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Hello and welcome to November's SI CS um education evening update. Um I, we are delighted to be joined by our first double act to present one of these um uh SI CS evening updates today. Um I know that just before we start and shamelessly, I know that many of you will be SI CS members but um just in case you aren't aware of the society, si CS um is a organization which aims to improve the quality of care delivered to critically ill patients throughout Scotland. Does that through three main ways through education, through audit and research and through engagement with our members. Um There are a number of different membership categories available um for different healthcare professionals. And um information is available on the SI S website. There's a number of benefits of joining including reduced um membership rates at meetings, comprehensive travel insurance, and then access to travel and educational bursaries. And we will be uh with the early bird registration for our AM. Next year has just opened and that'll be heard held on the 1st and 2nd of May next year at Reef Hydro. We've got a new location. So um it'll be a new spa to try um introducing the speakers for this evening. Um uh We are delighted to be joined by Ian mcleod and Helen Tyler to update us about the code of practice updates for the diagnosis and confirmation of death. Um You many of you will know them both. Doctor mcleod is an ICU consultant for 14 years up in Gram and he now works in NHS F for, he's the deputy MD there. He is the regional clinical lead for Scotland and has been for the last nine years is the advisor to the Scottish government for donation. He co chairs the Scottish donation and transplant group which advises ministers on matters related to donation and transplantation. Dr Tyler has been a consultant interest and assist in Forth Valley for the last 10 years having previously trained in Oxford. She has a particular interest in end of life care in the ICU and regularly teaches on both the clinical and wider patient center to a considerations for this area of practice. She is the joint regional clinical lead for donation in Scotland and a faculty member on the National Deceased donation course. Um So thank you to both of you for joining us today. I'm gonna hand over to you if you have any questions to ask in our speakers this evening, there's a chat box on your right hand side where you can enter messages and we will put them to them at the end of the talk. Thank you so much. Thank you very much Julie. Uh I'm, I'm gonna kick off uh this talk. Welcome to everybody and thank you for the very kind introduction. Um We are sitting here er, together in Helen's very nice er, kitchen. Um We haven't been able to switch off the slide at the back, so uh it's all wide. Um and we're going to talk to you tonight uh about the updated code of practice for the diagnosis and confirmation of death. This is something that's relevant to all practitioners in, in certain, in intensive care. But um all medical practitioners uh across, across the country. Um So we'll kick off uh this will be in parts, we'll, we'll talk about the, the, the changes to the code of practice, why they've come about and what they are. And then we'll talk specifically in the second half about changes to death by ne testing criteria and the, the forms and paperwork that we will be using from the beginning of next year. So I'll move on the slide and there we go. So the important news really is that this is coming soon. It's coming to all of your units. It's coming to all of your practice as of the beginning of 2025 this becomes, this becomes live and becomes relevant. So anything to do with the diagnosis and confirmation of death in the UK um will be subject to the changes in this in this practice in this document, which has been kind of circulated just now. It has been worked up by the Medical uh sorry, the Academy of Medical Royal Colleges. Um So this is a kind of an independent group of the of the Royal colleges who have looked at the various different documents, criterias, international consensus, et cetera around how we diagnose death in in in the UK. Uh For those of you who've been around for a fair while there are some older, older documents. Um but the one that has been most relevant up until up until lately has been the 2008 code of practice, that was the last time that this was that this was looked at um and was and had something published about it. So it's 16 years since we last had an update to that code of practice. So a group of wise people have got together to um look at how we diagnose and confirm that this isn't specific to intensive care practice. This is uh this is general general practice across, across medicine. Um And really the, the plan was to look at what we have in the 2008 code to see what, what needed to be done with that. Did it needed updated? Was there anything that had changed uh new science, et cetera, et cetera? So these are the kind of um the principles of the, of the practice I should say at this point as well that the, these slides were written by Dale Gardner as the, as the coa of this group. And so I have to thank him for all of his work and the slides that we're presenting this evening. Um So these are the, uh the principles that that group got together, neither Helen nor I were involved in, in this work. Um But this is the, uh I suppose this is the the the presentation that's coming out of, of all of those uh signed off reports. So um basically, we were looking to update and evolve the 2008 codes. And I think this, this seems really simple, but death has not changed and that the old criteria were indeed safe. So there, there was nothing bad in the code that was there before. Um but it, it has gone on to be updated and sorry, an acknowledgement that uh this is 16 years old and that we were needing to see if anything had had uh changed or needed to be improved upon. Um the guy that's needed to be authoritative. So people need to um understand and accept um what comes out in this, this code. And I think that's why getting the Academy of Medical Royal Colleges on board um to get some consensus across the various different Royal colleges is, is very helpful. Um There's a bit about articulating diagnostic criteria and it really, this doesn't need to be safe. Uh in, in terms of the diagnosis, we need to have confidence in the ability to diagnose death. Um And if, if at all possible to strengthen any of the recommendations within the code, um Quite a lot of the work that we'll talk about tonight, some of the drivers for this is around trying to work with international colleagues. Um So there are various different codes of practice around this topic in different countries and uh increasingly are working together to try and come up with some consensus and and some uniformity of practice. So a lot of the work tonight and some of the reasoning about some of the changes is around and conforming with, with international guidelines and, and working with, with colleagues around the world. Um a couple of other kind of principles to update that this is around communication and to make sure that patients families and the public are, are aware of what's going on that this is transparent and that we are acting in the best interests of our patients. Um And, and lastly, um just to try and support colleagues to know how to diagnose the and be confident in that in that diagnosis. So those are the the principles with within which the uh the the group set about looking at the code of practice and then looking at the updates. So nothing has changed when it comes to this. Um There are um there is 11 death which is the permanent loss of the capacity for consciousness, the permanent loss of the capacity to breathe. Um So that is the diagnosis of death and it has not changed. And then three sort of criteria, I suppose, um within which those can be diagnosed with somatic criteria, circulatory criteria and neurological. And we'll just go into those in a wee bit detail. So who can um who can diagnose those we'll start with somatic. Um And another slide on that coming up. So appropriately trained and competent individuals who are present with the patient being diagnosed as deceased and somatic criteria um will come on to you in on the next slide um within circulating criteria. Again, we've got appropriately trained and competent individuals who are ordinarily a healthcare professional again, present with the person being diagnosed as deceased, competent in the use of a stethoscope. So, and able to examine and know what they're looking for to, to work out if that person is alive or dead. And then lastly, neurological criteria, which I suppose is uniquely relevant to um to, to, to, to our group, two doctors who have full registration with the General Medical Council equivalent for more than five years. Uh One of those doctors must be a consultant um and a slight change there, a minimum of two doctors, but on occasions up to four doctors because recognizing that you do two sets of tests with the way shift patterns, et cetera work these days, there may be a change of personnel and it, it cannot always be the same two people that do both sets of tests. So those are the um those are the who can diagnose the various different um ways that somebody may have died. Um And moving on to the next slide, the somatic criteria are, are really the things that we probably we don't see in hospital and these are overwhelming trauma, these are decapitations, et cetera, et cetera. A bunch of really horrible conditions there that people may die of. And it doesn't take, it doesn't take a medical professional to say that that person has died. Um So those are what are called the somatic criteria and within the, the 2025 code, the only thing that's changed there is that CPR is not required. So there's an explicit statement that's been put in there to say that CPR is not required. So if you find somebody um after road traffic accident who um you know, he'd been attended by the ambulance service whose head is not attached to their body, CPR would not be expected to be carried out in that situation. So that's a change within the code as compared to the one in 2008. And then just a wee comment at the bottom there that this is trying to align with the other uh groups who uh would be involved in seeing these patients. So these people Um So the ambulance service, the uh the fire service, et cetera moving on from somatic criteria. Um sorry. Uh So, into the circulating criteria, very little has changed. Um We have some clarification to why we wait five minute or why we examine it for five minutes and that's about the possibility of spontaneous resumption of cardiac function passing. So within five minutes of, of circulatory arrest, um we will not see um spontaneous resumption of cardiac function at that time. And, and we have just um beefed up the part about a clinical examination being being required. Um some pre conditions which have been set out that around again, around resuscitation. The decision has been made not to start resuscitating or after resuscitation and the decision has been made to, to stop um unsuccessful resuscitation. So, before you can diagnose death by circulating criteria, resuscitation cannot be part of the uh part of the story. So um looking at these circulatory criteria, we're looking for a five minute examination of a, of a patient who is unconscious, who is apneic and has absent circulation. And that's, and that's done by feeling your pulse and listening with the stethoscope. Um And this goes on to say that there's no requirement for that to be done for five minutes. So the expectation is not that you will feel the pulse for five minutes. The expectation is that entire examination will take five minutes, but the healthcare professional must be there the whole time to satisfy their examination uh that the patient has um has, has passed away and has none of these signs of life. So, um here, we're again looking at, so the physical examination we've just spoken about um in this part here um to support a timely diagnosis soon after cardio respiratory rest. And we can use some of these other um modalities which I suppose are maybe more uh pertinent to our practice within uh within critical care. So, we've got absence of a of an ECG, we've got absence of um cardiac contractility on, on an echo. And then we've also got um no postal arterial pressure on, on the arterial line. So we've got the difference here between um mechanical asystole and and clinical asystole. So, in that five minute period, um so after the onset of circulatory circulatory arrest and apnea, um we then got that five minute period thereafter. Um and we're using our, we can use echo and we can use um arterial pressure monitoring to detect circulatory arrest more rapidly than the ECG because the ECG may continue to have electrical activity for a period of time after. Uh there has been the absence of flow and therefore the difference here between mechanical and and clinically. So um the final point there, oh sorry, um jumped on slightly early, come back, electrical systole therefore, is not required if we've got echo or intrathecal pressure monitoring and that's certainly pertinent to our practice within, within it care after that five minutes of, um, making sure we don't have, um, we don't have, uh, circulatory activity. Uh, we are looking for pupillary responses as, um, as we are all familiar with and the absence of pupillary response to light and the absence of supra pressure. Um, we also recommend or it is recommended that hernia reflexes are checked thereafter as well. Um, and the point at the end here is that if there is any suggestion of a return of circulation, so if the arterial line were to change and there were to become a waveform or on an echo, you begin to see some, some contractility, then the clock resets and then you go back to the beginning again until you have absence of those and then a further five minutes uh is then required to make sure we've got, we've got confidence in our diagnosis. Um This should be done as soon as possible after a patient has, has died, obviously from a, you know, family and family and friends point of view. Um And then we're just saying here, families should be advised that there might be a difference between the time of the last observed breath and the documented time of death. Um So there, there may be a difference between those, those two things and then there is some comment here around retrieval procedures. Um And then specifically, I mention here around protocols to make sure that no blood circulation returns to the brain and that is part of routine practice within, within BCD. Um So I don't want to dwell on that at the moment, but that could come back to questions if anybody wishes later on. Um, ok, so that's, that's circulatory criteria um which I hope um is reasonable. So, very little change there, I think really, we just kind of laying out in a little bit more, more detail and being a bit more prescriptive, moving on to neurological criteria, which I suspect is what many of you are here for this evening. Um These are the changes to the diagnosis of death and neurological criteria which are going to be relevant to our practice within critical care. Um So these are the, these are the main changes. So the time of the time of death has been changed uh for those of you who've done this and have been around this for a long time will be used to diagnosing death as the completion of the first set of tests that has been changed or is going to be changed as of the first of next uh next month. Sorry, the first of uh January 25 to the uh the, the second set of tests. Uh There's a change to the apnea test in terms of the starting PP CO2 and what we're expecting the CO2 to climb by during the test. Um And uh we'll talk about that in a bit more detail in the rest of this talk. Um I suspect the majority of listeners will be practicing adult critical care medicine. But there has been some change to the use of diagnosis of neurological death in um in neonates. So we have said or sorry, the Academy of Medical Royal Colleges have said that um you cannot diagnose death by neurological criteria in neonates less than 37 weeks and between 37 weeks and 24 months. Uh, the testing is the same as in adults, except for some, um, some caveats and those are listed there. Um, there needs to be 24 hours, um, before testing, then there needs to be a further 24 hours between the two sets of tests and there's no role for ancillary investigations in these, in this age group for, uh, Children, uh, older than 24 months. Uh, things are as the same as in adult testing and, uh, it, it comments about specialist advice for similar investigations. Uh, so those are the, the first three changes to our, um, diagnosis of death by neurological criteria. So, um, it, we'll just go through those 11 by one. So, uh, the completion of the second set of tests, um, is going to be the, the time recorded as the time of death. Um, there is a, a slight, I suppose another caveat there around ancillary investigations. So if you're waiting for the result of an, an silly investigation to come back. And that comes after the second set of tests have been done, the time of death will be when that's when that unsly investigation, if that is crucial to the diagnosis, that will become the time of death. Um There's some just justification there as to why we're changing at this, at this point. And I think this one really does mostly um sit with international alignment. So this is bringing us into alignment with, with other uh contemporary pieces of work from around the world. Uh We know that not all countries do two sets of tests. Um And there was really no change, there was no desire to depart from the 22,008 code um to carry on those two sets of tests. So we wanted to carry on with the two including two apnea tests. Uh You can see there from over the years that this has, this has kind of evolved um from the 19 seventies eighties into the, into the twenties um where we are in a position now where we're doing these two sets of tests routinely. Um We have got some, I suppose some uh case law now as well, which is, is is backing this up. And then the final point which I think probably brings most true with, with me is um families increasingly witnessing the second set of tests and I wish to present to be to be there at the time of death. And I think that I think it's quite difficult to then have that conversation and kind of kind of backtrack. So I think, I think that seems that seems reasonable, but I think mostly this is around the international alignment. So um just to clarify, so go backwards and just to um make that point again, the time of death uh from the first of uh January of next year will be at the time of completion of the second set of tests, uh moving into the apnea test. Uh So we have a, a change in, in practice here where we're required to have a starting P CO2 greater than 5.3 kopas pills. And then an NC two after the test, a minimum of five minutes where that rises above eight KPA PS with a ph less than 7.3. Uh We're asking for a rise of um of P two of 2.7 KLOS, which is 20 millimeters of mercury. So if you start at 5.3 and it rises by 2.7 and you reach the magic number of eight, but equally, if you start at six, then you're going to have to get that to rise to uh six plus 2.7. So 8.7 in order to fulfill those criteria. Um So that's a, a change from the practice that we've been carrying out over the past uh past several years again. Uh why change uh and I think the first thing to say there is that there was no safety concerns around the current test. Um But um again, this is about alignment with international practice and it can be used across all age groups. So this uh table here shows us. So uh we are currently sitting on the uh on the left side there, the Academy of Medical Royal Colleges Guidance from 2008 where we, we requiring a starting PA U two of six ph less than 7.4 and a rise in C two of 0.5 over a minimum of five minutes. On the far right, you can see the new guidelines and with the ones in between, we can follow the Royal College of um Child, child pediatrics and Child Health. Oh sorry. Uh go back. So the real Royal College of Pediatrics and Child Health, the um um World Brain Death and project next Anz X guidelines, Canadian guidelines and American guidelines. So we're they are um looking for a rise in Paco two. It's 20 millimeters of mercury um really across the world. So we are, I suppose joining, joining that. Uh and our NC two is also um becoming uh becoming similar. Um So just going back to that uh those figures are all there, this, this guidance will be out for everybody to see. And it's certainly within all the documentation that Helen's going to talk to just in a few minutes. Um But uh you can see there but that the reason that these, this awkward number of 2.7 kg pacos exists is because this is based around um millimeters of mercury in, in, in other practice. So we need to get calculators out and we're all going to need to write this down. But the, but the paperwork I think is helpful in that regard. So those are the er changes in terms of the rise in PC two. Um I'm just gonna skip that slide. This is a summary of where of where we've been. Um I think I've probably covered most of this as well. It's just, it's just repeating the same thing about where we're starting where we want to end. Um, it's important that it's not performed while on a ventilator and we'll talk about that in, in due course. Um, we've spoken about where the number 2.7 comes from and the rise that we're looking to see. And I think this next point is, is important as well that it may take longer than that for the P two to rise above eight. And um may, yeah, take longer to arise by, by 2.7 you know, two patients are the same. So it might take longer, you might need to, to carry out the test for a longer period of time. And that is entirely acceptable until you've got that rise. That is, that is there. I think I feel more comfortable with this in many ways. And II was slightly we previously around the base small increase in pu two of 0.5 of the KOPAS. And so I think this feels like a more substantial rise. And I think it's more consistent with what I normally see in practice, you would tend to see uh after five minutes of a ventilator, a much higher P CO2. And I think that also covers our patients with COPD and, and, and AAA higher starting CO2 because we're still looking for that increment and to ensure that we are um how confident in our diagnosis of. Uh sorry, I've gone backwards again. Um I'm going backwards, sorry, I am going backwards, pressing the wrong side of the noise. Let's try again. Um Right. Where was II was here? Um So back to the age age categories and again, probably cover this. So this is done in conjunction with the Royal College of Pediatrics and Child Health. And as I've said, we're not able to diagnose death by neurological criteria in those under 37 weeks. Um And we have got guidelines now for a different documentation for patients between 37 weeks and 24 months. Um And then over 24 months, we're doing the same, the same testing forms. Uh This again is around international consensus um around the lower limit of 37 weeks and then using um advice from, from international colleagues around how to diagnose death in um in, in younger Children. Um So it says there are a pragmatic as a pragmatic solution taken together all the available evidence combined with a desire to align more closely with international guidance. Uh and not wanting to pass out on any previous diagnosis of death in the UK. The work recommends an age of greater than 24 months. So that's the pragmatic solution that we've taken around and diagnosis of death in Children. Um Here, we've got some other updates uh to the diagnosis of death by neurological criteria. And it's just, I suppose um giving us a bit more, a bit more detail and just and having it laid out in black and white. So there's some clarification around if you can test, um you need to have full registration with a GMC of five years or equivalent. So people who have worked in, in other countries. Um uh you have um worked the same, the same level and equivalence can, can test um if they are familiar with the procedure. And as I said previously, I think the recognition of the way that that modern shift patterns work up to four doctors may be needed to diagnose death by neurological criteria. Ideally, it would be the same people. I think consistency is helpful, but a recognition that this can be the case, um There's an encouragement to offer families opportunity to observe the second set of tests. I think that's something that many of us have done for some time. Um But it can be helpful um especially for those who are finding the diagnosis difficult, um the recognition of the responsibility of professional bodies. Um So that is around how we, how we learn, how we um how we pick up any difficulties in testing, how we share learning. Um And, and I think that's something that we have seen an improvement of around some of the difficult cases that we've had over the last five years. Um How we've shared that learning, how we've developed the um the red flags and the caveats around neurological testing. So that has that has also been strengthened in this, in this guidance. Um There's an expanded discussion on non no sorry nonbrain mediated movements um just in terms of describing that. Um And then also around cervical spinal cord pathology, the red flag patient groups are um haven't changed in this update. Uh But they are now laid out within the, the um within the documentation um in the in the preconditions. So I think that's probably easier to follow through again. We'll cover that later in the top. Um I think one of the ones which is going to cause us some um some difficulty as a group is the minimum core temperature of 36. So there's an expectation that before testing, a patient will have a minimum core temperature of 36 degrees and will have had that for 24 hours. Again, this is around international consistency. Um It is accepted that there might be some transient falls below 30 six degrees and that is acceptable. Um And it doesn't require another 24 hours of observation. But if you have a patient who is hypothermic, the expectation is that they would be warm to 36 degrees uh before testing is undertaken um for a period of of 20 of 24 hours. Um So I think that is definitely a change to practice and, and may cause us some uh some difficulties. In the first instance, I know there's been quite a lot of talk around how to rewarm. What's the best way to do that? I suspect it'll be using your protocols that you use for um for post cardiac arrest patients and, and the uh machinery, equipment, et cetera that you currently have in place for that, that each unit is going to have its own solution to how to warn patients in those circumstances. Uh We're also uh being asked to use a peripheral nerve stimulator uh to confirm that there is no neuromuscular function. Uh And that's something that's been stipulated within this update. There's a change to the minimum sodium concentration which did say previously at 115 up to 100 and 20. So that's now risen to 100 and 25. So the range of sodium concentration now needs to say between 100 and 25 and 100 and 60. And finally, um, it must be possible to examine both eyes and both ears. And again, that's around international consistency. Um, so if you have a trauma patient, for example, um, and you're not able to, uh, examine the 11 of the eyes or one of the ears, then, um, you're not going to be able to diagnose uh death by neurological criteria. Um, unless until the investigations can be used to back up your further examination. So again, that is a change in practice. Uh And so we in investigations. So this is where things get interesting and this is certainly something that we've seen more, uh, more time spent on over the past the past couple of years, this asked to do until the investigations which tend to be things like, um, CT angiography. Um, and uh, eegs et cetera. So they, they're not being routinely required within this update. And, and there's also a comment that it's not a full replacement for the clinical diagnosis of death that we've just been talking about. So it's additional to, um, to practice, um, not really to be used routinely within Children and definitely not less than 24 months. Um And actually, we're now saying that eeg no longer is, is recommended. So we're talking about CT angiography in, in the main, um, where it is required is where a comprehensive neurological examination cannot be carried out. And so it's not possible and the examples given there as I've just been talking about when you can examine the eyes and ears or when there's highs of vital cord pathology, uh, or if there's ongoing confounding factors, uh which don't allow you to meet the preconditions. Um, it can be considered where there's uncertainty regarding uh nonbrain mediated movements or spinal reflexes, et cetera. Um, and it might be helpful to, um, allow a family to come to terms with the uh with the diagnosis. The issues and difficulties with silly investigations will be, will be familiar to many. Um, these are not uh 100% sensitive and specific. Uh there is some, uh some, some difficulty accessing them and certainly getting them reported. And I think putting the burden of this on to some of her new radiology colleagues is uh is, is tricky in many ways, there's ongoing work in this space to try and get consensus around how to use these investigations. A meeting held within the last couple of weeks to discuss this more fully of which I've not heard any updates yet. But I think until the investigations are certainly something that we're going to hear more about and we're potentially going to be asked to do in more circumstances in the future, uh kind of covered that, I suppose. And just in, in, in what I've said, um, work certainly ongoing work with colleagues in new radiology and a consensus guideline written in 2023. So um over a year ago now, um which many of us will have seen and many of us will have commented on. Um So I think this is a, I think it almost feels like a watch the space kind of area for me, but it is something I suspect many of you will have questions about and we will try and answer if we can. Um So, um basically, what we're saying is that as of the first of January 2025 there's a change to the code of practice that we're all using around how we confirm and diagnose death. Uh The updates are there to find um on the Academy website and, and on the website, we find testing forms. I know that the forms have been circulated around um around our units as we speak to be in place for the first of January. Um And I'm gonna hand over to hell and you be fed up to listen to my voice. Thank you. All right. So, um with the change in um the criteria that we're using and the code of practice um around um diagnosis by neurological criteria, um will come a new form. So you'll all be used to the long and short form that have been available to walk us through the process of brain stem tests or diagnosis of death by neurological criteria over a number of years now. And that's gone through a few evolutions that has for a long time been both a long and short form. Um but there will now be form which will come into effect from the midnight on the new year. So as of the first of January only, this now blue new testing form should be in use and there's a single version of that which will be hosted on the website and that's where we should go to access that. So what, how it's going to look. Um It's broadly similar, you will recognize a lot of formats. Um But uh it's somewhere in the middle, between the long form and the short form, it's eight pages long, which some would say is long enough. Um But within that is an awful lot of guidance. So it's taking you through what you're doing and why you're doing it as well. Um and relates to the code and um gives you the um the link between uh the sections of the code and the practice that you're going to use uh in your clinical examination. It's the same form for everybody over two years of age that will be this blue form. Um As we've said, there's slightly different criteria between the 37 weeks to two years old child. And for that, there will be a separate form coming, I believe it's to be yellow. Um But that form isn't completed yet and we wouldn't be using that in our adult practice. So we were talking about um there's a bit more um of an expansion around some of the guidance, talking about the ancillary testing as we've alluded to how the CT is used and when it's used and, and it's been divided up into three broad sections now, which would be your preconditions, your examination process and then your confirmation of death. Um And that now sits what used to be your red flags and things that you had at the point that have been added and adjusted over the years with the last update in 2021. Um And that all that information, all that learning that had been added into the form over the years has now been built into this new form working through as pre conditions that you would accept before you even. So put their name on it. So the first bit is a fairly straightforward um apply your appropriate demographic details, make sure you've got the right patient and um make sure that all the information you need is available. We're going to um talk about uh the patient selection. So um no uh surprises in that really is going to be a patient that has a devastating brain injury and remains deeply some guidance written in around who cares the neurological criteria. That's all there if you're in any doubt. Um That's all been spelled out within the document, that's nothing different to what I just walked you through and then some guidance around the equipment that you're going to need to perform the tests um for people who are un with doing this or if you want to delegate the collection of the equipment, there's some guidance there on things that you like. I'm going to get to the mean of it. So, precondition one. So you're going to ask if there's an etiology severe enough to cause permanent cessation of brain stem function. If you don't believe that you have an etiology that um would cause permanent cessation of brain cell function, then you should not be looking to diagnose that by neurological criteria. Um So it's going to ask you for the etiology of the process and then any new imaging or evidence that you have that confirms that you have got a severe enough injury to explain this presentation. And that's going to be completed on both sets of tests by doctor one and doctor two stating that they are in agreement with precondition. One two would be that an adequate assessment period is sufficient to exclude the potential for recovery has been undertaken. So, um the doctors should be satisfied that recovery or improvement and the patient's condition will not occur with the passage of time. So, neurological criteria should not be applied until at least six hours following the loss of the last observed brainstem reflex or 24 hours. If the mechanism is post hypoxic and the cardio respiratory arrest, um patients that we very often see in that group. So um those you recognize um were built into the, the previous uh guidance that are explicitly set out here as part of the precondition too. Likewise, the hypothermia that is just spoken about uh waiting 24 hours after the rewarming to 36 degrees. Um And that um you're confident that the uh pathology is not reversible. So you're then going to have doctor one and doctor two confirming precondition two that um is the assessment period sufficient to exclude the potential for recovery. Yes or that the answer isn't. Yes. Precondition free with the exclusion of potentially reversible factors internally contributing to the or. So you'll recognize these again as um areas that we've looked out for some time within the patients in this group looking for things such as depressant drugs, um other neuromuscular disorders and high cervical cord pathology, those that might mimic this situation. So specifically, you'll be walked through. Um Here's the core temperature greater than or equal to 36 degrees. Um And we've talked about that needing to have been present for 24 hours prior to that. Um depressant drugs. Are you satisfied that there's no ongoing drug effect to contribute to your patient's coma or apnea, neuromuscular weakness? And um it's now uh asked that you always use a peripheral nerve stimulator to confirm um that uh neuromuscular function is present and you need to be satisfied that there's no neuromuscular blocking agent or other drug or preexisting or acquired neuromuscular disorder that's contributing to apnea or neuromuscular weakness. Uh cervical cord in cervical spinal cord pathology. So, are you satisfied that no further investigation is required to exclude high cervical spinal cord pathology? And this is about cord pathology, not necessarily bony injury, but where you have bone injury, you need to have a look for spinal cord pathology associated with that and excluded if possible. Um If you can't exclude it, then you need to think about diagnosis of testing. Um because uh spinal cord pathology could be in there, circulatory and respiratory disturbances. Are you satisfied that no cardiovascular or respiratory disturbance is entirely contributing to the outcome and then um your electrolytes. Um exactly. Um as before, except as you said, the um sodium has been uh narrowed to 155 to 160 range glucose and any other electrolyte and metabolic disturbance. That may be of note for endocrine disturbance. And importantly, with the endocrine disturbance. The question is, are you satisfied that there's no clinical reason to suspect that an endocrine disturbance is materially contributing to the apnea? So you need to actually have a pathology that may be mimicking uh neurological death in creating this coma or apnea state. And um minor endocrine chronic endocrine diseases would not be relevant. They were being managed appropriately. So that will bring you to um sign for precondition. Three. Are you satisfied potentially reversible factors which could be contributing to the apnea, considered unexpected. Yes, sir. Um Within that, we've talked about things such as spinal cord injury where um if you cannot exclude that um by imaging or examination, you would need to perform an ancillary investigation in order such as a CTA CTA in order to further support a diagnosis of neurological death because there may be confounding factors in that. And you'd need to document that here what you were using to mitigate that. And if you're not able to do that, then you can proceed four additional caution in uncommon uncommon circumstances. So you'll recognize these from discussion over recent years, talking about ati primarily isolated in the posterior fossa of the brain stem, therapeutic decompressive craniectomy and patients receiving therapeutic steroids to reduce brain edema for some reason. Um and things have been recognized in the red flags previously as high risk situations that are uncommon circumstances that you would want to stop and take extra consideration around potentially waiting a little longer or performing further investigations to support your diagnosis if you were unable to exclude these. So that brings you to some guidance around ancillary investigations and the situations in which you might miss them as discussed. CTA is the ancillary investigation that the code refers to as being the standard that we would use as an ancillary investigation to support this diagnosis. So if you are highlighting from your preconditions that you have a situation where an ancillary investigation would be appropriate, you can document here the reason that you've identified and the investigation you've undertaken and when that's been performed and the outcome of that investigation, there is a recognition that it will not always occur in this order though. So you may identify at this point that an ancillary investigation is indicated, but it might be that you can't get your CT for a number of hours. It doesn't mean that you can't proceed to do the clinical examination of the test. The ancillary may be performed at a later point, but you're not going to be able to complete your diagnosis of death until you have got your ancillary confirming that it's in agreement with the diagnosis of neurological death before you're going to be able to complete all of this. So that takes you on to how you're going to perform the clinical examination for the diagnosis. And that will be the clinical testing for the absence of brainstem reflexes as we've done over a number of years. Now, the majority of this has not changed in its process. It's still going to be two sets of clinical tests performed by two clinicians on each occasion as we've discussed, that may amount to a total of four doctors and it's going to require you now under the new code to be able to examine both eyes and both ears as part of that examination. Um And you would want to prepare all of your equipment ahead of time before each step so removed the order of some of these. So some of you will notice that the vestibular ocular reflex has moved down um, later in the process than it used to be. But otherwise, um, the majority of these initial steps are exactly as they were before. So you're going to examine for your pupillary reflex to the pupils react to light for your corneal reflex. Is there any eyelid movement when each cornea is touched for motor response? Is there any motor response within the cranial nerve or somatic distribution? When supraorbital pressure is applied, the gag reflex and then the cough reflex and you'll notice a little guidance given as to how we need to perform each of these investigations. And then the vestibular ocular reflex has moved down to the bottom of the page there. But those um tests are unchanged, then the apnea test ha has changed as you've heard. So the apnea test must not be performed whilst the patient is connected to a mechanical. This has been advice for some time now, but it's now clearly stated um within the code and within the testing form that the patient should be removed from the ventilator. Um And uh the recommendation given is now that you prepare a CPAP um circuit using usually a maple sensor. Um And the five minutes observation is am you may choose to observe for longer and uh you can proceed to potentially diagnose death by neurological criteria. Without completing an apnea test. But this should only ever be due to an absolute inability to complete the apnea element of the test. And an ancillary investigation would always be required in that situation. And, and by an absolute inability, that is essentially um the cervical spinal cord pathology um that we've spoken about earlier. So how you're going to uh document your um apnea test now will look a little bit different. This is how the page looks. So for each set of tests, it's going to walk you through what your start time is, what uh your start arterial pa Co2 is. Um And that, that needs to be at least 5.3 kg as stated before having established your start P AC at two, then you're going to calculate what the target would be. The target must be a rise of 2.7 K. I did some beautiful maths in his head earlier because he chose easy numbers. But the recommendation is absolutely that you find some form of calculator and, and make sure that you get this number right. Um Because uh that's absolutely crucial to make a safe diagnosis here. So document what your target CO2 is going to be. Um And then you're going to perform your apnea test waiting at least the five minutes as you would have before with the patient disconnected from the ventilator and then you're going to check another blood gas um at five minutes and you're looking to see what the CO2 on that blood gas is to ensure that it is greater than, or equal to the target. Uh CO2 that you've written in the box above the two boxes come up together. You should be able to easily compare the two. Um And you also need your NPH to be less than 7.3 for hydrogen. Um, and then you're going to document the end of time before you having the test. And that may in fact be more than five minutes after your start time. If you choose to wait to get the gas, make sure this is done potentially repeated gas. If you've not achieved your rise, you may have waited a total time, that is greater than five minutes, whatever that time is documented into the bottom. And then you're gonna answer exactly the same questions you answered. Um On the previous form was any spontaneous respiratory effort observed over a minimum of five minutes from a disconnection from the ventilator. Yes or no. And the answer must be know clearly in order to reach a diagnosis of just in case it wasn't clear enough. Those are the key boxes, you document your start C two, you're gonna calculate your target C two. And then you're gonna document NC two to make sure that you have achieved your target. Your target must be greater than eight because your start must be greater or equal to 5.3. And um you must have had a rise of 2.7 and then your ph I document it any time, as I said earlier, over five minutes, you usually see um a fairly significant rise in CO2. Um We've only been looking historically for a rise of 0.5 is not fairly easy to get um and usually exceeded by quite a long way. Most of tests I can think of would have achieved that 2.7. But um the documented um estimated rise time is um rise is only of half a to the pa per minute. So um so that is only just going to get you there based on the paper calculation that doesn't seem to be the feel in practice. But you may choose to wait beyond the five minutes if your patient is stable to ensure that you hit that because it is quite a significant rise, you know, and then you need to confirm the outcome of your heart and then you're going to fill out the register as in this case, test ones, doctors one and two as you have done before. And likewise on the second set of tests, the doctors will sign and add their G and C numbers at the end of the test to confirm who has performed them. But the difference is on the new form, you'll find that there is then an additional box beyond that because you're going to perform your tests twice. Um but um, you're then going to make a separate assessment as that second set of doctors, you're going to ask yourself, are you satisfied that death has been confirmed following the permanent cessation of brainstem function? And answering this is a separate question that you are satisfied that the criteria met the death because we're now very clearly stating through the code and through this form that you're performing both a clinical examination here of the brainstem reflexes. But you're also adding that potentially to ancillary investigations. And only when you've got all the required information to confirm death when you sign your final books, and that will be the time of death. So the time of death is the completion of both sets of tests and all additional information that is required to confirm. So, um if the ancillary investigation, if the CTA is the last piece of information to be obtained, that will become the time of death, only when all information has been gathered and agreed by those doctors. Um And uh and that's the time you'll write down here. And that is the time of death in those circumstances, even if A CTA is being done, the second set of test will still be the last thing. Um And that will be the end of the second set test will be the same as the time, but it doesn't happen. So that is it, that is the new form. So the new form version two of the form for the diagnosis of death. Urological criteria will come into action. As of the first of January, the um change in your hospital should be preparing to remove any of the uh old purple forms and all the information across um And um uh the um downloadable forms from the internet will become the new version to uh as of the first of January. Thank you very much. Uh We'll take any questions if you can put them in the chat, then happy to answer any questions. If anybody hasn't just making easy, we didn't remember this. Thanks. Uh Thanks so much. Um Helen Le and um uh just whilst there's some questions popping out and I've got a um a couple in my head that popped out. The first thing listening to that and the thing that stuck out to me is in the, the temperature thing which often, you know, these patients are quite a difficult group to keep warm anyway, they've lost their kind of their temperature regulation and often like, you know, in a context, devastating brain injury, you're moving quite quickly or you, you might be moving relatively quickly in their stay towards um confirmation of death by neurological criteria is my interpretation, right? That if at any point during the previous 24 hours, their temperature has been less than 36 you need to extend out the time with that. So the codes quite clear that transient dips below the 36 is acceptable. But the word they put in there is transient and there's no time limit given on that talking to people who have been involved in the development of the code. They are saying that there needs to be evidence that you have rewarmed successfully and achieved rewarm to 36 degrees. And then that that has been maintained as the the baseline for the 24 hours prior to testing. If there are a couple of sets of observations that dip transiently below that, then that would be acceptable, provided that it's returning back to that 36 baseline. There's no time limit given on that, that's going to be open to your clinical judgment. But so there is some allowance for slight blips in that. But you're going to have to pay attention as you say, if you don't get warmer on these um patients and you don't actively manage temperature, you're going to find that the temperature is going to drop quite a bit. Um So it is going to require a little bit more thought, a little bit more proactive treatment to control. Um And the important thing is that when you go to test, you do need to be back to 36. So you need that, that, that set of s to be at 36. Um before you start your test, it's useful to know you don't, you're not necessarily going to have to extend out 24 hours if they've got a little transient, you have to start the clock again provided um you've been able to remedy. Um And then we were speaking a little bit about this earlier, but I'm just interested in your thoughts on this so much of what we do in critical care medicine. It relies not only on clinical assessment but on sort of in, in incorporating different forms of information. Um And I just wondered, I guess as clinicians who are very interested in this, whether you foresee a future code of practice, which mandates the integration of um of ancillary tests into the confirmation of death by neurological criteria or whether you think it will remain a predominantly clinical test. I think as Helen spoke the last time, I'm going to have to speak this time, I mean, I think this is a, this is a controversial area. I think my answer is that we've demonstrated there an evolution in the code of practice over over time and where we were 1020 30 years ago, we're now in a very different place. Um Antle testing has been talked increasingly about over the last sort of 5, 1010 years. Uh And, and so I can, I can anticipate over time that that will continue and will become, will become a further part of this. The difficulty we have currently with our anility tests is that I I'm not sure there is consensus despite there being, you know, guidelines now being written despite really good work with, you know, our colleagues in your radiology um to try and come up with some support and guidance. II, don't think that's fully accepted. I've had, I've had conversations with colleagues at the New Institute in Glasgow over the past few months and you know, they, they are new radio, they are a relatively high volume center and I don't think they as a group feel confident in, in, in the role of CT angiography, you know, it's not 100% sensitive specific, um it might be helpful but can we base our diagnosis completely on it? I don't think we would feel comfortable with clinicians and I'm pretty sure any radiology colleagues will not feel comfortable to write a report which says this there is, you know, absence of flow and this person is dead. That, that, that feels like a step too far. So I, so II think that to answer your question over time, I think we will see a greater reliance on ne I as part of that diagnosis, but I think it feels more safe to be multimodal and I think that makes it more robust. But I suspect when the next version of this is written in whether it's another 16 years time or whatever, um then there'll be more stuff in there about your neuroimaging and I may have changed and evolved and actually interesting. I cannot see any questions coming through which I think reflects the fact that you've just given information very clearly, um, which is really good. And, uh, I would like to thank both of you for giving up your Thursday evening to join us and to educate us on the, um, the changes to the code of practice. And it's a thing we don't do all that often, but, um, it's a really useful education update. So, thank you. I'm about to pop a feedback link in the chat that will take you to the feedback, which will generate your CPD certificate for those of you who are logging the CPD activity. Um You would be really welcome to join us on Thursday the 19th of December when Doctor Bob Docking from the QE is returning for a third consecutive year to the S IC education updates to, to present top 10 trials of the year. Um, so thank you all so much. Um, and enjoy your evenings. Thank you.