Download PDF
Semin Neurol 2006; 26(4): 452-459
DOI: 10.1055/s-2006-948326
Copyright © 2006 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Ethical Issues in Critical Care and Cardiac Arrest: Clinical Research, Brain Death, and Organ Donation

Luke A. Donatelli1 , Romergryko G. Geocadin1 , 2 , 3 , Michael A. Williams1 , 2 , 4
  • 1Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 3Department of Anesthesiology-Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 4The Phoebe R. Berman Bioethics Institute, Johns Hopkins University, Baltimore, Maryland
Further Information

Publication History

Publication Date:
10 August 2006 (online)

    Permissions and Reprints

ABSTRACT

Cardiac arrest results in global hypoxic-ischemic brain injury from which there is a range of possible neurological outcomes. In most cases, patients may require a surrogate to make decisions regarding end-of-life care, including the withdrawal of life-sustaining therapies. This article reviews ethical considerations that arise in the clinical care of patients following cardiac arrest, including decisions to continue or withdraw life-sustaining therapies; brain death determination; and organ donation in the context of brain death and cardiac death (so-called non-heart-beating donation). This article also discusses ethical concerns pertaining to the design and conduct of resuscitation research that is necessary for the development of effective therapies to prevent anoxic brain injury or promote neurological recovery.

KEYWORDS

Cardiac arrest - brain death - organ donation - clinical research - informed consent

REFERENCES

  • 1 Diem S J, Lantos J D, Tulsky J A. Cardiopulmonary resuscitation on television: miracles and misinformation.  N Engl J Med. 1996;  334 1578-1582
    CrossrefPubMedGoogle Scholar
  • 2 Casarett D, Fishman J M, MacMoran H J, Pickard A, Asch D A. Epidemiology and prognosis of coma in daytime television dramas.  BMJ. 2005;  331 1537-1539
    CrossrefPubMedGoogle Scholar
  • 3 Brain Resuscitation Clinical Trial I Study Group . Randomized clinical study of thiopental loading in comatose survivors of cardiac arrest.  N Engl J Med. 1986;  314 397-403
    PubMedGoogle Scholar
  • 4 Brain Resuscitation Clinical Trial II Study Group . A randomized clinical study of a calcium-entry blocker (lidoflazine) in the treatment of comatose survivors of cardiac arrest.  N Engl J Med. 1991;  324 1225-1231
    PubMedGoogle Scholar
  • 5 Hypothermia after Cardiac Arrest Study Group . Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest.  N Engl J Med. 2002;  346 549-556
    CrossrefPubMedGoogle Scholar
  • 6 Jastremski M, Sutton-Tyrrell K, Vaagenes P et al.. Glucocorticoid treatment does not improve neurological recovery following cardiac arrest.  JAMA. 1989;  262 3427-3430
    CrossrefPubMedGoogle Scholar
  • 7 Roine R O, Kaste M, Kinnunen A et al.. Nimodipine after resuscitation from out-of-hospital ventricular fibrillation: a placebo-controlled, double-blind, randomized trial.  JAMA. 1990;  264 3171-3177
    CrossrefPubMedGoogle Scholar
  • 8 Thel M C, Armstrong A L, McNulty S E et al.. Randomised trial of magnesium in in-hospital cardiac arrest.  Lancet. 1997;  350 1272-1276
    CrossrefPubMedGoogle Scholar
  • 9 Longstreth Jr W T, Copass M K, Dennis L K et al.. Intravenous glucose after out-of-hospital cardiopulmonary arrest: a community-based randomized trial.  Neurology. 1993;  43 2534-2541
    PubMedGoogle Scholar
  • 10 Longstreth Jr W T, Fahrenbruch C E, Olsufka M et al.. Randomized clinical trial of magnesium, diazepam, or both after out-of-hospital cardiac arrest.  Neurology. 2002;  59 506-514
    PubMedGoogle Scholar
  • 11 Herlitz J, Andersson E, Bang A et al.. Experiences from treatment of out-of-hospital cardiac arrest during 17 years in Goteborg.  Eur Heart J. 2000;  21 1251-1258
    CrossrefPubMedGoogle Scholar
  • 12 Pusswald G, Fertl E, Faltl M et al.. Neurological rehabilitation of severely disabled cardiac arrest survivors: Part II. Life situation of patients and families after treatment.  Resuscitation. 2000;  47 241-248
    CrossrefPubMedGoogle Scholar
  • 13 The Pew Research Center .Strong Public Support for Right to Die: More Americans Discussing-and Planning-End-of-Life Treatment [Internet]. Washington, DC; The Pew Research Center 2006 Available at: http://people-press.org/reports/pdf/266.pdf Accessed March 11, 2006
    Google Scholar
  • 14 Larriviere D, Bonnie R J. Terminating artificial nutrition and hydration in persistent vegetative state patients: current and proposed state laws.  Neurology. 2006;  66 1624-1628
    CrossrefPubMedGoogle Scholar
  • 15 The American Academy of Neurology Code of Professional Conduct.  Neurology. 1993;  43 1257-1260
    PubMedGoogle Scholar
  • 16 Field MJ, Cassel CK Approaching Death: Improving Care at the End of Life. Washington, DC; National Academy Press 1997
    Google Scholar
  • 17 Curtis JR, Rubenfeld GD Managing Death in the ICU: The Transition from Cure to Comfort. New York; Oxford University Press 2001
    Google Scholar
  • 18 Geocadin R G, Buitrago M, Torbey M T et al.. Neurological prognosis and withdrawal of life support after resuscitation from cardiac arrest.  Neurology. 2006;  67 105-108
    CrossrefPubMedGoogle Scholar
  • 19 The Organ Procurement and Transplantation Network .Deceased Donors Recovered in the U.S. by Cause of Death. Available at: http://www.optn.org/latestData/viewDataReports.asp Accessed April 27, 2006
    Google Scholar
  • 20 The American Academy of Neurology .Practice Parameter? Determining Brain Death in Adults. Available at: http://www.aan.com/professionals/practice/guideline/index.cfm Accessed March 25, 2006
    Google Scholar
  • 21 Wijdicks E FM. Determining brain death in adults.  Neurology. 1995;  45 1003-1011
    CrossrefPubMedGoogle Scholar
  • 22 Chase C M, Williams M A. Brain death and organ donation. In: Bhardwaj A, Mirski MA, Ulatowski JA Current Clinical Neurology: Handbook of Neurocritical Care. Totowa, NJ; Humana Press 2005: 311-324
    Google Scholar
  • 23 American Academy of Pediatrics Task Force on Brain Death in Children . Report of the Special Task Force: guidelines for the determination of brain death in children.  Pediatrics. 1987;  80 298-300
    PubMedGoogle Scholar
  • 24 Wijdicks E FM. The diagnosis of brain death.  N Engl J Med. 2001;  344 1215-1221
    CrossrefPubMedGoogle Scholar
  • 25 American EEG Society . Guidelines in EEG and evoked potentials.  J Clin Neurophysiol. 1994;  11 1-143
    PubMedGoogle Scholar
  • 26 US Department of Health and Human Services .Summary of the HIPAA Privacy Rule [Internet]. Washington, DC; US Department of Health and Human Services 2003 Available at: http://www.hhs.gov/ocr/privacysummary.pdf Accessed March 25, 2006
    Google Scholar
  • 27 Childress JF, Liverman CT Organ Donation: Opportunities for Action. Washington, DC; National Academy Press 2006
    Google Scholar
  • 28 The Organ Procurement and Transplantation Network .OPTN/SRTR Annual Report-Chapter II: Organ Donation and Utilization. Available at: http://www.optn.org/AR2005/Chapter_II_AR_CD.htm?cp=3 Accessed March 25, 2006
    Google Scholar
  • 29 Herdman R, Potts J T. Non-Heart-Beating Organ Transplantation: Medical and Ethical Issues in Procurement. Washington, DC; National Academy Press 1997
    Google Scholar
  • 30 Committee on Non-Heart-Beating Transplantation II .The Scientific and Ethical Basis for Practice and Protocols. Non-Heart-Beating Organ Transplantation: Practice and Protocols. Washington, DC; National Academy Press 2000
    Google Scholar
  • 31 U.S. Department of Health and Human Services .Collaborative Home. Available at: http://www.organdonationnow.org/ Accessed April 27, 2006
    Google Scholar
  • 32 American College of Critical Care Medicine . Ethics Committee: recommendations for nonheartbeating organ donation.  Crit Care Med. 2001;  29 1826-1831
    PubMedGoogle Scholar
  • 33 Bernat J L, D'Alessandro A M, Port F K et al.. Report of a National Conference on Donation after Cardiac Death.  Am J Transplant. 2006;  6 281-291
    CrossrefPubMedGoogle Scholar
  • 34 D'Alessandro A M, Fernandez L A, Chin L T et al.. Donation after cardiac death: the University of Wisconsin experience.  Ann Transplant. 2004;  9 68-71
    PubMedGoogle Scholar
  • 35 Morgenweck C J. Innovation to research: some transitional obstacles in critical care units.  Crit Care Med. 2003;  31 S172-S177
    PubMedGoogle Scholar
  • 36 National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research . The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Available at: http://ohsr.od.nih.gov/guidelines/belmont.html Accessed May 10, 2006
    Google Scholar
  • 37 World Medical Association .Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. Available at: http://www.wma.net/e/policy/b3.htm Accessed May 10, 2006
    Google Scholar
  • 38 Bigatello L M, George E, Hurford W. Ethical considerations for research in critically ill patients.  Crit Care Med. 2003;  31 S178-S181
    PubMedGoogle Scholar
  • 39 Luce J M. Research ethics and consent in the intensive care unit.  Curr Opin Crit Care. 2003;  9 540-544
    PubMedGoogle Scholar
  • 40 Schweickert W, Hall J. Informed consent in the intensive care unit: ensuring understanding in a complex environment.  Curr Opin Crit Care. 2005;  11 624-628
    CrossrefPubMedGoogle Scholar
  • 41 Luce J M. Is the concept of informed consent applicable to clinical research involving critically ill patients?.  Crit Care Med. 2003;  31 S153-S156
    PubMedGoogle Scholar
  • 42 Chen D T, Miller F G, Rosenstein D L. Clinical research and the physician-patient relationship.  Ann Intern Med. 2003;  138 669-672
    PubMedGoogle Scholar
  • 43 Karlawish J H. Research involving cognitively impaired adults.  N Engl J Med. 2003;  348 1389-1392
    CrossrefPubMedGoogle Scholar
  • 44 Coppolino M, Ackerson L. Do surrogate decision makers provide accurate consent for intensive care research?.  Chest. 2001;  119 603-612
    CrossrefPubMedGoogle Scholar
  • 45 Beauchamp T L, Childress J F. Principles of Medical Ethics. 4th ed. New York; Oxford University Press 1994: 120-188
    Google Scholar
  • 46 U.S. Department of Health and Human Services .Informed Consent Requirements in Emergency Research. Available at: http://www.hhs.gov/ohrp/humansubjects/guidance/hsdc97-01.htm Accessed May 10, 2006
    Google Scholar
  • 47 Baren J M, Nathanson P G. Recruitment and communication process of participation in the 2005 AEM consensus conference on the ethical conduct of resuscitation research: methodology, challenges, lessons learned.  Acad Emerg Med. 2005;  12 1027-1030
    CrossrefPubMedGoogle Scholar
  • 48 Hiller K M, Haukoos J S, Heard K, Tashkin J S, Paradis N A. Impact of the final rule on the rate of clinical cardiac arrest research in the United States.  Acad Emerg Med. 2005;  12 1091-1098
    CrossrefPubMedGoogle Scholar
  • 49 Delorio N M, McClure K B. Does the emergency exception from informed consent process protect research subjects?.  Acad Emerg Med. 2005;  12 1056-1059
    CrossrefPubMedGoogle Scholar

Michael A WilliamsM.D. 

Department of Neurology, Johns Hopkins Hospital

600 North Wolfe Street, Phipps 102, Baltimore, MD 21287

      >