- General Surgery 2U - Liver Transplant Center, AOU Città della Salute e della Scienza di Torino, Molinette Hospital, University of Turin, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Critical Care, AOU Città della Salute e della Scienza di Torino, Molinette Hospital, Turin, Italy
| | - Stefan G Tullius
- Transplant Surgery, Harvard Medical School, Division of Transplant Surgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Eduardo Miñambres
- Donor Transplant Coordination Unit and Service of Intensive Care, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Spain
| | - Mario Royo-Villanova
- Donor Transplant Coordination Unit and Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Francis L Delmonico
- New England Donor Services, Department of Surgery, Harvard Medical School at the Massachusetts General Hospital, Boston, MA
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11
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Shlobin NA, Aru J, Vicente R, Zemmar A. What happens in the brain when we die? Deciphering the neurophysiology of the final moments in life. Front Aging Neurosci 2023; 15:1143848. [PMID: 37228251 PMCID: PMC10203241 DOI: 10.3389/fnagi.2023.1143848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/12/2023] [Indexed: 05/27/2023] Open
Abstract
When do we die and what happens in the brain when we die? The mystery around these questions has engaged mankind for centuries. Despite the challenges to obtain recordings of the dying brain, recent studies have contributed to better understand the processes occurring during the last moments of life. In this review, we summarize the literature on neurophysiological changes around the time of death. Perhaps the only subjective description of death stems from survivors of near-death experiences (NDEs). Hallmarks of NDEs include memory recall, out-of-body experiences, dreaming, and meditative states. We survey the evidence investigating neurophysiological changes of these experiences in healthy subjects and attempt to incorporate this knowledge into the existing literature investigating the dying brain to provide valuations for the neurophysiological footprint and timeline of death. We aim to identify reasons explaining the variations of data between studies investigating this field and provide suggestions to standardize research and reduce data variability.
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Affiliation(s)
- Nathan A. Shlobin
- Department of Neurosurgery, Henan Provincial People’s Hospital, Henan University School of Medicine, Zhengzhou, China
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jaan Aru
- Institute of Computer Science, University of Tartu, Tartu, Estonia
| | - Raul Vicente
- Institute of Computer Science, University of Tartu, Tartu, Estonia
| | - Ajmal Zemmar
- Department of Neurosurgery, Henan Provincial People’s Hospital, Henan University School of Medicine, Zhengzhou, China
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, United States
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12
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Murphy N, Weijer C, Debicki D, Laforge G, Norton L, Gofton T, Slessarev M. Ethics of non-therapeutic research on imminently dying patients in the intensive care unit. JOURNAL OF MEDICAL ETHICS 2023; 49:311-318. [PMID: 35728941 PMCID: PMC10176359 DOI: 10.1136/medethics-2021-107953] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 05/23/2022] [Indexed: 05/14/2023]
Abstract
Non-therapeutic research with imminently dying patients in intensive care presents complex ethical issues. The vulnerabilities of the imminently dying, together with societal disquiet around death and dying, contribute to an intuition that such research is beyond the legitimate scope of scientific inquiry. Yet excluding imminently dying patients from research hinders the advancement of medical science to the detriment of future patients. Building on existing ethical guidelines for research, we propose a framework for the ethical design and conduct of research involving the imminently dying. To enable rapid translation to practice, we frame the approach in the form of eight ethical questions that researchers and research ethics committees ought to answer prior to conducting any research with this patient population. (1) Does the study hypothesis require the inclusion of imminently dying patients? (2) Are non-therapeutic risks and burdens minimised consistent with sound scientific design? (3) Are the risks of these procedures no more than minimal risk? (4) Are these non-therapeutic risks justified insofar as they are reasonable in relation to the anticipated benefits of the study? (5) Will valid informed consent be obtained from an authorised surrogate decision maker? (6) How will incidental findings be handled? (7) What additional steps are in place to protect families and significant others of research participants? (8) What additional steps are in place to protect clinical staff and researchers? Several ethical challenges hinder research with imminently dying patients. Nonetheless, provided adequate protections are in place, non-therapeutic research with imminently dying patients is ethically justifiable. Applying our framework to an ongoing study, we demonstrate how our question-driven approach is well suited to guiding investigators and research ethics committees.
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Affiliation(s)
- Nicholas Murphy
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Philosophy, Western University, London, Ontario, Canada
| | - Charles Weijer
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Philosophy, Western University, London, Ontario, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Derek Debicki
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Brain and Mind Institute, Western University, London, Ontario, Canada
| | - Geoffrey Laforge
- Brain and Mind Institute, Western University, London, Ontario, Canada
- Department of Psychology, Western University, London, Ontario, Canada
| | - Loretta Norton
- Department of Psychology, King's University College at Western University, London, Ontario, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Marat Slessarev
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Brain and Mind Institute, Western University, London, Ontario, Canada
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13
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Maundrell R. Brain Death: Still A Puzzle After All These Years. NEUROETHICS-NETH 2023. [DOI: 10.1007/s12152-022-09513-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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14
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Lalgudi Ganesan S, Hornby L, Weiss M, Dawe K, Lanos C, Wollny K, Dhanani S, Gofton T. Brain-based arterial pulse pressure threshold for death determination: a systematic review. Can J Anaesth 2023; 70:685-698. [PMID: 37138154 PMCID: PMC10202984 DOI: 10.1007/s12630-023-02425-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 05/05/2023] Open
Abstract
PURPOSE There is lack of consensus regarding the minimum arterial pulse pressure required for confirming permanent cessation of circulation for death determination by circulatory criteria in organ donors. We assessed direct and indirect evidence supporting whether one should use an arterial pulse pressure of 0 mm Hg vs more than 0 (5, 10, 20, 40) mm Hg to confirm permanent cessation of circulation. SOURCE We conducted this systematic review as part of a larger project to develop a clinical practice guideline for death determination by circulatory or neurologic criteria. We systematically searched Ovid MEDLINE, Ovid Embase, Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library, and Web of Science for articles published from inception until August 2021. We included all types of peer-reviewed original research publications related to arterial pulse pressure as monitored by an indwelling arterial pressure transducer around circulatory arrest or determination of death with either direct context-specific (organ donation) or indirect (outside of organ donation context) data. PRINCIPAL FINDINGS A total of 3,289 abstracts were identified and screened for eligibility. Fourteen studies were included; three from personal libraries. Five studies were of sufficient quality for inclusion in the evidence profile for the clinical practice guideline. One study measured cessation of cortical scalp electroencephalogram (EEG) activity after withdrawal of life-sustaining measures and showed that EEG activity fell below 2 μV when the pulse pressure reached 8 mm Hg. This indirect evidence suggests there is a possibility of persistent cerebral activity at arterial pulse pressures > 5 mm Hg. CONCLUSION Indirect evidence suggests that clinicians may incorrectly diagnose death by circulatory criteria if they apply any arterial pulse pressure threshold of greater than 5 mm Hg. Moreover, there is insufficient evidence to determine that any pulse pressure threshold greater than 0 and less than 5 can safely determine circulatory death. STUDY REGISTRATION PROSPERO (CRD42021275763); first submitted 28 August 2021.
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Affiliation(s)
- Saptharishi Lalgudi Ganesan
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
- Paediatric Critical Care Medicine, Children's Hospital - London Health Sciences Center, London, ON, Canada.
| | | | - Matthew Weiss
- Transplant Québec, Montreal, QC, Canada
- CHU de Québec, Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Kirk Dawe
- Discipline of Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
- Critical Care Program, Eastern Health, St. John's, NL, Canada
| | - Chelsea Lanos
- County of Renfrew Paramedic Service, Pembroke, ON, Canada
| | - Krista Wollny
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Sonny Dhanani
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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15
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Maitre G, Shemie SD, Baker A, Chassé M, Hornby L, Sarti AJ, Teitelbaum J, Dhanani S. Knowledge gaps in the definition and determination of death. Can J Anaesth 2023; 70:610-616. [PMID: 37131033 PMCID: PMC10203022 DOI: 10.1007/s12630-023-02422-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 11/23/2022] [Accepted: 11/27/2022] [Indexed: 05/04/2023] Open
Affiliation(s)
- Guillaume Maitre
- McGill University, Montreal, QC, Canada.
- McGill University Health Center, Montreal, QC, Canada.
- Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.
- Division of Pediatric Critical Care, Montreal Children's Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada.
| | - Sam D Shemie
- McGill University, Montreal, QC, Canada
- McGill University Health Center, Montreal, QC, Canada
- McGill University Health Center Research Institute, Montreal, QC, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Andrew Baker
- University of Toronto, Toronto, ON, Canada
- Unity Health Toronto, Toronto, ON, Canada
| | | | | | - Aimee J Sarti
- University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeanne Teitelbaum
- McGill University, Montreal, QC, Canada
- McGill University Health Center, Montreal, QC, Canada
| | - Sonny Dhanani
- University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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16
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Cappucci SP, Smith WS, Schwartzstein R, White DB, Mitchell SL, Fehnel CR. End-Of-Life Care in the Potential Donor after Circulatory Death: A Systematic Review. Neurohospitalist 2023; 13:61-68. [PMID: 36531837 PMCID: PMC9755608 DOI: 10.1177/19418744221123194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Donation after circulatory death (DCD) is becoming increasingly common, yet little is known about the way potential donors receive end-of-life care. Purpose The aims of this systematic review are to describe the current practice in end-of-life care for potential donors and identify metrics that are being used to assess discomfort among these patients. Research design and Study Sample This review encompasses published literature between June 1, 2000 and June 31, 2020 of end-of-life care received by potential DCD patients. The population of interest was defined as patients eligible for Maastracht classification III donation after circulatory death for a solid organ transplantation. Outcomes examined included: analgesic or palliative protocols, and surrogates of discomfort (eg dyspnea, agitation). Results Among 141 unique articles, 27 studies were included for full review. The primary reason for exclusion was lack of protocol description, or lack of reporting on analgesic medications. No primary research studies specifically examined distress in the DCD eligible population. Numerous professional guidelines were identified. Surveys of critical care practitioners identified concerns regarding the impact of symptom management on hastening the dying process in the DCD population as a potential barrier to end-of-life palliative treatment. Conclusions There is a paucity of empirical evidence for end-of-life symptom assessment and management for DCD patients. Key evidence gaps identified for DCD include the need for: i) a multidisciplinary structure of treatment teams and preferred environment for DCD, ii) objective tools for monitoring of distress in this patient population, and iii) evidence guiding the administration of analgesic medications following withdrawal of life sustaining therapy.
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Affiliation(s)
- Stefanie P Cappucci
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Wade S Smith
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | - Douglas B White
- Department of Critical Care, University of PittsburghSchool of Medicine, Pittsburgh, PA, USA
| | - Susan L Mitchell
- Harvard Medical School, Boston, MA, USA
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
| | - Corey R Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
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17
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Gofton TE, Norton L, Laforge G, Gibson R, Debicki D, Althenayan E, Scales N, Beinum AV, Hornby L, Shemie S, Dhanani S, Slessarev M. Cerebral cortical activity after withdrawal of life-sustaining measures in critically ill patients. Am J Transplant 2022; 22:3120-3129. [PMID: 35822321 DOI: 10.1111/ajt.17146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 06/09/2022] [Accepted: 07/04/2022] [Indexed: 01/25/2023]
Abstract
Establishing when cerebral cortical activity stops relative to circulatory arrest during the dying process will enhance trust in donation after circulatory determination of death. We used continuous electroencephalography and arterial blood pressure monitoring prior to withdrawal of life sustaining measures and for 30 min following circulatory arrest to explore the temporal relationship between cessation of cerebral cortical activity and circulatory arrest. Qualitative and quantitative EEG analyses were completed. Among 140 screened patients, 52 were eligible, 15 were enrolled, 11 completed the full study, and 8 (3 female, median age 68 years) were included in the analysis. Across participants, EEG activity stopped at a median of 78 (Q1 = -387, Q3 = 111) seconds before circulatory arrest. Following withdrawal of life sustaining measures there was a progressive reduction in electroencephalographic amplitude (p = .002), spectral power (p = .008), and coherence (p = .003). Prospective recording of cerebral cortical activity in imminently dying patients is feasible. Our results from this small cohort suggest that cerebral cortical activity does not persist after circulatory arrest. Confirmation of these findings in a larger multicenter study are needed to help promote stakeholder trust in donation after circulatory determination of death.
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Affiliation(s)
- Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Western Institute for Neuroscience, Western University, London, Ontario, Canada
| | - Loretta Norton
- Department of Psychology, King's University College at Western University, London, Ontario, Canada
| | - Geoffrey Laforge
- Western Institute for Neuroscience, Western University, London, Ontario, Canada
| | - Raechelle Gibson
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Derek Debicki
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Western Institute for Neuroscience, Western University, London, Ontario, Canada
| | - Eyad Althenayan
- Department of Medicine/Critical Care, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Nathan Scales
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Laura Hornby
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Canadian Blood Services, Ottawa, Ontario, Canada
| | - Sam Shemie
- Canadian Blood Services, Ottawa, Ontario, Canada.,Pediatric Intensive Care, McGill University Health Centre & Research Institute, Montreal, Quebec, Canada
| | - Sonny Dhanani
- Pediatric Critical Care, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Marat Slessarev
- Department of Psychology, King's University College at Western University, London, Ontario, Canada.,Department of Medicine/Critical Care, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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18
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Greyson B, van Lommel P, Fenwick P. Commentary: Enhanced Interplay of Neuronal Coherence and Coupling in the Dying Human Brain. Front Aging Neurosci 2022; 14:899491. [PMID: 35663570 PMCID: PMC9157615 DOI: 10.3389/fnagi.2022.899491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/04/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Bruce Greyson
- Department of Psychiatry & Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States
- *Correspondence: Bruce Greyson
| | - Pim van Lommel
- Department of Cardiology, Rijnstate Hospital, Arnhem, Netherlands
| | - Peter Fenwick
- Department of Psychiatry, Emeritus Maudsley Hospital and Emeritus Kings College Institute of Psychiatry, London, England
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19
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Abstract
BACKGROUND Electroencephalography (EEG) findings following cardiovascular collapse in death are uncertain. We aimed to characterize EEG changes immediately preceding and following cardiac death. METHODS We retrospectively analyzed EEGs of patients who died from cardiac arrest while undergoing standard EEG monitoring in an intensive care unit. Patients with brain death preceding cardiac death were excluded. Three events during fatal cardiovascular failure were investigated: (1) last recorded QRS complex on electrocardiogram (QRS0), (2) cessation of cerebral blood flow (CBF0) estimated as the time that blood pressure and heart rate dropped below set thresholds, and (3) electrocerebral silence on EEG (EEG0). We evaluated EEG spectral power, coherence, and permutation entropy at these time points. RESULTS Among 19 patients who died while undergoing EEG monitoring, seven (37%) had a comfort-measures-only status and 18 (95%) had a do-not-resuscitate status in place at the time of death. EEG0 occurred at the time of QRS0 in five patients and after QRS0 in two patients (cohort median - 2.0, interquartile range - 8.0 to 0.0), whereas EEG0 was seen at the time of CBF0 in six patients and following CBF0 in 11 patients (cohort median 2.0 min, interquartile range - 1.5 to 6.0). After CBF0, full-spectrum log power (p < 0.001) and coherence (p < 0.001) decreased on EEG, whereas delta (p = 0.007) and theta (p < 0.001) permutation entropy increased. CONCLUSIONS Rarely may patients have transient electrocerebral activity following the last recorded QRS (less than 5 min) and estimated cessation of cerebral blood flow. These results may have implications for discussions around cardiopulmonary resuscitation and organ donation.
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20
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Domínguez-Gil B, Ascher N, Capron AM, Gardiner D, Manara AR, Bernat JL, Miñambres E, Singh JM, Porte RJ, Markmann JF, Dhital K, Ledoux D, Fondevila C, Hosgood S, Van Raemdonck D, Keshavjee S, Dubois J, McGee A, Henderson GV, Glazier AK, Tullius SG, Shemie SD, Delmonico FL. Expanding controlled donation after the circulatory determination of death: statement from an international collaborative. Intensive Care Med 2021; 47:265-281. [PMID: 33635355 PMCID: PMC7907666 DOI: 10.1007/s00134-020-06341-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/21/2020] [Indexed: 12/14/2022]
Abstract
A decision to withdraw life-sustaining treatment (WLST) is derived by a conclusion that further treatment will not enable a patient to survive or will not produce a functional outcome with acceptable quality of life that the patient and the treating team regard as beneficial. Although many hospitalized patients die under such circumstances, controlled donation after the circulatory determination of death (cDCDD) programs have been developed only in a reduced number of countries. This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation. The Statement addresses three fundamental aspects of the cDCDD pathway. First, it describes the process of determining a prognosis that justifies the WLST, a decision that should be prior to and independent of any consideration of organ donation and in which transplant professionals must not participate. Second, the Statement establishes the permanent cessation of circulation to the brain as the standard to determine death by circulatory criteria. Death may be declared after an elapsed observation period of 5 min without circulation to the brain, which confirms that the absence of circulation to the brain is permanent. Finally, the Statement highlights the value of perfusion repair for increasing the success of cDCDD organ transplantation. cDCDD protocols may utilize either in situ or ex situ perfusion consistent with the practice of each country. Methods to accomplish the in situ normothermic reperfusion of organs must preclude the restoration of brain perfusion to not invalidate the determination of death.
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Affiliation(s)
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Alexander M Capron
- Scott H. Bice Chair in Healthcare Law, Policy and Ethics, Department of Medicine and Law, University of Southern California, Los Angeles, CA, USA
| | - Dale Gardiner
- Intensive Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alexander R Manara
- Consultant in Intensive Care Medicine, The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - James L Bernat
- Department of Neurology and Medicine, Active Emeritus, Dartmouth Geisel School of Medicine, Hanover, NH, USA
| | - Eduardo Miñambres
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - Jeffrey M Singh
- University of Toronto, and Trillium Gift of Life Network, Toronto, Canada
| | - Robert J Porte
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - James F Markmann
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kumud Dhital
- Department of Cardiothoracic Surgery, Sant Vincent'S Hospital, Sidney, Australia
| | - Didier Ledoux
- Department of Anesthesia and Intensive Care, University of Liège, Liège, Belgium
| | - Constantino Fondevila
- General and Digestive Surgery, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Sarah Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Dirk Van Raemdonck
- University Hospitals Leuven and Catholic University Leuven, Leuven, Belgium
| | - Shaf Keshavjee
- Toronto General Hospital, University of Toronto, Toronto, Canada
| | - James Dubois
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew McGee
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane City, Australia
| | - Galen V Henderson
- Director of Neurocritical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Stefan G Tullius
- Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sam D Shemie
- Pediatric Intensive Care, Montreal Children's Hospital, McGill University, Medical Advisor, Deceased Donation, Canadian Blood Services, Montreal, Canada
| | - Francis L Delmonico
- Chief Medical Officer, New England Donor Services, 60 1st Ave, Waltham, MA, 02451, USA.
- Department of Surgery, Harvard Medical School at Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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21
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Lott DT, Yeshi T, Norchung N, Dolma S, Tsering N, Jinpa N, Woser T, Dorjee K, Desel T, Fitch D, Finley AJ, Goldman R, Bernal AMO, Ragazzi R, Aroor K, Koger J, Francis A, Perlman DM, Wielgosz J, Bachhuber DRW, Tamdin T, Sadutshang TD, Dunne JD, Lutz A, Davidson RJ. No Detectable Electroencephalographic Activity After Clinical Declaration of Death Among Tibetan Buddhist Meditators in Apparent Tukdam, a Putative Postmortem Meditation State. Front Psychol 2021; 11:599190. [PMID: 33584435 PMCID: PMC7876463 DOI: 10.3389/fpsyg.2020.599190] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Recent EEG studies on the early postmortem interval that suggest the persistence of electrophysiological coherence and connectivity in the brain of animals and humans reinforce the need for further investigation of the relationship between the brain's activity and the dying process. Neuroscience is now in a position to empirically evaluate the extended process of dying and, more specifically, to investigate the possibility of brain activity following the cessation of cardiac and respiratory function. Under the direction of the Center for Healthy Minds at the University of Wisconsin-Madison, research was conducted in India on a postmortem meditative state cultivated by some Tibetan Buddhist practitioners in which decomposition is putatively delayed. For all healthy baseline (HB) and postmortem (PM) subjects presented here, we collected resting state electroencephalographic data, mismatch negativity (MMN), and auditory brainstem response (ABR). In this study, we present HB data to demonstrate the feasibility of a sparse electrode EEG configuration to capture well-defined ERP waveforms from living subjects under very challenging field conditions. While living subjects displayed well-defined MMN and ABR responses, no recognizable EEG waveforms were discernable in any of the tukdam cases.
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Affiliation(s)
- Dylan T. Lott
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Tenzin Yeshi
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - N. Norchung
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Sonam Dolma
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Nyima Tsering
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Ngawang Jinpa
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Tenzin Woser
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Kunsang Dorjee
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Tenzin Desel
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | - Dan Fitch
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Anna J. Finley
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Robin Goldman
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | | | - Rachele Ragazzi
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Karthik Aroor
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - John Koger
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Andy Francis
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - David M. Perlman
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Joseph Wielgosz
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - David R. W. Bachhuber
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
| | - Tsewang Tamdin
- Men-Tsee-Khang/TMAI, Upmuhal, Dharamshala, Himachal Pradesh, India
| | | | - John D. Dunne
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
- Department of East Asian Languages and Literature, University of Wisconsin-Madison, Madison, WI, United States
| | - Antoine Lutz
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
- Lyon Neuroscience Research Centre, INSERM U1028, CNRS UMR5292, Lyon 1 University, Lyon, France
| | - Richard J. Davidson
- Center for Health Minds, University of Wisconsin-Madison, Madison, WI, United States
- Departments of Psychology and Psychiatry, University of Wisconsin-Madison, Madison, WI, United States
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22
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Xu J, Mohamed W, Basha MM, Zutshi D. Electroencephalogram Characteristics in Critical Ill Patients Before Cardiac Arrest: A Case Series. Clin EEG Neurosci 2019; 50:423-428. [PMID: 31353957 DOI: 10.1177/1550059419865679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background/Objectives. To illustrate characteristic electroencephalogram (EEG) features in patients prior to their first cardiac arrest. Methods. We identified 15 patients who suffered cardiac arrest during continuous EEG at our institution from June 2016 to June 2019. Eight patients were excluded due to co-administration of intravenous anesthetics (which may confound EEG) or if they had a previous prolonged cardiac arrest (>5 minutes) during the same hospitalization. We collected background information, analyzed the time span and vital signs between the initial background change and cardiac arrest. Results. The time span range (minutes) from initial background change to cardiac arrest was 4 to 483 (average 128.9), initial background change to suppression was 0 to 372 (average 75.6), suppression to cardiac arrest was 1 to 140 (average 53.3), suppression to complete suppression was 0 to 66 (average 20.4), and complete suppression to cardiac arrest was 1 to 111 (average 32.9). Three patients showed background changes more than 160 minutes before cardiac arrest. All patients showed progressive heart rate (HR) decline at or before the beginning of suppression on EEG. HR (beats/min) (mean ± SE) at background change, background suppression, complete suppression, and cardiac arrest was 86.3 ± 7.5, 63.9± 7.5, 36.0 ± 6.8, and 0, respectively. We found statistically significant HR changes (P < .05) between background change and complete suppression time points. Conclusions. Our data indicate that EEG pattern change can occur minutes to hours before the initial cardiac arrest. These patterns may be due to progressive cerebral ischemia. Further studies with broad-scale monitoring of vital signs and evoked potentials may help develop models for predicting cardiac insufficiency.
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Affiliation(s)
- Jian Xu
- 1 Detroit Medical Center/Wayne State University, Detroit, MI, USA
| | - Wazim Mohamed
- 1 Detroit Medical Center/Wayne State University, Detroit, MI, USA
| | - Maysaa M Basha
- 1 Detroit Medical Center/Wayne State University, Detroit, MI, USA
| | - Deepti Zutshi
- 1 Detroit Medical Center/Wayne State University, Detroit, MI, USA
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23
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Walter U, Fernández-Torre JL, Kirschstein T, Laureys S. When is “brainstem death” brain death? The case for ancillary testing in primary infratentorial brain lesion. Clin Neurophysiol 2018; 129:2451-2465. [DOI: 10.1016/j.clinph.2018.08.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/20/2018] [Accepted: 08/25/2018] [Indexed: 12/19/2022]
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24
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Shemie SD, Gardiner D. Circulatory Arrest, Brain Arrest and Death Determination. Front Cardiovasc Med 2018; 5:15. [PMID: 29662882 PMCID: PMC5890102 DOI: 10.3389/fcvm.2018.00015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 02/12/2018] [Indexed: 12/18/2022] Open
Abstract
Technological advances, particularly in the capacity to support, replace or transplant failing organs, continue to challenge and refine our understanding of human death. Given the ability to reanimate organs before and after death, both inside and outside of the body, through reinstitution of oxygenated circulation, concepts related to death of organs (e.g. cardiac death) are no longer valid. This paper advances the rationale for a single conceptual determination of death related to permanent brain arrest, resulting from primary brain injury or secondary to circulatory arrest. The clinical characteristics of brain arrest are the permanent loss of capacity for consciousness and loss of all brainstem functions. In the setting of circulatory arrest, death occurs after the arrest of circulation to the brain rather than death of the heart. Correspondingly, any intervention that resumes oxygenated circulation to the brain after circulatory arrest would invalidate the determination of death.
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Affiliation(s)
- Sam David Shemie
- Division of Critical Care, Montreal Children's Hospital, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Deceased Organ Donation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Dale Gardiner
- Adult Intensive Care Units, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.,NHS Blood and Transplant, Bristol, United Kingdom
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Dreier JP, Major S, Foreman B, Winkler MKL, Kang EJ, Milakara D, Lemale CL, DiNapoli V, Hinzman JM, Woitzik J, Andaluz N, Carlson A, Hartings JA. Terminal spreading depolarization and electrical silence in death of human cerebral cortex. Ann Neurol 2018; 83:295-310. [PMID: 29331091 PMCID: PMC5901399 DOI: 10.1002/ana.25147] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/08/2018] [Accepted: 01/09/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Restoring the circulation is the primary goal in emergency treatment of cerebral ischemia. However, better understanding of how the brain responds to energy depletion could help predict the time available for resuscitation until irreversible damage and advance development of interventions that prolong this span. Experimentally, injury to central neurons begins only with anoxic depolarization. This potentially reversible, spreading wave typically starts 2 to 5 minutes after the onset of severe ischemia, marking the onset of a toxic intraneuronal change that eventually results in irreversible injury. METHODS To investigate this in the human brain, we performed recordings with either subdural electrode strips (n = 4) or intraparenchymal electrode arrays (n = 5) in patients with devastating brain injury that resulted in activation of a Do Not Resuscitate-Comfort Care order followed by terminal extubation. RESULTS Withdrawal of life-sustaining therapies produced a decline in brain tissue partial pressure of oxygen (pti O2 ) and circulatory arrest. Silencing of spontaneous electrical activity developed simultaneously across regional electrode arrays in 8 patients. This silencing, termed "nonspreading depression," developed during the steep falling phase of pti O2 (intraparenchymal sensor, n = 6) at 11 (interquartile range [IQR] = 7-14) mmHg. Terminal spreading depolarizations started to propagate between electrodes 3.9 (IQR = 2.6-6.3) minutes after onset of the final drop in perfusion and 13 to 266 seconds after nonspreading depression. In 1 patient, terminal spreading depolarization induced the initial electrocerebral silence in a spreading depression pattern; circulatory arrest developed thereafter. INTERPRETATION These results provide fundamental insight into the neurobiology of dying and have important implications for survivable cerebral ischemic insults. Ann Neurol 2018;83:295-310.
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Affiliation(s)
- Jens P Dreier
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Departments of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Departments of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Brandon Foreman
- UC Gardner Neuroscience Institute.,Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Maren K L Winkler
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Eun-Jeung Kang
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Denny Milakara
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Vince DiNapoli
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Mayfield Clinic, Cincinnati, OH
| | - Jason M Hinzman
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Johannes Woitzik
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Norberto Andaluz
- UC Gardner Neuroscience Institute.,Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Mayfield Clinic, Cincinnati, OH
| | - Andrew Carlson
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM
| | - Jed A Hartings
- UC Gardner Neuroscience Institute.,Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
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VandenBosch J. “Heaven Is Overrated”: Two Movies That Posit Life Beyond Death. THE GERONTOLOGIST 2017; 57:998-1000. [DOI: 10.1093/geront/gnx126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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