To the Editor,
We thank Dr. Machado for his comments1 regarding the definition of death in the 2023 Canadian Clinical Practice Guideline2 and bringing attention to the alignment of this definition with the World Brain Death Project (WBDP). Both guidelines were widely endorsed by professional societies representing critical care, neurocritical care, neurology, neurosurgery, and numerous others. We fully agree with his assertion that “the critical attribute of life is consciousness” and that death is the “loss of both components of consciousness—arousal and awareness.” This was clearly articulated in our definition. Dr. Machado’s proposition to rephrase the WBDP definition of death should be directed to the authors of that JAMA publication.3 He makes an interesting assertion regarding the potential for residual control of the autonomic nervous system by the hypothalamus with implications for emotional awareness, while citing the potential for a “new state of disorder of consciousness” suggesting enduring awareness in the Jahi McMath case.4 While provocative, this remains unproven and it would be important for his team and other investigators to show whether these findings can be reproduced in other patients with techniques that have been used previously to assess for covert consciousness such as functional magnetic resonance imaging.
References
Machado C. Comment on: Canadian clinical practice guideline on brain death. Can J Anesth 2023; https://doi.org/10.1007/s12630-023-02660-7
Shemie SD, Wilson LC, Hornby L, et al. 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. Can J Anesth 2023; 70: 483–557. https://doi.org/10.1007/s12630-023-02431-42
Greer DM, Shemie SD, Lewis A, et al. Determination of brain death/death by neurologic criteria: the World Brain Death Project. JAMA 2020; 324: 1078–97. https://doi.org/10.1001/jama.2020.11586
Machado C. Jahi McMath: a new state of disorder of consciousness. J Neurosurg Sci 2020; 65: 211–3. https://doi.org/10.23736/s0390-5616.20.04939-5
Disclosures
Dr. Sam Shemie disclosed that he is the medical advisor for the System Development Team at Canadian Blood Services.
Funding statement
This Clinical Practice Guideline has been made possible through a financial contribution from Health Canada through the Organ Donation and Transplantation Collaborative (The Collaborative), and developed as a partnership between the Canadian Critical Care Society, Canadian Blood Services, and the Canadian Medical Association. The Collaborative is an initiative led by Health Canada with provinces and territories (except Quebec), Canadian Blood Services, patients, families, clinicians, and researchers. The Collaborative’s vision is to improve organ donation and transplantation systems across Canada.
Editorial responsibility
This submission was handled by Dr. Stephan K. W. Schwarz, Editor-in-Chief, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.
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Shemie, S.D., on behalf of the guideline development group for the Canadian Death Definition and Determination Project. In reply: Comment on: Canadian clinical practice guideline on brain death. Can J Anesth/J Can Anesth 70, 2015 (2023). https://doi.org/10.1007/s12630-023-02661-6
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DOI: https://doi.org/10.1007/s12630-023-02661-6