Spotlight paper in Canadian Journal of Anesthesia: Dr. Sam Shemie
The CDTRP would like to congratulate Dr. Sam Shemie and his team on the publication of their groundbreaking article, titled ‘A brain-based definition of death and criteria for its determination after arrest of circulation or neurologic function in Canada: a 2023 clinical practice guideline‘ in the Canadian Journal of Anesthesia/Journal canadien d’anesthésie. This is an important contribution to the field of donation and will undoubtedly have a major impact on medical practice in Canada. We are proud to have such talented and dedicated researchers in our community, and we look forward to seeing more of their innovative work in the future!
Abstract
This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as recommendations for death determination by circulatory criteria for potential organ donors and death determination by neurologic criteria for all mechanically ventilated patients regardless of organ donation potential. This Guideline is endorsed by the Canadian Critical Care Society, the Canadian Medical Association, the Canadian Association of Critical Care Nurses, Canadian Anesthesiologists’ Society, the Canadian Neurological Sciences Federation (representing the Canadian Neurological Society, Canadian Neurosurgical Society, Canadian Society of Clinical Neurophysiologists, Canadian Association of Child Neurology, Canadian Society of Neuroradiology, and Canadian Stroke Consortium), Canadian Blood Services, the Canadian Donation and Transplantation Research Program, the Canadian Association of Emergency Physicians, the Nurse Practitioners Association of Canada, and the Canadian Cardiovascular Critical Care Society.
A Brain-Based Definition of Death and Criteria for its Determination After Arrest of Circulation or Neurologic Function in Canada: Frequently Asked Questions
History and Context
In Canada, definitions of death may be found in provincial/territorial statutes and vary from province to province. Where a definition is included within this legislation, death is either defined as cessation of brain function, or includes brain death. Otherwise, it is left to the common law definition adopted by judges, who have accepted cessation of brain or cardiorespiratory function. In the majority of provinces, criteria for death determination in the context of organ donation are delegated by statutes to accepted medical practice.
Previous Canadian death determination guidelines that form the basis of accepted medical practice describe death as arising after cessation of brain function, circulatory function, and both circulatory and brain function.
Medical, legal, and ethical issues have emerged, all of which collectively provided strong impetus for review and update of the guidelines, including:
- Development of international standards to harmonize international practices for death determination by neurologic criteria (DNC)
- Advances in knowledge and emerging evidence related to physiology of the dying process after withdrawal of life-sustaining measures (WLSM) for death determination by circulatory criteria (DCC), and the use of ancillary investigation for DNC
- Recent legal cases in Ontario where families challenged DNC and the accepted medical guidelines
- Advances in technological support of organ function to support life prior to death, or preserve organs after death.
Furthermore, there has been a 16-year gap for the adult/pediatric DNC and organ donation after DCC recommendations, and five-year gap in pediatric organ donation after DCC recommendations. In the interim, not only has the volume of evidence available to inform recommendations increased, but, since 2006, so has the required rigour for the process of guideline development.
In response, Health Canada’s Organ Donation and Transplantation Collaborative funded a project entitled, “A Brain-Based Definition of Death and Criteria for its Determination After Arrest of Circulation or Neurologic Function in Canada,” a partnership between Canadian Blood Services, the Canadian Critical Care Society, and the Canadian Medical Association.
The project’s objectives were to develop a unified brain-based definition of death and update the criteria for its determination after devastating brain injury or circulatory arrest.
The recommendations outlined in the clinical practice guideline will result in changes to Canadian practice in several key areas:
Definition of death
- A single definition of death based on the permanent cessation of brain function.
Death determination by circulatory criteria (DCC):
- Five recommendations related to:
- Monitoring devices
- Cessation of circulation
- Observation time
Death determination by neurologic criteria (DNC):
- Fifteen recommendations related to:
- Clinical assessment & brain imaging after return of spontaneous circulation post cardiac arrest
- Core body temperature
- Pupillary assessment
- Vestibulo-ocular reflex
- Apnea testing
- Number of clinical assessments
- Ancillary investigations
In addition, historical nomenclature has been replaced by death determination by neurologic criteria (DNC) (previously referred to as neurologic determination of death or brain death) and death determination by circulatory criteria (DCC) (previously referred to as cardiocirculatory death, or circulatory death)
The priority of all healthcare professionals is always to save life. Death determination, and subsequently organ donation, are only considered after all life-saving efforts are exhausted, and there is no chance of recovery.
The ethical foundation for deceased organ donation, which accounts for more than 80% of all organ transplants in Canada, is the dead donor rule – “vital organs should only be taken from dead patients and, correlatively, living patients must not be killed by organ retrieval.” Trust in the health care system and the practice of deceased organ donation is predicated on a clear definition of death and criteria for its determination.
Using a rigorous and standardized process of guideline development that included systematic reviews of the scientific literature and assessing the quality of the available evidence, the recommendations in the clinical practice guideline apply to potential organ donors who will undergo death determination death determination by circulatory criteria (DCC), in addition to all mechanically ventilated patients who will undergo death determination by neurologic criteria (DNC), regardless of organ donation potential.
These guidelines are intended to minimize any risk of diagnostic error and, most importantly, err on the side of caution to avoid concluding that a patient is dead if they may not be. If a clinician has any uncertainty at all, then death should not be determined.
Supporting a loved one through the dying process often places overwhelming emotional and psychological burdens on families and substitute decision makers. A multidisciplinary support team (e.g., nurses, social workers, psychologists, spiritual care advisors, religious officials, and donor coordinators where applicable) should be included in care discussions as early as possible when it is suspected that a patient may progress to death.
Specific considerations to facilitate family members understanding and acceptance of death determination by neurologic criteria, in particular, include:
- Using clear and consistent language
- Preparing families and substitute decision makers early
- Anticipate and clarify questions about how death is determined
- Repeating information
- Using multiple methods to communicate
- Inviting families and substitute decision makers to witness the death determination process
- Acknowledging that seeing a patient’s chest rise or feeling their warm body makes it difficult for families and substitute decision makers to accept death has occurred
- Understanding the acceptance of death unfolds over time rather than in one isolated meeting
- Providing opportunities for end-of-life rituals
We spoke with Dr. Shemie to learn about the future steps and how the CDTRP could support this important work. The Canadian Critical Care Society (CCCS), Canadiane Blood Services (CBS), and the Canadian Medical Association (CMA), along with the project committee, are actively devising plans to ensure that the updated guidance is implemented at the bedside, while also addressing any medico-legal-ethical controversies that may arise. As for legislative changes, CBS continues to advocate for a brain-based definition of death, although it is not their specific role. Additionally, the CDTRP can help advance the research agenda outlined in Maitre et al’s knowledge gaps paper, that you can access here. Overall, there are several avenues for the CDTRP to contribute to this crucial work.
About Dr. Sam Shemie
Dr. Shemie’s area of interest is organ replacement during critical illness. He isa pediatric critical care physician, ECMO specialist and trauma team leader at the Montreal Children’s Hospital, McGill University Health Centre. He is a Professor of Pediatrics at the Montreal Children’s Hospital, McGill University and honourary staff in the Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto. He is medical advisor, deceased organ donation, with Canadian Blood Services. His academic focus is advancing the science and practice of deceased organ donation. His research interests include the clinical and policy impact of organ failure support technologies, the development and implementation of national ICU-based leading practices in organ donation and research at the intersection of end-of-life care, death determination and deceased donation.
ity of Alberta and has received training in patient-oriented research through the University of Calgary’s PACER (Patient and Community Engagement Research) Program. He is the Patient, Family, and Donor Partnerships & Education Manager with the Canadian Donation and Transplantation Research Program. In this role, Manuel builds relationships patient partners with investigators and strengthens capacity among CDTRP patient partners.
Anders Billström 
Gareth Wiltshire
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Sherrie Logan 
born and raised in Edmonton, AB. With a degree in Music Performance (saxophone performance) and Education, Lindsey has taught for over a decade in the Edmonton Public School system. When she is not teaching, she is very involved in the music community, performing in the Edmonton Winds, conducting her own community ensemble (The Beer League Band) and on numerous musical boards across the province. For the past 5 years, Lindsey has had to take a break from teaching after having her amazing son, George. Maternity leave did not goes as expected as George was diagnosed with Dilated Cardiomyopathy at 5 months old and required 2 heart transplants before the age of 4. During this time, Lindsey has also began to dedicate her time building and expanding her charity: Big Gifts for Little Lives, where they raise money to fund Pediatric Heart Transplant research at the Stollery.
Dr. Caigan Du is a scientist at the Vancouver Coastal Health Research Institute and an assistant professor in the Department of Urologic Sciences at the University of British Columbia. He received a Ph.D. degree in Biochemistry in UK and postdoctoral training in Immunology in USA. He is interested in the pathogenesis of kidney ischemia-reperfusion injury and transplant rejection, and molecular control of urinary malignancies. He has been studying the impact of kidney donor-derived factors on renal allograft rejection, and the molecular pathways of kidney injury and regeneration in experimental models. He is also interested in developing medical solution including drugs made from natural compounds for all kinds of health problems, including immune disorders, organ preservation, kidney failure and urinary cancer. He is the PI of many grant supports from the Kidney Foundation of Canada and the Canadian Institutes of Health Research.
Heather Badenoch is a non-directed living liver donor and communications strategist. As the president of Village PR, she provides strategic communications direction and training to not-for-profit clients in community and health. An active transplant volunteer, Heather helps transplant candidates find living donors by running their public appeals, small and large, pro-bono. She also mentors potential living donors on the path to living donation. Heather is a volunteer with the UHN Centre for Living Organ Donation and the Canadian Donation and Transplant Research Program. She and her spouse adopt rescue dogs and volunteer together with Community Veterinary Outreach, a group providing free veterinary care to the pets of people who are homeless.
Sean Dicks is a clinical psychologist who has 20 years’ experience supporting both families of organ donors and transplant recipients. While it is rare for him to have contact with a donor family and recipient linked to the same organ donation-transplantation event, his contact with families who have lived experience with organ donation on the one hand, and patients who have received transplants on the other hand has provided opportunities to explore how their journeys become linked when they attempt to make sense of and find meaning in their respective crises.
Terri Hansen-Gardiner is a Cree speaking Metis woman from Northern Saskatchewan as well as a 10 year Breast Cancer Survivor. Her tireless spirit and dedication to her community is undeniable. Terri is a cancer survivor who travels around the province to provide assistance, information, and support to Indigenous patients who are trying to access and navigate the cancer care system.
Dr. Golnaz Karoubi is Assistant Scientist at the Toronto General HospitalResearch Institute and principal investigator in the Latner Thoracic Research Labs. She currently holds an Assistant Professor appointment in the department of Laboratory Medicine and Pathobiology and a cross-appointment in the department of Mechanical and Industrial Engineering at the University of Toronto. Dr. Karoubi received her PhD in Applied Science and Engineering at the University of Toronto and joined the Lung Regenerative Medicine Program in the Department of Clinical Research in Berne University, Switzerland for a post-doctoral research fellowship. She stayed on as a Group Leader in 2008 to direct the basic and transitional science as related to Cancer Stem Cell and Lung Regenerative Medicine in the Department of Biomedical Research at the University of Berne until 2012. In early 2012, she joined the team of Dr. Tom Waddell at the Toronto General Hospital Research Institute as a Senior Scientific Associate and was appointed to Assistant Scientist at the Toronto General Hospital Research Institute (University Health Network) in November 2019 and to Assistant Professor in the Department of Laboratory Medicine and Pathobiology in July 2020.
Dr. Haykal graduated from the University of Ottawa Faculty of Medicine in2007 as class valedictorian and silver medalist, and subsequently completed her residency training in Plastic and Reconstructive Surgery at the University of Toronto in 2016. During her residency, she completed a four-year Doctorate of Philosophy (PhD) in tissue engineering, regenerative medicine and immunology with a focus on tracheal reconstruction. She obtained numerous grants and awards including a CIHR Vanier Scholarship. Dr. Haykal then pursued fellowship training in microsurgical reconstruction at the Albany Medical Centre in New York. Dr. Haykal joined the University Health Network and the Toronto General Hospital in 2018. Her clinical focus is on complex oncological reconstruction and microsurgical reconstruction of the breast, head and neck and extremity. She started a lymphedema program in 2019 where she offers microsurgical techniques for the treatment of lymphedema.
Dr. Ahmed is a Professor in the Cumming School of Medicine at the University of Calgary. The recipient of the 2022 Hypertension Canada Senior Investigator Award, she is a nephrologist and clinician-scientist with a focus on sex and gender differences in human cardiovascular/kidney physiology and clinical outcomes. Dr. Ahmed is the Vice Chair (Research) for the Department of Medicine, Lead of the Libin Institute Women’s Cardiovascular Health Research Initiative at the University of Calgary and Lead of the Alberta Strategy for Patient Oriented Research Capacity Development Platform. Dr. Ahmed is an Advisory Board member for the Canadian Institutes of Health Research Institute of Gender and Health, a member of the Canadian Medical Association Journal Governing Council and the President-Elect for the Organization for the Study of Sex Differences.
r. Christopher Nguan is an Associate Professor at the University of British Columbia in the Department of Urological Sciences, Surgical Head of Kidney Transplantation at Vancouver General Hospital and the Director of the Surgical Technologies Experimental Laboratory & Advanced Robotics (STELLAR) facility at Vancouver General Hospital.
r Caroline Lamarche is a clinician scientist and transplant nephrologist at Maisonneuve-Rosemont Hospital. She is an assistant clinical professor at the Université de Montréal. After her nephrology training at the Université de Montréal (2015), she completed a Master degree on the use of adoptive immunotherapy to treat/prevent BK nephropathy in kidney transplant recipients. She then pursued a post-doctoral fellowship with Dr. Megan Levings at the University of British Columbia on the use of chimeric antigen receptor (CAR) regulatory T cells (Tregs) to induce transplant tolerance. Her lab is working on the development of adoptive immunotherapy in nephrology and understanding Treg dysfunction.
Dr. Tandon is an Associate Professor of Medicine, Co-Director of the Cirrhosis Care Clinic, Transplant Hepatologist and lead of the Cirrhosis Care Alberta quality improvement program. She obtained her training at the University of Alberta, the Hospital Clinic in Barcelona and Yale University. Her clinical practice and research are focused on cirrhosis with research interests including cirrhosis related complications, malnutrition, frailty, exercise therapy, palliative care, integrative health approaches such as meditation and knowledge translation. It is her career goal to provide wholistic, interdisciplinary, evidence based, patient-centered care through education, empowerment, engagement and team-work.
Emily is a PhD student at the University of Alberta, where she completed her Master of Science (MSc) degree in medicine. With a passion for patient-oriented research and a commitment to improving health outcomes, Emily’s doctoral project focuses on EMPOWER, a 12-week online mind-body wellness program designed for adults living with chronic health conditions.
Dr Basil S. Nasir, M.B.B.Ch
Dr. Victor Ferreira is an Assistant Scientist in the Ajmera Transplant Centre at the University Health Network (UHN) and the Toronto General Hospital Research Institute (TGHRI). He is also an Assistant Professor at the University of Toronto in the Department of Laboratory Medicine and Pathobiology (LMP). He completed his PhD in Medical Sciences – Infection and Immunity Specialization at McMaster University in 2014 and post-doctoral training at UHN. His research program is focused on three pillars: I) using systems vaccinology to reveal insights into vaccine responses in immunocompromised individuals like transplant recipients; II) characterizing the impact of chronic viral infection on host immune responses; and III) developing novel methods for eliminating latent viruses in human organs. His work has been cited >2,500 times and is published in journals including the New England Journal of Medicine, Nature Immunology, the Lancet Infectious Diseases, Clinical Infectious Diseases, the American Journal of Transplantation and Journal of Infectious Diseases.