In Response

Abstract

In Response As is often the case, the genesis for our article1 was an observation of something occurring outside our normal expectation, during routine care of donation after cardiac death (DCD). The bispectral index (BIS) machine was initially used as an academic exercise to illustrate the difference between organ procurement during non\Nheart-beating donation and procurement from a brain-dead donor. To confirm these findings of increased BIS values during DCD, the second and third cases were recorded, after IRB approval. One recurring theme in the letters by Rady, Verheijde, Windokun, Thomas and Thomas2–4 is the need to further evaluate the true meaning of these observations of increased BIS values during the dying process, because these observations are not only reproducible with DCD patients, but in other end-of-life arenas as well. For clarity, all changes in BIS values occurred before declaration of death and all BIS values returned to zero before any organ procurement procedures. DCD is a valuable process to obtain organs for transplantation and we did not intend to provide observations that might question the use of DCD for organ procurement. If anything, understanding the dying process by monitoring electroencephalogram (EEG) may make families, health care professionals, and future donors more comfortable with end-of-life care. The secondary theme is the need to focus on informing our colleagues of best practice for end-of-life situations, and we find strong agreement for this theme. We neither intend nor anticipate that one would draw final conclusions based solely on these data. Rather, our findings, coupled with those of Chawla et al.,5 support a need for further research. We agree with Rady et al. and reiterate that dosing opioids and/or hypnotic agents may be reasonable if changes in processed EEG are observed during withdrawal of care. Perhaps these EEG changes reflect a physiologic process such as loss of membrane polarization or cellular death that may not be preventable with opioids or hypnotics. However, in end-of-life situations, we would much rather err in dosing these agents based on an EEG artifact than withholding these agents on the assumption of artifact when they might be truly indicated. David B. Auyong, MD Department of Anesthesiology Virginia Mason Medical Center Seattle, Washington [email protected] Stephen M. Klein, MD Tong J. Gan, MB, BS, FRCA Anthony M. Roche, MB, ChB DaiWai Olson, PhD, RN, CCRN Ashraf S. Habib, MB, ChB, MSc, FRCA Duke University Medical Center Durham, North Carolina