Rady, Mohamed Y.

Organ transplantation has become an established treatment option for end-stage organ disease. Both living and end-of-life (so called deceased) organ donation narrow the gap between supply and demand for transplantable organs. Advances in human biology prove that death occurs as a gradual process over time and not as a single discrete event. Declaring death with either neurological criteria (heart-beating organ donation) or circulatory criteria (non-heart-beating organ donation) enables the procurement of transplantable organs before human death is complete, namely, from the incipiently dying donor. Thus, surgical procurement of organs from the incipiently dying donor is the proximate cause of death, raising new questions on end-of-life organ donation. It is imperative to first and foremost care for the patient as a dying person. International Muslim scholars should reevaluate previous Islamic rulings and provide guidance about current practice of end-of-life organ donation.

Background: There remains a lack of awareness around the American Academy of Neurology (AAN) procedural criteria for brain death and the surrounding controversies, leading to significant practice variability. This survey study assessed for existing knowledge and attitude among healthcare professionals regarding procedural criteria and potential change after an educational intervention. Methods: Healthcare professionals with increased exposure to brain injury at Mayo Clinic hospitals in Arizona and Florida were invited to complete an online survey consisting of 2 iterations of a 14-item questionnaire, taken before and after a 30-minute video educational intervention. The questionnaire gathered participants’ opinion of (1) their knowledge of the AAN procedural criteria, (2) whether these criteria determine complete, irreversible cessation of brain function, and (3) on what concept of death they base the equivalence of brain death to biological death. Results: Of the 928 people contacted, a total of 118 and 62 participants completed the pre-intervention and post-intervention questionnaire, respectively. The results show broad, unchanging support for the concept of brain death (86.8%) and that current criteria constitute best practice. While 64.9% agree further that the loss of consciousness and spontaneous breathing is sufficient for death, contradictorily, 37.6% believe the loss of additional integrated bodily functions such as fighting infection is necessary for death. A plurality trusts these criteria to demonstrate loss of brain function that is irreversible (67.6%) and complete (43.6%) at baseline, but there is significantly less agreement on both at post-intervention. Conclusion: Although there is consistent support that AAN procedural criteria are best for clinical practice, results show a tenuous belief that these criteria determine irreversible and complete loss of all brain function. Despite support for the concept of brain death first developed by the President’s Council, participants demonstrate confusion over whether the loss of consciousness and spontaneous breath are truly sufficient for death.

We present a case of haemorrhagic enterocolitis in a patient with SARS-CoV-2 who recovered from respiratory failure after support with venovenous extracorporeal membrane oxygenation. We describe clinicopathological features consistent with the systemic coinfection/reactivation of cytomegalovirus (CMV) concurrent with COVID-19 infection and the protracted clinical course of resolution of gastrointestinal inflammation after the treatment of CMV infection. Stool PCR, abdominal CT perfusion scan and histological examination of ileal and colonic tissues excluded enterocolitis secondary to other causes of infection (common viral, bacterial and protozoal gastrointestinal pathogens), macrovascular and microvascular ischaemia and classic inflammatory bowel disease, respectively. We propose possible synergistic pathophysiologic mechanisms for enterocolitis complicating severe COVID-19 infection: (1) T lymphocyte depletion and immune response dysregulation, (2) use of immunomodulators in the management of severe COVID-19 infection and (3) high concentration of ACE-2 receptors for COVID-19 virus in the gastrointestinal tract.

In the recent court case of In Re Guardianship of Hailu, the Nevada Supreme Court cast doubt on the acceptability of the American Academy of Neurology’s guidelines as a medical standard for determining brain death. The Uniform Determination of Death Act, which has been adopted in every state, requires that brain death diagnoses be made in accordance with accepted medical standards. The Court expressed concern that the guidelines fail to ensure that there is an irreversible cessation of all functions of a person’s entire brain, which is a component of the Act’s definition of death. Although the Nevada Supreme Court remanded the case to the District Court to hear more expert evidence concerning whether the guidelines constitute “accepted medical standards,” the patient who was the subject of the case met the criteria for cardiopulmonary death several weeks prior to the hearing and the legal case became moot. As a result, the issue of whether the American Academy of Neurology guidelines, or some other criteria for determining brain death, are accepted medical standards for determining whether all brain function has ceased remains unresolved.