Medical-ethical guidelines: Determination of death with regard to organ transplantation and preparations for organ removal

The determination of death is a crucial prerequisite for post mortem organ removal. It is of ethical, legal and political importance and ensures that the living are not treated as if they were dead, and vice versa. What is required is not only a clearly defined, infallible criterion for the onset of death but also a reliable method for determining death. In the Transplantation Act,1 the criterion specified for a person’s death is the irreversible cessation of all functions of the brain, including the brainstem. This involves not only the irrevocable loss of consciousness – patients in a coma are not dead – but, in addition, the irreversible cessation of the integrative functions of the central nervous system, representing the loss of any possibility of continued life. This criterion of death has a scientific basis and is also valid irrespective of questions of organ transplantation. The irreversibility of brain death has been confirmed over many decades of practice. As regards the clinical procedure for the determination of death, the Transplantation Ordinance2 makes reference to the relevant sections of the guidelines on «The Determination of Death in the Context of Organ Transplantation» issued by the Swiss Academy of Medical Sciences on 24 May 2011. The present version of these guidelines takes account of the revision of the Transplantation Act dated 19 June 2015 and is designed to clarify and harmonise various aspects of current practice. From a scientific perspective, death is a biological process which unfolds with variable manifestations over a certain period of time; however, with regard to organ transplantation, it is essential – for ethical and legal reasons – that there should be a strictly standardised procedure for the determination of death. This means that, as well as being based on scientific facts, the determination of death is defined by society; accordingly, while the procedures applicable in different countries are fundamentally similar, they vary in certain respects.3 In each case, however, the goal is to provide the greatest possible certainty for all concerned, in the given context, that donors are indeed dead at the time of organ removal. To ensure that this certainty can be attained, three steps are necessary: firstly, the procedure for the determination of death – i.e. the irreversible cessation of brain, including brainstem, functions – must be precisely standardised and described. Secondly, the medical professionals involved in the procedure must receive appropriate training and support. Thirdly, the public needs to be informed in a clear and comprehensible manner. As well as providing technical instructions for the determination of death, the present guidelines also cover in detail many other aspects of deceased organ donation, such as the procedure for ascertaining the patient’s wishes, discussions with relatives, guidance for difficult decision situations, respectful management of the dying patient and the cadaver, and the performance of preparatory medical measures. The guidelines should make it easier for the care team to comply with legal requirements and to deal more effectively with the ethical issues.