Variability in the determination of death after cardiac arrest: a review of guidelines and statements.

INTRODUCTION: The reemergence of organ donation after circulatory determination of death (DCDD) in Canada demands the establishment of clear, evidence-based guidelines for the determination of death. The primary purpose of this study was to investigate the variability in specific criteria, diagnostic tests, and recommended wait periods for the determination of death after cardiac arrest.
METHODS: We used PubMed and Web of Science to perform a structured search of the medical literature for articles published up to January 1, 2010. We also performed an unstructured search of the internet for unrestricted, readily available, nonjournal sources. We limited the search to countries that are most active in DCDD.
RESULTS: A total of 26 documents were retrieved; 21 medical professional society/institution statements and 5 national/international guidelines. Specific criteria for the determination of death after cardiac arrest were cited in 24 documents: 14 recommend cardiocirculatory criteria alone; 6 oblige the requirement of a prolonged waiting period after declaration to ensure neurological death; 3 recommend following "accepted medical practice" without specific details; and 1 leaves the definition up to "national authorities." Only 16 of the documents require specific diagnostic procedures with unresponsiveness, absent arterial pulse and apnea cited the most consistently. Specific wait periods after declaration are required for the determination of death after cardiac arrest in 24 documents, cited times range from 2 to 10 minutes, with a 5-minute period the most frequent.
CONCLUSIONS: This review is the first to document the variability of guidelines and statements for the determination of death after cardiac arrest, in countries where the practice of DCDD is becoming increasingly common. The scarcity of peer-reviewed published guidelines in the medical literature exemplifies the need for further investigation. We believe these results will inform the ethical discussions surrounding the determination of death after cardiac arrest. Clear and consistent guidelines based on evidence are needed to fulfill medical, ethical, and legal obligation and to ensure public trust.