Many believe that the ethical problems of donation after cardiocirculatory death (DCD) have been "worked out" and that it is unclear why DCD should be resisted. In this paper we will argue that DCD donors may not yet be dead, and therefore that organ donation during DCD may violate the dead donor rule. We first present a description of the process of DCD and the standard ethical rationale for the practice. We then present our concerns with DCD, including the following: irreversibility of absent circulation has not occurred and the many attempts to claim it has have all failed; conflicts of interest at all steps in the DCD process, including the decision to withdraw life support before DCD, are simply unavoidable; potentially harmful premortem interventions to preserve organ utility are not justifiable, even with the help of the principle of double effect; claims that DCD conforms with the intent of the law and current accepted medical standards are misleading and inaccurate; and consensus statements by respected medical groups do not change these arguments due to their low quality including being plagued by conflict of interest. Moreover, some arguments in favor of DCD, while likely true, are "straw-man arguments," such as the great benefit of organ donation. The truth is that honesty and trustworthiness require that we face these problems instead of avoiding them. We believe that DCD is not ethically allowable because it abandons the dead donor rule, has unavoidable conflicts of interests, and implements premortem interventions which can hasten death. These important points have not been, but need to be fully disclosed to the public and incorporated into fully informed consent. These are tall orders, and require open public debate. Until this debate occurs, we call for a moratorium on the practice of DCD.

Cardiac extracorporeal life support had a 41% 2-year survival. Potentially modifiable variables (time for lactate to normalize and highest inotrope score early during extracorporeal life support) explained 69% of mental score variance.

Infants with congenital heart disease are at significant risk of both silent and clinically identified thrombosis. There seems to be no advantage in using heparin-bonded catheters in infants

The apnea test is recommended for the diagnosis of brain death. There are several reasons this test should be reconsidered. Confounding factors for performing the test are vaguely and poorly specified. The following 2 confounders are usually present and not considered: potentially reversible high cervical spinal cord injury and central endocrine failure of adrenal and thyroid axes. There are case reports of breathing at a higher partial pressure of arterial carbon dioxide threshold and cases of recovery of breathing after brain death is diagnosed. The test is dangerous for an injured brain in the setting of high intracranial pressure. It can convert viable penumbral brain tissue to irreversibly nonfunctioning tissue via a transient increase in intracranial pressure and no-reflow phenomena. Hyperoxia during the apnea test can further suppress the function of medullary respiratory rhythm centers. Finally, the philosophical rationale for the need to show lack of spontaneous breathing in brain death is lacking.

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The objective of this review is to assess the impact of enteral and total parenteral nutrition on clinically important outcomes in critically ill children. There are two primary hypotheses:1. the mortality rate of critically ill children fed enterally or parenterally is different compared to children who are given no nutrition; 2. the mortality rate of critically ill children fed enterally is different compared to children fed parenterally.If data are available, we will conduct subgroup analyses to examine whether the treatment effect is altered by: a. age (infants less than one year versus children greater than or equal to one year); b. type of patient (medical (purpose of admission to ICU is for medical illness without surgical intervention immediately prior to admission) versus surgical (purpose of admission to ICU is for postoperative care)).If there are other clinical trials that examine nutrition more distinctly, the following secondary hypotheses will also be examined: 3. the mortality rate is different in children who are given enteral nutrition alone versus enteral and parenteral combined; 4. the mortality rate is different in children who are given both enteral feeds and parenteral nutrition versus no nutrition.

BackgroundNeurologists often diagnose brain death (BD) and explain BD to families in the intensive care unit. This study was designed to determine whether neurologists agree with the standard concept of death (irreversible loss of integrative unity of the organism) and understand the state of the brain when BD is diagnosed.MethodsA previously validated survey was mailed to a random sample of 500 board-certified neurologists in the United States. Main outcomes were: responses indicating the concept of death that BD fulfills and the empirical state of the brain that would rule out BD.ResultsAfter the second mailing, 218 (44%) surveys were returned. Few (n = 52, 27%; 95% confidence interval (CI), 21%, 34%) responded that BD is death because the organism has lost integrative unity. The most common justification was a higher brain concept (n = 93, 48%; 95% CI, 41%, 55%), suggesting that irreversible loss of consciousness is death. Contrary to the recent President's Council on Bioethics, few (n = 22, 12%; 95% CI, 8%, 17%) responded that the irreversible lack of vital work of an organism is a concept of death that the BD criterion may satisfy. Many responded that certain brain functions remaining are not compatible with a diagnosis of BD, including EEG activity, evoked potential activity, and hypothalamic neuroendocrine function. Many also responded that brain blood flow and lack of brainstem destruction are not compatible with a diagnosis of BD.ConclusionsAmerican neurologists do not have a consistent rationale for accepting BD as death, nor a clear understanding of diagnostic tests for BD.

Within the neurosurgical community, a stand-alone concept of BD does not exist. There is also significant variability in the understanding of the tests that are compatible with the criterion of BD.