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!


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.

Read the full paper here.

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.

  • How does this guideline differ from previous Canadian guidelines?

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)

  • How does the guideline impact organ donation? Does it affect the hospital care of dying patients in order to acquire more organ donors?

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.

  • How should healthcare professionals communicate with families and substitute decision makers about death determination?

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
  • And how could the CDTRP support the future directions of this work?

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.