Materiały źródłowe

• #1 The diagnosis of brain death

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2772257/

  Physicians, health care workers, members of the clergy, and laypeople throughout the world have accepted fully that a person is dead when his or her brain is dead. […] There is a need to diagnose brain death with utmost accuracy and urgency because of an increased awareness amongst the masses for an early diagnosis of brain death and the requirements of organ retrieval for transplantation. […] The purpose of this review article is to provide health care providers in India with requirements for determining brain death, increase knowledge amongst health care practitioners about the clinical evaluation of brain death, and reduce the potential for variations in brain death determination policies and practices amongst facilities and practitioners. […] Brain death is defined as the irreversible loss of all functions of the brain, including the brainstem.

• #2 Diagnosis of brain death – UpToDate

  https://www.uptodate.com/contents/diagnosis-of-brain-death

  Diagnosis of brain death […] Brain death implies the permanent absence of cerebral and brainstem functions. […] Brain death signifies the complete, irreversible cessation of brain function, including the capacity for the brainstem to regulate respiratory and vegetative activities. […] While most countries have a legal provision for brain death, institutional protocols for diagnosis are not universal and are often absent, particularly in lower-income countries and in those without an organized transplant network. […] Even among countries with an organized diagnostic protocol, there is substantial variation in the criteria that are used. […] In most adult series, trauma and subarachnoid hemorrhage are the most common events leading to brain death.

• #3 Brain Death | National Kidney Foundation

  https://www.kidney.org/kidney-topics/brain-death

  Brain death is the complete and irreversible loss of all brain function. It is diagnosed through clinical tests and confirmed by medical guidelines. […] The diagnosis of brain death is defined as „death based on the absence of all neurologic function.” […] Brain death is a legal definition of death. It is the complete stopping of all brain function and cannot be reversed. It means that, because of extreme and serious trauma or injury to the brain, the body’s blood supply to the brain is blocked, and the brain dies. Brain death is death. It is permanent. […] A doctor will do tests to make a diagnosis of brain death. These tests are based on sound and legally accepted medical guidelines. Tests include a clinical examination to show that an individual has no brain reflexes and cannot breathe on his or her own.

• #4 Brain death – Wikipedia

  https://en.wikipedia.org/wiki/Brain_death

  Brain death is the permanent, irreversible, and complete loss of brain function, which may include cessation of involuntary activity (e.g., breathing) necessary to sustain life. […] A differential diagnosis can medically distinguish these differing conditions. […] Brain death is used as an indicator of legal death in many jurisdictions, but it is defined inconsistently and often confused by the public. […] The diagnosis of brain death is often required to be highly rigorous, in order to be certain that the condition is irreversible. […] The patient should have a normal temperature and be free of drugs that can suppress brain activity if the diagnosis is to be made on EEG criteria. […] The diagnosis of brain death has become accepted as a basis for the certification of death for legal purposes, it is a very different state from biological death the state universally recognized and understood as death.

• #5 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  In practice, diagnosis of BD/DNC is essential to organ transplantation, particularly cardiac, in that brain dead donors are the only accepted source for cardiac transplant in the United States. However, importantly, declaration of BD/DNC is an important and separate medical diagnosis that should be made independent of the need for organ transplantation. […] The first and most widely accepted is the whole brain formulation which asserts that brain death is equivalent to catastrophic injury to all the major structures of the brain including the hemispheres, diencephalon, brainstem, and cerebellum. In this view, confirmation of complete and permanent damage to the whole brain should be confirmed before BD/DNC is ultimately declared. […] The clinical determination of BD/DNC is detailed and can be daunting even to experienced critical care providers and neurologists. Correct diagnosis is of utmost importance, and the minimum clinical criteria and examination involves many steps.

• #6 Brain death – Wikipedia

  https://en.wikipedia.org/wiki/Brain_death

  When mechanical ventilation is used to support the body of a brain-dead organ donor pending a transplant into an organ recipient, the donor’s date of death is listed as the date that brain death was diagnosed. […] The continuing function of vital organs in the bodies of those diagnosed brain-dead, if mechanical ventilation and other life-support measures are continued, provides optimal opportunities for their transplantation. […] The diagnosis of brain death is often required to be highly rigorous, in order to be certain that the condition is irreversible.

• #7 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  In practice, diagnosis of BD/DNC is essential to organ transplantation, particularly cardiac, in that brain dead donors are the only accepted source for cardiac transplant in the United States. However, importantly, declaration of BD/DNC is an important and separate medical diagnosis that should be made independent of the need for organ transplantation. […] The first and most widely accepted is the whole brain formulation which asserts that brain death is equivalent to catastrophic injury to all the major structures of the brain including the hemispheres, diencephalon, brainstem, and cerebellum. In this view, confirmation of complete and permanent damage to the whole brain should be confirmed before BD/DNC is ultimately declared. […] The clinical determination of BD/DNC is detailed and can be daunting even to experienced critical care providers and neurologists. Correct diagnosis is of utmost importance, and the minimum clinical criteria and examination involves many steps.

• #8 Brain Death • LITFL • CCC Clinical Governance

  https://litfl.com/brain-death/

  Brain death is the irreversible loss of all functions of the brain, including the brainstem. […] The three essential findings in brain death are coma (unresponsiveness), absence of brainstem reflexes, and apnoea. […] Important considerations in the determination and management of brain death are: Preconditions for diagnosis of brain death, Examination, Investigations, Pathophysiology, Management and organ donation process. […] Preconditions for diagnosis of brain death include: cause for coma consistent with brain death, at least 4 hours of observation during which preconditions must be met (GCS 3, pupil non-reactive, no cough, apnoea), neuro-imaging consistent with acute brain pathology that could cause brain death, normothermia (T35C), normotension (SBP90 or MAP60mmHg in an adult), no sedation or analgesia, absence of severe electrolyte, metabolic and endocrine disturbances, no paralysis, ability to assess brain stem reflexes, and ability to perform apnoea test.

• #9 Brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/brain-death-diagnosis/

  when the accurate evaluation of a component of the BD/DNC neurologic examination cannot be assessed safely, clinicians must perform ancillary testing to complete the BD/DNC determination […] there must be no doubt about the cause of BD/DNC and the irreversibility of brain damage […] exclude all potentially reversible causes […] the effects of drugs altering the central nervous system function (sedatives, hypnotics, and opioids) […] the metabolism of sedatives and myorelaxants may be significantly altered in critically ill patients, and their effects may persist for many hours after the last administration […] the patient must not be pharmacologically depressed and relaxed to the extent that inhibits brainstem reflexes […] repeated tests show the irreversibility of the clinical condition (interval 4 hours)

• #10

  https://step2.medbullets.com/neurology/120269/brain-death-diagnosis

  A previously healthy 46-year-old female presents to the emergency department after a motor vehicle accident. The patient is unresponsive to noxious stimuli. Pupils are dilated and unresponsive to light. Oculovestibular and gag reflexes are absent. The patient is intubated due to loss of spontaneous respirations. After further workup, an apnea test is performed, which shows no respiratory response with a PaCO2 60 mm Hg. […] brain death = death […] to determine brain death, one must do the following: neurologic exam: permanent irreversible coma, loss of response to painful stimuli from brain-originating motor area, loss of brainstem reflex: e.g., corneal, pupillary, jaw-jerk, oculovestibular, gag reflex […] exclude metabolic, poisons, intoxication causes […] establish normothermia ( 97F ( 36C))

• #11 Brain Death – Neurologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/neurologic-disorders/coma-and-impaired-consciousness/brain-death

  Brain death, also known as brain death/death by neurologic criteria, refers to a permanent loss of brain function that cannot resume spontaneously and cannot be restored by medical interventions. Function of the entire cerebrum and brain stem is lost, resulting in coma, no spontaneous respiration, and loss of all brain stem reflexes. […] The determination that brain death/death by neurologic criteria (ie, total cessation of integrated brain function, especially that of the brain stem) constitutes a persons death has been accepted legally and culturally in most of the world. […] Diagnosis of Brain Death/Death by Neurologic Criteria includes serial determination of clinical criteria to demonstrate permanent loss of brain function, including that of the brain stem, apnea testing, and sometimes electroencephalography (EEG), brain vascular imaging, or both. […] For a clinician to declare brain death, a known catastrophic and permanent brain injury must have occurred, a structural or metabolic cause of brain damage must be present, and potentially reversible metabolic abnormalities must be excluded.

• #12 Brain Death • LITFL • CCC Clinical Governance

  https://litfl.com/brain-death/

  Brain death is the irreversible loss of all functions of the brain, including the brainstem. […] The three essential findings in brain death are coma (unresponsiveness), absence of brainstem reflexes, and apnoea. […] Important considerations in the determination and management of brain death are: Preconditions for diagnosis of brain death, Examination, Investigations, Pathophysiology, Management and organ donation process. […] Preconditions for diagnosis of brain death include: cause for coma consistent with brain death, at least 4 hours of observation during which preconditions must be met (GCS 3, pupil non-reactive, no cough, apnoea), neuro-imaging consistent with acute brain pathology that could cause brain death, normothermia (T35C), normotension (SBP90 or MAP60mmHg in an adult), no sedation or analgesia, absence of severe electrolyte, metabolic and endocrine disturbances, no paralysis, ability to assess brain stem reflexes, and ability to perform apnoea test.

• #13

  https://step2.medbullets.com/neurology/120269/brain-death-diagnosis

  A previously healthy 46-year-old female presents to the emergency department after a motor vehicle accident. The patient is unresponsive to noxious stimuli. Pupils are dilated and unresponsive to light. Oculovestibular and gag reflexes are absent. The patient is intubated due to loss of spontaneous respirations. After further workup, an apnea test is performed, which shows no respiratory response with a PaCO2 60 mm Hg. […] brain death = death […] to determine brain death, one must do the following: neurologic exam: permanent irreversible coma, loss of response to painful stimuli from brain-originating motor area, loss of brainstem reflex: e.g., corneal, pupillary, jaw-jerk, oculovestibular, gag reflex […] exclude metabolic, poisons, intoxication causes […] establish normothermia ( 97F ( 36C))

• #14 Diagnosing Death using Neurological Criteria | The Faculty of Intensive Care Medicine

  https://www.ficm.ac.uk/diagnosing-death-using-neurological-criteria

  The working group had no safety concerns with the current UK apnoea test as outlined in the 2008 Code. […] This update more closely aligns the UK to international practice, reflects the evolving recommendation for two mandated sets of clinical tests of brainstem function (2008 and 2025 Code), fits with the 2025 Code general recommendation to time death to when the healthcare professionals are satisfied all the relevant criteria to diagnose death are met. […] In patients who are hypothermic (defined as a core temperature less than 36C), either therapeutic or accidental, a minimum 24 hour observation period is required following correction of hypothermia. […] In the case of an inability to examine both eyes or both ears, for whatever reason, ancillary investigation will be required. […] Given that the eyes are required in the clinical testing of three of the six brainstem reflexes used in neurological criteria, it is recommended that it must be possible to examine both eyes and there should be no reason to suspect an eye injury or abnormality would prevent the reflex occurring if it could. […] Pauline underlines the AoMRC group’s desire to ensure that all deaths are diagnosed and confirmed in an accurate, standardised and timely manner.

• #15 Brain Death • LITFL • CCC Clinical Governance

  https://litfl.com/brain-death/

  Brain death is the irreversible loss of all functions of the brain, including the brainstem. […] The three essential findings in brain death are coma (unresponsiveness), absence of brainstem reflexes, and apnoea. […] Important considerations in the determination and management of brain death are: Preconditions for diagnosis of brain death, Examination, Investigations, Pathophysiology, Management and organ donation process. […] Preconditions for diagnosis of brain death include: cause for coma consistent with brain death, at least 4 hours of observation during which preconditions must be met (GCS 3, pupil non-reactive, no cough, apnoea), neuro-imaging consistent with acute brain pathology that could cause brain death, normothermia (T35C), normotension (SBP90 or MAP60mmHg in an adult), no sedation or analgesia, absence of severe electrolyte, metabolic and endocrine disturbances, no paralysis, ability to assess brain stem reflexes, and ability to perform apnoea test.

• #16 Brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/brain-death-diagnosis/

  when the accurate evaluation of a component of the BD/DNC neurologic examination cannot be assessed safely, clinicians must perform ancillary testing to complete the BD/DNC determination […] there must be no doubt about the cause of BD/DNC and the irreversibility of brain damage […] exclude all potentially reversible causes […] the effects of drugs altering the central nervous system function (sedatives, hypnotics, and opioids) […] the metabolism of sedatives and myorelaxants may be significantly altered in critically ill patients, and their effects may persist for many hours after the last administration […] the patient must not be pharmacologically depressed and relaxed to the extent that inhibits brainstem reflexes […] repeated tests show the irreversibility of the clinical condition (interval 4 hours)

• #17 Brain Death • LITFL • CCC Clinical Governance

  https://litfl.com/brain-death/

  Brain death is the irreversible loss of all functions of the brain, including the brainstem. […] The three essential findings in brain death are coma (unresponsiveness), absence of brainstem reflexes, and apnoea. […] Important considerations in the determination and management of brain death are: Preconditions for diagnosis of brain death, Examination, Investigations, Pathophysiology, Management and organ donation process. […] Preconditions for diagnosis of brain death include: cause for coma consistent with brain death, at least 4 hours of observation during which preconditions must be met (GCS 3, pupil non-reactive, no cough, apnoea), neuro-imaging consistent with acute brain pathology that could cause brain death, normothermia (T35C), normotension (SBP90 or MAP60mmHg in an adult), no sedation or analgesia, absence of severe electrolyte, metabolic and endocrine disturbances, no paralysis, ability to assess brain stem reflexes, and ability to perform apnoea test.

• #18 Brain Death • LITFL • CCC Clinical Governance

  https://litfl.com/brain-death/

  Brain death is the irreversible loss of all functions of the brain, including the brainstem. […] The three essential findings in brain death are coma (unresponsiveness), absence of brainstem reflexes, and apnoea. […] Important considerations in the determination and management of brain death are: Preconditions for diagnosis of brain death, Examination, Investigations, Pathophysiology, Management and organ donation process. […] Preconditions for diagnosis of brain death include: cause for coma consistent with brain death, at least 4 hours of observation during which preconditions must be met (GCS 3, pupil non-reactive, no cough, apnoea), neuro-imaging consistent with acute brain pathology that could cause brain death, normothermia (T35C), normotension (SBP90 or MAP60mmHg in an adult), no sedation or analgesia, absence of severe electrolyte, metabolic and endocrine disturbances, no paralysis, ability to assess brain stem reflexes, and ability to perform apnoea test.

• #19 Brain Death • LITFL • CCC Clinical Governance

  https://litfl.com/brain-death/

  Brain death is the irreversible loss of all functions of the brain, including the brainstem. […] The three essential findings in brain death are coma (unresponsiveness), absence of brainstem reflexes, and apnoea. […] Important considerations in the determination and management of brain death are: Preconditions for diagnosis of brain death, Examination, Investigations, Pathophysiology, Management and organ donation process. […] Preconditions for diagnosis of brain death include: cause for coma consistent with brain death, at least 4 hours of observation during which preconditions must be met (GCS 3, pupil non-reactive, no cough, apnoea), neuro-imaging consistent with acute brain pathology that could cause brain death, normothermia (T35C), normotension (SBP90 or MAP60mmHg in an adult), no sedation or analgesia, absence of severe electrolyte, metabolic and endocrine disturbances, no paralysis, ability to assess brain stem reflexes, and ability to perform apnoea test.

• #20 Brain Death • LITFL • CCC Clinical Governance

  https://litfl.com/brain-death/

  Brain death is the irreversible loss of all functions of the brain, including the brainstem. […] The three essential findings in brain death are coma (unresponsiveness), absence of brainstem reflexes, and apnoea. […] Important considerations in the determination and management of brain death are: Preconditions for diagnosis of brain death, Examination, Investigations, Pathophysiology, Management and organ donation process. […] Preconditions for diagnosis of brain death include: cause for coma consistent with brain death, at least 4 hours of observation during which preconditions must be met (GCS 3, pupil non-reactive, no cough, apnoea), neuro-imaging consistent with acute brain pathology that could cause brain death, normothermia (T35C), normotension (SBP90 or MAP60mmHg in an adult), no sedation or analgesia, absence of severe electrolyte, metabolic and endocrine disturbances, no paralysis, ability to assess brain stem reflexes, and ability to perform apnoea test.

• #21 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12

  It is critical for brain death diagnosis to be accurate. […] A determination of death must be made in accordance with accepted medical standards. […] The American Academy of Neurology has since established and reaffirmed standards for determination of brain death. […] Nevertheless, confusion exists among physicians regarding definitions of and distinctions among brain death, coma, persistent vegetative state, and minimally conscious state. […] In a survey of physicians who perform brain death examinations, only 25% reported compliance with current practice guidelines. […] The team informed the family that the patient was not brain dead. […] A clinical diagnosis of brain death was not possible because a number of the brain stem reflexes and other responses were not testable. […] In addition to the patient not meeting prerequisites for determination of brain death, there were 2 contraindications to apnea testingparenchymal lung disease/CO2 retention and high cervical spinal cord injury.

• #22 The diagnosis of brain death

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2772257/

  The diagnosis of brain death is primarily clinical. No other tests are required if the full clinical examination, including each of two assessments of brain stem reflexes and a single apnoea test, are conclusively performed. […] The determination of brain death requires the identification of the proximate cause and irreversibility of coma. […] The diagnosis of brain death is primarily clinical. No other tests are required if the full clinical examination, including each of two assessments of brain stem reflexes and a single apnoea test, is conclusively performed. […] In the absence of either complete clinical findings consistent with brain death, or confirmatory tests demonstrating brain death, brain death cannot be diagnosed and certified. […] When the full clinical examination, including both assessments of brain stem reflexes and the apnoea test, is conclusively performed, no additional testing is required to determine brain death. […] Brain death can be certified by a single physician privileged to make brain death determinations.

• #23 Brain Death • LITFL • CCC Clinical Governance

  https://litfl.com/brain-death/

  Brain death is the irreversible loss of all functions of the brain, including the brainstem. […] The three essential findings in brain death are coma (unresponsiveness), absence of brainstem reflexes, and apnoea. […] Important considerations in the determination and management of brain death are: Preconditions for diagnosis of brain death, Examination, Investigations, Pathophysiology, Management and organ donation process. […] Preconditions for diagnosis of brain death include: cause for coma consistent with brain death, at least 4 hours of observation during which preconditions must be met (GCS 3, pupil non-reactive, no cough, apnoea), neuro-imaging consistent with acute brain pathology that could cause brain death, normothermia (T35C), normotension (SBP90 or MAP60mmHg in an adult), no sedation or analgesia, absence of severe electrolyte, metabolic and endocrine disturbances, no paralysis, ability to assess brain stem reflexes, and ability to perform apnoea test.

• #24

  https://www.nhs.uk/conditions/brain-death/diagnosis/

  There are a number of criteria for diagnosing brain death. […] For a diagnosis of brain death: a person must be unconscious and fail to respond to outside stimulation […] there must be clear evidence that serious brain damage has occurred and it cannot be cured. […] The diagnosis of brain death has to be made by 2 doctors, and at least 1 of them must be a senior doctor. […] Brain death is diagnosed if a person fails to respond to all of these tests. […] These movements are spinal reflexes and do not involve the brain at all. They will not change the diagnosis of brain death.

• #25 American Academy of Neurology: Neurology Resources | AAN

  https://www.aan.com/PressRoom/Home/PressRelease/842

  In an effort to create a uniform and accurate method for determining brain death, the American Academy of Neurology has issued an updated guideline that provides doctors with a step-by-step process for determining brain death in adults. […] The brain death diagnosis can be made only after a comprehensive clinical evaluation and often involves more than 25 separate assessments. […] Brain death is the permanent loss of brain function and means the person has died. […] According to the guideline, there are three signs that a persons brain has permanently stopped functioning. First, the person is comatose, and the cause of the coma is known. Second, all brainstem reflexes have permanently stopped working. Third, breathing has permanently stopped. […] The guideline describes several complex steps doctors must follow to diagnose brain death. […] The guideline also makes clear that this complex process must be completed by a doctor with considerable skill and experience in diagnosing brain death.

• #26

  https://www.nhs.uk/conditions/brain-death/diagnosis/

  There are a number of criteria for diagnosing brain death. […] For a diagnosis of brain death: a person must be unconscious and fail to respond to outside stimulation […] there must be clear evidence that serious brain damage has occurred and it cannot be cured. […] The diagnosis of brain death has to be made by 2 doctors, and at least 1 of them must be a senior doctor. […] Brain death is diagnosed if a person fails to respond to all of these tests. […] These movements are spinal reflexes and do not involve the brain at all. They will not change the diagnosis of brain death.

• #27 Brain stem death | NHS inform

  https://www.nhsinform.scot/illnesses-and-conditions/brain-nerves-and-spinal-cord/brain-stem-death/

  Brain stem death is when a person no longer has any brain stem function. When someone loses their brain stem function permanently, medical professionals will confirm theyre dead. […] There are a number of criteria for diagnosing brain stem death. […] A patient must be unconscious and fail to respond to outside stimulation. […] Once these factors have been ruled out, tests are carried out to confirm brain death. The diagnosis of brain death also has to be made by two senior doctors. […] Brain death will only be diagnosed if a person does not respond to all of these tests. […] Once brain stem death is diagnosed, even though the patients heart is still beating, they are legally dead.

• #28 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  Once the above criteria have been established, it must be proven that the brain injury is irreversible, meaning that loss of function is complete and constant over time. […] After establishing a comatose state with complete unresponsiveness to maximal stimuli, determination of BD/DNC includes assessment for loss of brainstem reflexes, as follows: loss of pupillary responsiveness, loss of corneal, oculocephalic, oculovestibular, gag, and cough reflexes, absence of facial movement to noxious stimuli, and absence of cerebrally mediated movement to noxious stimulation of the extremities. […] The goal of apnea testing is to create a buildup of carbon dioxide that maximally stimulates the medullary respiratory centers, which are ultimately triggered by the ensuing acidic pH of the cerebrospinal fluid (CSF).

• #29 06. Brain Death | Hospital Handbook

  https://hospitalhandbook.ucsf.edu/content/06-brain-death

  Irreversible and complete loss of cerebral and brainstem function. There is variation between states and institutions regarding the tests necessary to confirm this diagnosis. The following is based upon the UCSF Medical Center protocol. […] Patients must meet the following criteria before a diagnosis of brain death can be made: […] Absent cerebral function: Coma (if due to hypoxic-ischemic event, at least 24 hours must pass before a declaration of brain death is made) […] Absent brainstem function: Pupils: mid-position to dilated, absent response to bright light […] Confirmatory Testing can be helpful and is required by law in some states. May include: Isoelectric EEG with machine set to high gain (again, patient cannot be on sedating medications) with lack of reactivity to somatosensory and audiovisual stimuli […] Absence of cerebral blood flow as demonstrated by conventional angiography or radioisotope brain scan.

• #30

  https://step2.medbullets.com/neurology/120269/brain-death-diagnosis

  A previously healthy 46-year-old female presents to the emergency department after a motor vehicle accident. The patient is unresponsive to noxious stimuli. Pupils are dilated and unresponsive to light. Oculovestibular and gag reflexes are absent. The patient is intubated due to loss of spontaneous respirations. After further workup, an apnea test is performed, which shows no respiratory response with a PaCO2 60 mm Hg. […] brain death = death […] to determine brain death, one must do the following: neurologic exam: permanent irreversible coma, loss of response to painful stimuli from brain-originating motor area, loss of brainstem reflex: e.g., corneal, pupillary, jaw-jerk, oculovestibular, gag reflex […] exclude metabolic, poisons, intoxication causes […] establish normothermia ( 97F ( 36C))

• #31 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  Once the above criteria have been established, it must be proven that the brain injury is irreversible, meaning that loss of function is complete and constant over time. […] After establishing a comatose state with complete unresponsiveness to maximal stimuli, determination of BD/DNC includes assessment for loss of brainstem reflexes, as follows: loss of pupillary responsiveness, loss of corneal, oculocephalic, oculovestibular, gag, and cough reflexes, absence of facial movement to noxious stimuli, and absence of cerebrally mediated movement to noxious stimulation of the extremities. […] The goal of apnea testing is to create a buildup of carbon dioxide that maximally stimulates the medullary respiratory centers, which are ultimately triggered by the ensuing acidic pH of the cerebrospinal fluid (CSF).

• #32 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  Once the above criteria have been established, it must be proven that the brain injury is irreversible, meaning that loss of function is complete and constant over time. […] After establishing a comatose state with complete unresponsiveness to maximal stimuli, determination of BD/DNC includes assessment for loss of brainstem reflexes, as follows: loss of pupillary responsiveness, loss of corneal, oculocephalic, oculovestibular, gag, and cough reflexes, absence of facial movement to noxious stimuli, and absence of cerebrally mediated movement to noxious stimulation of the extremities. […] The goal of apnea testing is to create a buildup of carbon dioxide that maximally stimulates the medullary respiratory centers, which are ultimately triggered by the ensuing acidic pH of the cerebrospinal fluid (CSF).

• #33 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  Once the above criteria have been established, it must be proven that the brain injury is irreversible, meaning that loss of function is complete and constant over time. […] After establishing a comatose state with complete unresponsiveness to maximal stimuli, determination of BD/DNC includes assessment for loss of brainstem reflexes, as follows: loss of pupillary responsiveness, loss of corneal, oculocephalic, oculovestibular, gag, and cough reflexes, absence of facial movement to noxious stimuli, and absence of cerebrally mediated movement to noxious stimulation of the extremities. […] The goal of apnea testing is to create a buildup of carbon dioxide that maximally stimulates the medullary respiratory centers, which are ultimately triggered by the ensuing acidic pH of the cerebrospinal fluid (CSF).

• #34 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  Once the above criteria have been established, it must be proven that the brain injury is irreversible, meaning that loss of function is complete and constant over time. […] After establishing a comatose state with complete unresponsiveness to maximal stimuli, determination of BD/DNC includes assessment for loss of brainstem reflexes, as follows: loss of pupillary responsiveness, loss of corneal, oculocephalic, oculovestibular, gag, and cough reflexes, absence of facial movement to noxious stimuli, and absence of cerebrally mediated movement to noxious stimulation of the extremities. […] The goal of apnea testing is to create a buildup of carbon dioxide that maximally stimulates the medullary respiratory centers, which are ultimately triggered by the ensuing acidic pH of the cerebrospinal fluid (CSF).

• #35 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  Once the above criteria have been established, it must be proven that the brain injury is irreversible, meaning that loss of function is complete and constant over time. […] After establishing a comatose state with complete unresponsiveness to maximal stimuli, determination of BD/DNC includes assessment for loss of brainstem reflexes, as follows: loss of pupillary responsiveness, loss of corneal, oculocephalic, oculovestibular, gag, and cough reflexes, absence of facial movement to noxious stimuli, and absence of cerebrally mediated movement to noxious stimulation of the extremities. […] The goal of apnea testing is to create a buildup of carbon dioxide that maximally stimulates the medullary respiratory centers, which are ultimately triggered by the ensuing acidic pH of the cerebrospinal fluid (CSF).

• #36 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  Once the above criteria have been established, it must be proven that the brain injury is irreversible, meaning that loss of function is complete and constant over time. […] After establishing a comatose state with complete unresponsiveness to maximal stimuli, determination of BD/DNC includes assessment for loss of brainstem reflexes, as follows: loss of pupillary responsiveness, loss of corneal, oculocephalic, oculovestibular, gag, and cough reflexes, absence of facial movement to noxious stimuli, and absence of cerebrally mediated movement to noxious stimulation of the extremities. […] The goal of apnea testing is to create a buildup of carbon dioxide that maximally stimulates the medullary respiratory centers, which are ultimately triggered by the ensuing acidic pH of the cerebrospinal fluid (CSF).

• #37

  https://www.nhs.uk/conditions/brain-death/diagnosis/

  There are a number of criteria for diagnosing brain death. […] For a diagnosis of brain death: a person must be unconscious and fail to respond to outside stimulation […] there must be clear evidence that serious brain damage has occurred and it cannot be cured. […] The diagnosis of brain death has to be made by 2 doctors, and at least 1 of them must be a senior doctor. […] Brain death is diagnosed if a person fails to respond to all of these tests. […] These movements are spinal reflexes and do not involve the brain at all. They will not change the diagnosis of brain death.

• #38 Clinical testing for neurological determination of death | Deranged Physiology

  https://derangedphysiology.com/main/required-reading/organ-and-tissue-donation/Chapter-612/clinical-testing-neurological-determination-death

  Apnoea testing must be carried out only after the brainstem reflexes have been tested, and if any of them were found to be positive any further brain death testing cannot continue. […] Findings compatible with brain death: Spinal reflexes in response to noxious stimulus, Sweating, Blishing, Tachycardia, Normal blood pressure in absence of vasopressors, Absence of diabetes insipidus. […] Observations incompatible with brain death: Extensor posturing (decorticate), Flexor posturing (decerebrate), True extensor or flexor responses to painful stimuli, Seizures, Attempt at breathing, defined as any respiratory muscle activity that results in abdominal or chest excursions or activity of accessory respiratory muscles.

• #39 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  Once the above criteria have been established, it must be proven that the brain injury is irreversible, meaning that loss of function is complete and constant over time. […] After establishing a comatose state with complete unresponsiveness to maximal stimuli, determination of BD/DNC includes assessment for loss of brainstem reflexes, as follows: loss of pupillary responsiveness, loss of corneal, oculocephalic, oculovestibular, gag, and cough reflexes, absence of facial movement to noxious stimuli, and absence of cerebrally mediated movement to noxious stimulation of the extremities. […] The goal of apnea testing is to create a buildup of carbon dioxide that maximally stimulates the medullary respiratory centers, which are ultimately triggered by the ensuing acidic pH of the cerebrospinal fluid (CSF).

• #40 Apnea test for brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/apnea-test-brain-death/

  brain death (BD) is defined as the permanent cessation of all brain functions (including those of the brainstem) […] the apnea test is a key confirmatory test of brain death (BD)/death by neurologic criteria (DNC); if positive (absence of respiratory drive), it is a crucial indicator of the loss of brainstem function […] absence of respiratory movements when target hypercapnia and pH achieved confirms BD/DNC […] respiratory movements or cough BD/DNC criteria not met (test is negative) […] if the patient experiences hemodynamic instability or hypoxemia at any point during the test, apnea testing should be aborted […] if cough or respiratory movements occur apnea testing is considered negative, and further brain death evaluation is discontinued […] if the apnea test cannot be performed or completed, ancillary tests must be used (EEG, SPECT, DSA, TCD/TCCD) Brain death diagnosis […] Brain death is defined as the irreversible loss of all brain functions (including the brainstem), regardless of the continued function of the cardiovascular system and other organs.

• #41 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  The basic concept of apnea testing remains the same: pre-oxygenation, observation for spontaneous breaths, and measurements proving the buildup of CO2 in arterial circulation. […] The indications for ancillary testing in ECMO patients, and interpretation of different types of testing, are not well studied, and particular caution should be taken with use of TCD, as it relies on measurement of pulsatile flow. […] It should be noted that in V-A ECMO, due to the phenomenon of mixing occurring when residual native circulation allows antegrade flow from through the left ventricle into the aorta and mixes with retrograde flow from the arterial cannula, distal arterial measurements may be inconsistent with those from the membrane oxygenator circuit, and should be collected simultaneously to avoid inconsistencies.

• #42

  https://step2.medbullets.com/neurology/120269/brain-death-diagnosis

  hypothermia may confound apnea test […] establish normotension […] should know the cause of brain death […] Clinical diagnosis: see above […] presence of spinal cord reflexes is still compatible with brain death […] Apnea testing performed after brain death criteria is met […] to display absence of respiratory drive: no respiratory response with a PaCO2 60 mmHg […] Ancillary testing performed when unable to do apnea testing, or neurological exam is unreliable […] tests include: EEG, cerebral angiography „gold standard”, nuclear scan, transcranial Dopppler ultrasonography.

• #43 LearnPICU – Brain Death

  https://www.learnpicu.com/neurology/brain-death

  The loss of all functions of the entire brain is IRREVERSIBLE. […] The absence of spontaneous respiration, in the presence of hypercarbia (paCO2 greater than 60 mm Hg AND at least 20 mm Hg above the baseline paCO2) should be observed by a physician and carefully documented. […] The determination of brain death may be made on the basis of clinical observations alone. […] Irreversibility is recognized when the evaluation discloses each of the following: […] The cessation of all brain functions continues to exist after an appropriate period of observation and/or trial of therapy. […] Brain death should be declared only after both examinations have been completed and the attending physician performing the second examination has documented in the hospital medical record that all criteria for brain death have been met. […] When it has been determined that a patient meets all criteria for brain death, death is to be pronounced before artificial means of supporting respiratory and circulatory functions are terminated.

• #44 Apnea test for brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/apnea-test-brain-death/

  brain death (BD) is defined as the permanent cessation of all brain functions (including those of the brainstem) […] the apnea test is a key confirmatory test of brain death (BD)/death by neurologic criteria (DNC); if positive (absence of respiratory drive), it is a crucial indicator of the loss of brainstem function […] absence of respiratory movements when target hypercapnia and pH achieved confirms BD/DNC […] respiratory movements or cough BD/DNC criteria not met (test is negative) […] if the patient experiences hemodynamic instability or hypoxemia at any point during the test, apnea testing should be aborted […] if cough or respiratory movements occur apnea testing is considered negative, and further brain death evaluation is discontinued […] if the apnea test cannot be performed or completed, ancillary tests must be used (EEG, SPECT, DSA, TCD/TCCD) Brain death diagnosis […] Brain death is defined as the irreversible loss of all brain functions (including the brainstem), regardless of the continued function of the cardiovascular system and other organs.

• #45 Apnea test for brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/apnea-test-brain-death/

  brain death (BD) is defined as the permanent cessation of all brain functions (including those of the brainstem) […] the apnea test is a key confirmatory test of brain death (BD)/death by neurologic criteria (DNC); if positive (absence of respiratory drive), it is a crucial indicator of the loss of brainstem function […] absence of respiratory movements when target hypercapnia and pH achieved confirms BD/DNC […] respiratory movements or cough BD/DNC criteria not met (test is negative) […] if the patient experiences hemodynamic instability or hypoxemia at any point during the test, apnea testing should be aborted […] if cough or respiratory movements occur apnea testing is considered negative, and further brain death evaluation is discontinued […] if the apnea test cannot be performed or completed, ancillary tests must be used (EEG, SPECT, DSA, TCD/TCCD) Brain death diagnosis […] Brain death is defined as the irreversible loss of all brain functions (including the brainstem), regardless of the continued function of the cardiovascular system and other organs.

• #46 Apnea test for brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/apnea-test-brain-death/

  brain death (BD) is defined as the permanent cessation of all brain functions (including those of the brainstem) […] the apnea test is a key confirmatory test of brain death (BD)/death by neurologic criteria (DNC); if positive (absence of respiratory drive), it is a crucial indicator of the loss of brainstem function […] absence of respiratory movements when target hypercapnia and pH achieved confirms BD/DNC […] respiratory movements or cough BD/DNC criteria not met (test is negative) […] if the patient experiences hemodynamic instability or hypoxemia at any point during the test, apnea testing should be aborted […] if cough or respiratory movements occur apnea testing is considered negative, and further brain death evaluation is discontinued […] if the apnea test cannot be performed or completed, ancillary tests must be used (EEG, SPECT, DSA, TCD/TCCD) Brain death diagnosis […] Brain death is defined as the irreversible loss of all brain functions (including the brainstem), regardless of the continued function of the cardiovascular system and other organs.

• #47 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12

  It is critical for brain death diagnosis to be accurate. […] A determination of death must be made in accordance with accepted medical standards. […] The American Academy of Neurology has since established and reaffirmed standards for determination of brain death. […] Nevertheless, confusion exists among physicians regarding definitions of and distinctions among brain death, coma, persistent vegetative state, and minimally conscious state. […] In a survey of physicians who perform brain death examinations, only 25% reported compliance with current practice guidelines. […] The team informed the family that the patient was not brain dead. […] A clinical diagnosis of brain death was not possible because a number of the brain stem reflexes and other responses were not testable. […] In addition to the patient not meeting prerequisites for determination of brain death, there were 2 contraindications to apnea testingparenchymal lung disease/CO2 retention and high cervical spinal cord injury.

• #48 The diagnosis of brain death

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2772257/

  The diagnosis of brain death is primarily clinical. No other tests are required if the full clinical examination, including each of two assessments of brain stem reflexes and a single apnoea test, are conclusively performed. […] The determination of brain death requires the identification of the proximate cause and irreversibility of coma. […] The diagnosis of brain death is primarily clinical. No other tests are required if the full clinical examination, including each of two assessments of brain stem reflexes and a single apnoea test, is conclusively performed. […] In the absence of either complete clinical findings consistent with brain death, or confirmatory tests demonstrating brain death, brain death cannot be diagnosed and certified. […] When the full clinical examination, including both assessments of brain stem reflexes and the apnoea test, is conclusively performed, no additional testing is required to determine brain death. […] Brain death can be certified by a single physician privileged to make brain death determinations.

• #49 Brain death | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/brain-death-2?lang=us

  Brain death (or death by neurological criteria) refers to the irreversible end of all brain activity and is usually assessed clinically. […] Radiographic testing may be used as additional support for a clinical diagnosis of brain death, such as when clinical tests are impossible to perform, e.g. facial or ocular trauma, precluding brainstem function assessment. […] As the diagnosis of brain death is considered equivalent to cardiac death in many jurisdictions and it allows organ donation for transplantation or withdrawal of life support, most countries have specific and varied related legal standards and practice guidelines. […] It should be noted that brain death imaging is not synonymous with identifying extensive global hypoxic-ischemic injury. […] Most imaging tests for brain death rely on the absence of cerebral blood flow as a surrogate for brain death.

• #50 Brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/brain-death-diagnosis/

  when the accurate evaluation of a component of the BD/DNC neurologic examination cannot be assessed safely, clinicians must perform ancillary testing to complete the BD/DNC determination […] there must be no doubt about the cause of BD/DNC and the irreversibility of brain damage […] exclude all potentially reversible causes […] the effects of drugs altering the central nervous system function (sedatives, hypnotics, and opioids) […] the metabolism of sedatives and myorelaxants may be significantly altered in critically ill patients, and their effects may persist for many hours after the last administration […] the patient must not be pharmacologically depressed and relaxed to the extent that inhibits brainstem reflexes […] repeated tests show the irreversibility of the clinical condition (interval 4 hours)

• #51 Confirmatory Tests for Brain Death

  https://www.verywellhealth.com/confirmatory-tests-for-brain-death-2488871

  Brain death is one of the most serious diagnoses a neurologist can make. Unlike severe forms of coma, a diagnosis of brain death means there is no coming back. Medically, brain death is death. […] If the diagnosis is made properly, it can be done just by ensuring the patient is in a coma of a known and irreversible cause, and that certain physical exam findings are absent, including brainstem reflexes and any effort to breathe during an apnea test. […] There are no well-documented cases of a diagnosis of brain death is carefully made in which the patient then had a meaningful recovery. […] However, there are times when meeting all the technical qualifications for brain death is impossible. […] In these cases, additional testing is called for. […] Furthermore, because the diagnosis of brain death is so serious, many families prefer to have additional testing done before making decisions about stopping mechanical ventilation or considering organ donation.

• #52 Brain Death Imaging | Radiology Key

  https://radiologykey.com/brain-death-imaging/

  The objective of ancillary tests in the diagnosis of brain death is to demonstrate the absence of cerebral electrical activity (EEG and evoked potentials) or cerebral circulatory arrest. […] Currently, only catheter cerebral angiography and perfusion scintigraphy are widely accepted as ancillary tests in the determination of cerebral circulatory arrest. […] Catheter cerebral angiography is considered as a reference method in the diagnosis of majority of cerebrovascular pathologies including cerebral circulatory arrest. […] Cerebral circulatory arrest can be documented by catheter cerebral angiography if all of the following conditions are met: 1. Filling of external carotid arteries confirming a proper contrast delivery 2. No filling of ICAs beyond the level of the anterior clinoid process 3. No filling of VAs beyond their dural penetration 4. No filling of the internal cerebral veins. […] Catheter angiography is widely accepted as a reference test in the diagnosis of brain death.

• #53 Brain death | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/brain-death-2?lang=us

  Brain death (or death by neurological criteria) refers to the irreversible end of all brain activity and is usually assessed clinically. […] Radiographic testing may be used as additional support for a clinical diagnosis of brain death, such as when clinical tests are impossible to perform, e.g. facial or ocular trauma, precluding brainstem function assessment. […] As the diagnosis of brain death is considered equivalent to cardiac death in many jurisdictions and it allows organ donation for transplantation or withdrawal of life support, most countries have specific and varied related legal standards and practice guidelines. […] It should be noted that brain death imaging is not synonymous with identifying extensive global hypoxic-ischemic injury. […] Most imaging tests for brain death rely on the absence of cerebral blood flow as a surrogate for brain death.

• #54 PulmCrit- Brain death, mimics, and flow scans

  https://emcrit.org/pulmcrit/brain-death-flow-scan/

  Lack of blood flow to the brain is 100% specific for catastrophic brain injury with inability to regain consciousness. A good-quality flow scan showing absence of flow is universally accepted as confirming brain death within the appropriate clinical context. […] Like any diagnostic test, a flow scan is only useful when applied in the correct clinical context. The presence of impaired flow may be consistent with the early phases of brain death, so in this case a repeat study should be considered in 12-24 hr. A normal scan should prompt an aggressive search for wrong-diagnosis brain death mimics. […] Brain death diagnosis should be considered only after patient stabilization and evaluation for other possible causes of coma. […] The most concerning mimics of brain death are missed alternative diagnoses (e.g. intoxication, C-spine injury), because these may be treatable. […] Radionuclide flow scan may be used in confusing situations. The scan isn’t entirely sensitive, because limited flow may continue in the early phases of brain death. However, lack of blood flow allows for a confident diagnosis of brain death (high specificity).

• #55

  https://step2.medbullets.com/neurology/120269/brain-death-diagnosis

  hypothermia may confound apnea test […] establish normotension […] should know the cause of brain death […] Clinical diagnosis: see above […] presence of spinal cord reflexes is still compatible with brain death […] Apnea testing performed after brain death criteria is met […] to display absence of respiratory drive: no respiratory response with a PaCO2 60 mmHg […] Ancillary testing performed when unable to do apnea testing, or neurological exam is unreliable […] tests include: EEG, cerebral angiography „gold standard”, nuclear scan, transcranial Dopppler ultrasonography.

• #56 Brain Death Imaging | Radiology Key

  https://radiologykey.com/brain-death-imaging/

  The objective of ancillary tests in the diagnosis of brain death is to demonstrate the absence of cerebral electrical activity (EEG and evoked potentials) or cerebral circulatory arrest. […] Currently, only catheter cerebral angiography and perfusion scintigraphy are widely accepted as ancillary tests in the determination of cerebral circulatory arrest. […] Catheter cerebral angiography is considered as a reference method in the diagnosis of majority of cerebrovascular pathologies including cerebral circulatory arrest. […] Cerebral circulatory arrest can be documented by catheter cerebral angiography if all of the following conditions are met: 1. Filling of external carotid arteries confirming a proper contrast delivery 2. No filling of ICAs beyond the level of the anterior clinoid process 3. No filling of VAs beyond their dural penetration 4. No filling of the internal cerebral veins. […] Catheter angiography is widely accepted as a reference test in the diagnosis of brain death.

• #57 Brain Death Imaging | Radiology Key

  https://radiologykey.com/brain-death-imaging/

  The objective of ancillary tests in the diagnosis of brain death is to demonstrate the absence of cerebral electrical activity (EEG and evoked potentials) or cerebral circulatory arrest. […] Currently, only catheter cerebral angiography and perfusion scintigraphy are widely accepted as ancillary tests in the determination of cerebral circulatory arrest. […] Catheter cerebral angiography is considered as a reference method in the diagnosis of majority of cerebrovascular pathologies including cerebral circulatory arrest. […] Cerebral circulatory arrest can be documented by catheter cerebral angiography if all of the following conditions are met: 1. Filling of external carotid arteries confirming a proper contrast delivery 2. No filling of ICAs beyond the level of the anterior clinoid process 3. No filling of VAs beyond their dural penetration 4. No filling of the internal cerebral veins. […] Catheter angiography is widely accepted as a reference test in the diagnosis of brain death.

• #58 Radiological testing for brain death | Deranged Physiology

  https://derangedphysiology.com/main/required-reading/organ-and-tissue-donation/Chapter-613/radiological-testing-brain-death

  Radiological confirmation of brain death is required when the preconditions for clinical brain death testing cannot be met. The objective of these tests is to demonstrate an absence of blood flow above the foramen magnum. […] Broadly speaking, these are almost the same as the contraindications to clinical testing. […] Gold standard; injection of contrast into both carotids and both vertebrals. Blood flow should not be demonstrated above the level of the carotid siphon in the anterior circulation, or above the foramen magnum in the posterior circulation. […] This refers specifically to the Tc-99 HMPAO SPECT scan, which (after the four-vessel DSA) is viewed by the ANZICS Statement on Death and Organ Donation as the second best way of confirming that there is no blood flow to the noggin.

• #59 Brain Death – EMCrit Project

  https://emcrit.org/ibcc/brain-death/

  Potential reasons to pursue a formal diagnosis of brain death: Will resolve confusion regarding goals of care and/or issues with surrogate decision-makers. […] The most useful confirmatory test is cerebral scintigraphy: Radiolabeled dye is injected into a peripheral vein. If there is perfusion to the brain, the dye will be taken up in brain tissue. […] In brain death, lack of brain perfusion causes an empty skull sign. […] A cerebral scintigraphy which shows lack of blood flow to the brain is extremely solid evidence of brain death.

• #60 Brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/brain-death-diagnosis/

  if any findings on neurologic examination or apnea test are consistent with brain-mediated activity, the patient does not meet criteria for BD/DNC, and ancillary testing must not be performed […] clinicians should not use EEGs as ancillary test to assist with the diagnosis of BD/DNC […] the absence of any detectable EEG activity does not provide information about the presence or absence of brainstem function […] clinicians may use radionuclide perfusion scintigraphy as an ancillary test to aid in the diagnosis of BD/DNC […] brain death is indicated by a complete absence of brain perfusion […] clinicians may use TCD/TCCD in adult patients as an ancillary test to aid in the diagnosis of BD/DNC confirmation of cerebral circulatory arrest

• #61 Brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/brain-death-diagnosis/

  if any findings on neurologic examination or apnea test are consistent with brain-mediated activity, the patient does not meet criteria for BD/DNC, and ancillary testing must not be performed […] clinicians should not use EEGs as ancillary test to assist with the diagnosis of BD/DNC […] the absence of any detectable EEG activity does not provide information about the presence or absence of brainstem function […] clinicians may use radionuclide perfusion scintigraphy as an ancillary test to aid in the diagnosis of BD/DNC […] brain death is indicated by a complete absence of brain perfusion […] clinicians may use TCD/TCCD in adult patients as an ancillary test to aid in the diagnosis of BD/DNC confirmation of cerebral circulatory arrest

• #62 CT Angiography for Brain Death Diagnosis | American Journal of Neuroradiology

  http://www.ajnr.org/content/30/8/1566

  Lack of cerebral circulation is an important confirmatory test for brain death (BD). […] Conventional angiography remains the standard imaging method, but CT angiography (CTA) is emerging as an alternative. […] France accepts BD diagnoses relying on a score based on lack of opacification of 7 intracerebral vessels in CTA images. […] The purpose of this study was to validate the efficiency of this score and to evaluate the sensitivity of a novel 4-point CTA score in confirming BD. […] Lack of opacification in the cortical segments of the MCAs and internal veins in CTA is efficient and reliable for confirming BD. […] The novel 4-point CTA score based on the lack of opacification of 4, instead of 7, cerebral vessels appears more sensitive in confirming BD than the accepted 7-point CTA score.

• #63 Brain death | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/brain-death-2?lang=us

  It is important to note that not all modalities and examinations are approved for the legal determination of brain death and that this will vary from country to country. […] Furthermore, it is essential to realize that the absence of brain perfusion implies brain death, but the converse is not true. […] In 2023 various UK bodies including the Faculty of Intensive Care Medicine, British Society of Neuroradiologists and the RCR published a consensus document on the use of CT angiography as ancillary testing for death by neurological criteria (DNC). […] This consensus is for adult patients only (not pediatric patients). […] Although MRI can demonstrate extensive ischemic change more accurately than CT, only MR angiography has been proposed as a potential ancillary test for the diagnosis of brain death, using similar criteria to CT angiography.

• #64 CT Angiography for Brain Death Diagnosis | American Journal of Neuroradiology

  http://www.ajnr.org/content/30/8/1566

  Lack of cerebral circulation is an important confirmatory test for brain death (BD). […] Conventional angiography remains the standard imaging method, but CT angiography (CTA) is emerging as an alternative. […] France accepts BD diagnoses relying on a score based on lack of opacification of 7 intracerebral vessels in CTA images. […] The purpose of this study was to validate the efficiency of this score and to evaluate the sensitivity of a novel 4-point CTA score in confirming BD. […] Lack of opacification in the cortical segments of the MCAs and internal veins in CTA is efficient and reliable for confirming BD. […] The novel 4-point CTA score based on the lack of opacification of 4, instead of 7, cerebral vessels appears more sensitive in confirming BD than the accepted 7-point CTA score.

• #65 CT Angiography for Brain Death Diagnosis | American Journal of Neuroradiology

  http://www.ajnr.org/content/30/8/1566

  A demonstration of lack of cerebral circulation may be required for BD confirmation. […] The absence of ICVs and bilateral cortical branches of the MCAs constitutes the best criterion of BD diagnosis by using CTA. […] The absence of the ICV also appears to be the most sensitive and earliest sign. […] The novel 4-point CTA score appears more sensitive (85.7%) and requires analysis of only 4 vessels. […] CTA remains a 100% specific method as shown by the 10 conventional angiographies and 12 EEGs performed when the CTA score was 7. […] The novel 4-point CTA score based on nonopacification of the cortical segments of the MCAs and the ICVs appears highly sensitive for confirming brain death, maintaining a specificity of 100%.

• #66 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  Brain death, also commonly referred to as death by neurologic criteria, has been considered a legal definition of death for decades. Its determination involves many considerations and subtleties. In this review, we discuss the philosophy and history of brain death, its clinical determination, and special considerations. We discuss performance of the main clinical components of the brain death exam: assessment of coma, cranial nerves, motor testing, and apnea testing. We also discuss common ancillary tests, including advantages and pitfalls. Special discussion is given to extracorporeal membrane oxygenation, target temperature management, and determination of brain death in pediatric populations. Lastly, we discuss existing controversies and future directions in the field. […] In 1968, a group of Harvard faculty proposed the first clinical definition as the Harvard Brain Death Criteria, which consisted of clinical and EEG criteria.

• #67

  https://journals.lww.com/neur/fulltext/2018/66020/brain_death_revisited.5.aspx

  For certifying brain death, the following need to be evaluated: Presence of irreversible coma; and, the cessation of spontaneous respiration confirmed with apnea tests, absence of pupillary light reflexes, corneal reflexes, doll’s eye movements, gag reflex, cough reflex (tracheal), eye movements on caloric testing bilaterally, motor response in any cranial nerve distribution, and motor response on stimulation of face/limb/trunk. […] Confirmatory tests are optional in most guidelines and reserved for the situation when clinical diagnosis cannot be completed or is doubtful. […] Cerebral angiography, particularly a four-vessel angiogram, that demonstrates an absent cerebral circulation remains the gold-standard supplementary test for the diagnosis of brain-death. […] The other confirmatory tests include: Loss of bioelectric brain activity for at least 30 minutes of recording, as measured by a 16 or 18-channel EEG, is a reliable confirmatory test for the diagnosis of brain death.

• #68 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  The mainstay of diagnosis of BD/DNC rests on the above described criteria, that is: establishment of a clear, irreversible cause of brain injury, exclusion of confounders, persistent coma, clinical assessment of brainstem reflexes, and apnea testing. If a patient can be determined BD/DNC based on clinical criteria, ancillary testing is not needed. […] In general, a useful ancillary test can be thought of as having the characteristics of an ideal biomarker: it should be noninvasive, easily measured, inexpensive, produce rapid results, have high sensitivity and specificity, and should aid in prognostication. […] EEG has the ability to detect electrical activity, and as one of the first neurologic tests in general, it has long been used to augment the clinical determination of BD/DNC. However, EEG has perhaps proved more valuable in cases that aim to detect subtle meaningful residual cerebral activity, such as covert consciousness, rather than to exclude the presence of meaningful cerebral function.

• #69 Brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/brain-death-diagnosis/

  if any findings on neurologic examination or apnea test are consistent with brain-mediated activity, the patient does not meet criteria for BD/DNC, and ancillary testing must not be performed […] clinicians should not use EEGs as ancillary test to assist with the diagnosis of BD/DNC […] the absence of any detectable EEG activity does not provide information about the presence or absence of brainstem function […] clinicians may use radionuclide perfusion scintigraphy as an ancillary test to aid in the diagnosis of BD/DNC […] brain death is indicated by a complete absence of brain perfusion […] clinicians may use TCD/TCCD in adult patients as an ancillary test to aid in the diagnosis of BD/DNC confirmation of cerebral circulatory arrest

• #70 Brain death diagnosis | STROKE MANUAL

  https://www.stroke-manual.com/brain-death-diagnosis/

  if any findings on neurologic examination or apnea test are consistent with brain-mediated activity, the patient does not meet criteria for BD/DNC, and ancillary testing must not be performed […] clinicians should not use EEGs as ancillary test to assist with the diagnosis of BD/DNC […] the absence of any detectable EEG activity does not provide information about the presence or absence of brainstem function […] clinicians may use radionuclide perfusion scintigraphy as an ancillary test to aid in the diagnosis of BD/DNC […] brain death is indicated by a complete absence of brain perfusion […] clinicians may use TCD/TCCD in adult patients as an ancillary test to aid in the diagnosis of BD/DNC confirmation of cerebral circulatory arrest

• #71 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM

  https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know

  One of the things that we did is we added recommendations for special situations, for example, evaluating pregnant persons for brain death, doing the apnea test, and the rest of the evaluation in patients supported on VA and VV ECMO. […] For pediatrics, again, the fundamental criteria have not changed from the prior guidelines 10 years ago to the guidelines now. We provide a little bit of additional clarity in terms of doing the neurologic examination. […] In adults, one exam and one apnea test are required. We recommend that a second exam can be done, which will help decrease the likelihood of a false-positive brain death determination. […] One of the things that we emphasize in the guidelines that were published at the end of last year is that practitioners who perform the evaluation should be adequately trained and competent in performing the evaluation.

• #72 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  The basic concept of apnea testing remains the same: pre-oxygenation, observation for spontaneous breaths, and measurements proving the buildup of CO2 in arterial circulation. […] The indications for ancillary testing in ECMO patients, and interpretation of different types of testing, are not well studied, and particular caution should be taken with use of TCD, as it relies on measurement of pulsatile flow. […] It should be noted that in V-A ECMO, due to the phenomenon of mixing occurring when residual native circulation allows antegrade flow from through the left ventricle into the aorta and mixes with retrograde flow from the arterial cannula, distal arterial measurements may be inconsistent with those from the membrane oxygenator circuit, and should be collected simultaneously to avoid inconsistencies.

• #73 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  The basic concept of apnea testing remains the same: pre-oxygenation, observation for spontaneous breaths, and measurements proving the buildup of CO2 in arterial circulation. […] The indications for ancillary testing in ECMO patients, and interpretation of different types of testing, are not well studied, and particular caution should be taken with use of TCD, as it relies on measurement of pulsatile flow. […] It should be noted that in V-A ECMO, due to the phenomenon of mixing occurring when residual native circulation allows antegrade flow from through the left ventricle into the aorta and mixes with retrograde flow from the arterial cannula, distal arterial measurements may be inconsistent with those from the membrane oxygenator circuit, and should be collected simultaneously to avoid inconsistencies.

• #74 Diagnosing Death using Neurological Criteria | The Faculty of Intensive Care Medicine

  https://www.ficm.ac.uk/diagnosing-death-using-neurological-criteria

  The working group had no safety concerns with the current UK apnoea test as outlined in the 2008 Code. […] This update more closely aligns the UK to international practice, reflects the evolving recommendation for two mandated sets of clinical tests of brainstem function (2008 and 2025 Code), fits with the 2025 Code general recommendation to time death to when the healthcare professionals are satisfied all the relevant criteria to diagnose death are met. […] In patients who are hypothermic (defined as a core temperature less than 36C), either therapeutic or accidental, a minimum 24 hour observation period is required following correction of hypothermia. […] In the case of an inability to examine both eyes or both ears, for whatever reason, ancillary investigation will be required. […] Given that the eyes are required in the clinical testing of three of the six brainstem reflexes used in neurological criteria, it is recommended that it must be possible to examine both eyes and there should be no reason to suspect an eye injury or abnormality would prevent the reflex occurring if it could. […] Pauline underlines the AoMRC group’s desire to ensure that all deaths are diagnosed and confirmed in an accurate, standardised and timely manner.

• #75 Diagnosing Death using Neurological Criteria | The Faculty of Intensive Care Medicine

  https://www.ficm.ac.uk/diagnosing-death-using-neurological-criteria

  The working group had no safety concerns with the current UK apnoea test as outlined in the 2008 Code. […] This update more closely aligns the UK to international practice, reflects the evolving recommendation for two mandated sets of clinical tests of brainstem function (2008 and 2025 Code), fits with the 2025 Code general recommendation to time death to when the healthcare professionals are satisfied all the relevant criteria to diagnose death are met. […] In patients who are hypothermic (defined as a core temperature less than 36C), either therapeutic or accidental, a minimum 24 hour observation period is required following correction of hypothermia. […] In the case of an inability to examine both eyes or both ears, for whatever reason, ancillary investigation will be required. […] Given that the eyes are required in the clinical testing of three of the six brainstem reflexes used in neurological criteria, it is recommended that it must be possible to examine both eyes and there should be no reason to suspect an eye injury or abnormality would prevent the reflex occurring if it could. […] Pauline underlines the AoMRC group’s desire to ensure that all deaths are diagnosed and confirmed in an accurate, standardised and timely manner.

• #76 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM

  https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know

  One of the things that we did is we added recommendations for special situations, for example, evaluating pregnant persons for brain death, doing the apnea test, and the rest of the evaluation in patients supported on VA and VV ECMO. […] For pediatrics, again, the fundamental criteria have not changed from the prior guidelines 10 years ago to the guidelines now. We provide a little bit of additional clarity in terms of doing the neurologic examination. […] In adults, one exam and one apnea test are required. We recommend that a second exam can be done, which will help decrease the likelihood of a false-positive brain death determination. […] One of the things that we emphasize in the guidelines that were published at the end of last year is that practitioners who perform the evaluation should be adequately trained and competent in performing the evaluation.

• #77 Inconsistency in Brain Death Determination Should Not Be Tolerated | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/inconsistency-brain-death-determination-should-not-be-tolerated/2020-12

  Since it was proposed in 1980, the Uniform Determination of Death Act has provided the legal basis for determination of death by neurological criteria. […] Since 1995, the American Academy of Neurology has provided guidelines for brain death determination (revised in 2010), but nationwide adherence to these guidelines has been incomplete. […] These guidelines stated that brain death has occurred when the irreversible loss of function of the brain, including the brain stem, has been determined by the demonstration of complete loss of consciousness (coma), brain stem reflexes, and the independent capacity for ventilatory drive (apnea) in the absence of any factors that imply possible reversibility. […] Despite the 2010 update, significant variability remains in hospital policies across the United States.

• #78 Diagnosis of brain death – UpToDate

  https://www.uptodate.com/contents/diagnosis-of-brain-death/print

  Diagnosis of brain death […] Death is an irreversible, biologic event that consists of permanent cessation of the critical functions of the organism as a whole. This concept allows for survival of tissues in isolation, but it requires the loss of integrated function of various organ systems. Death of the brain therefore qualifies as death, as the brain is essential for integrating critical functions of the body. The equivalence of brain death with death is largely, although not universally, accepted. […] Brain death implies the permanent absence of cerebral and brainstem functions. Although the term „brain dead” is often used colloquially in a way that erroneously encompasses patients with severe brain damage and those who remain unresponsive, in medical-legal terms its meaning is very specific. Chronic disorders of consciousness are described elsewhere.

• #79 Diagnosis: Brain & Circulatory Death in Organ Donation | Donor Alliance

  https://www.donoralliance.org/diagnosis/

  There are numerous laws, regulations and standards that govern how and when a medical professional can make an official declaration of death. What is most important to know is that hospitals and emergency medical professionals will make every effort to save a patient’s life regardless of their status as a donor. […] Death can occur in one of two ways: cardiac death, when the heart is no longer able to beat on its own, and brain death, which is the irreversible loss of function of the brain, including the brain stem. […] According to the Uniform Determination of Death Act, brain death is defined as the irreversible cessation of all functions of the entire brain, including the brain stem. A brain-dead person is dead, although his or her cardiopulmonary functioning may be artificially maintained for some time.

• #80 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM

  https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know

  In the United States, the legal basis for brain death stems from the UDDA, the Uniform Determination of Death Act, which was enacted in 1981 in the United States. It states that an individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brainstem, is dead. […] What the panel decided and what has been written into the guidelines is that you have a duty to inform families that you are going to proceed with a brain death evaluation. However, you do not need to obtain consent for doing the evaluation, that we have an obligation as clinicians to know whether the patient who we are taking care of in front of us is alive or dead. […] There are a variety of ancillary tests that are permissible by the guidelines. The first is four-vessel conventional angiography. There is nuclear medicine-based cerebral blood flow and perfusion studies. Then there is transcranial Doppler. […] I think we need to think of this in a variety of action items. Hospitals need to take the guidelines and they need to revise their institutional protocols to be consistent with the guidelines, keeping in mind state and local laws and regulations that also need to be adhered to.

• #81 Inconsistency in Brain Death Determination Should Not Be Tolerated | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/inconsistency-brain-death-determination-should-not-be-tolerated/2020-12

  Since it was proposed in 1980, the Uniform Determination of Death Act has provided the legal basis for determination of death by neurological criteria. […] Since 1995, the American Academy of Neurology has provided guidelines for brain death determination (revised in 2010), but nationwide adherence to these guidelines has been incomplete. […] These guidelines stated that brain death has occurred when the irreversible loss of function of the brain, including the brain stem, has been determined by the demonstration of complete loss of consciousness (coma), brain stem reflexes, and the independent capacity for ventilatory drive (apnea) in the absence of any factors that imply possible reversibility. […] Despite the 2010 update, significant variability remains in hospital policies across the United States.

• #82 Diagnosis of brain death – UpToDate

  https://www.uptodate.com/contents/diagnosis-of-brain-death

  Diagnosis of brain death […] Brain death implies the permanent absence of cerebral and brainstem functions. […] Brain death signifies the complete, irreversible cessation of brain function, including the capacity for the brainstem to regulate respiratory and vegetative activities. […] While most countries have a legal provision for brain death, institutional protocols for diagnosis are not universal and are often absent, particularly in lower-income countries and in those without an organized transplant network. […] Even among countries with an organized diagnostic protocol, there is substantial variation in the criteria that are used. […] In most adult series, trauma and subarachnoid hemorrhage are the most common events leading to brain death.

• #83 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12

  The case illustrates a series of errors that led to a false determination of brain death. […] Although the diagnosis of brain death and prognosis of neurological recovery after brain injury are well-defined in the literature, hospital policies in the United States for the determination of brain death are highly variable and often not in line with current practice guidelines. […] Without the safety net of standardized guidelines, false diagnoses of brain death are more likely to occur. […] The Neurocritical Care Society provides a brain death determination course to standardize brain death diagnosis.

• #84 American Academy of Neurology: Neurology Resources | AAN

  https://www.aan.com/PressRoom/Home/PressRelease/842

  In an effort to create a uniform and accurate method for determining brain death, the American Academy of Neurology has issued an updated guideline that provides doctors with a step-by-step process for determining brain death in adults. […] The brain death diagnosis can be made only after a comprehensive clinical evaluation and often involves more than 25 separate assessments. […] Brain death is the permanent loss of brain function and means the person has died. […] According to the guideline, there are three signs that a persons brain has permanently stopped functioning. First, the person is comatose, and the cause of the coma is known. Second, all brainstem reflexes have permanently stopped working. Third, breathing has permanently stopped. […] The guideline describes several complex steps doctors must follow to diagnose brain death. […] The guideline also makes clear that this complex process must be completed by a doctor with considerable skill and experience in diagnosing brain death.

• #85 Inconsistency in Brain Death Determination Should Not Be Tolerated | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/inconsistency-brain-death-determination-should-not-be-tolerated/2020-12

  Since it was proposed in 1980, the Uniform Determination of Death Act has provided the legal basis for determination of death by neurological criteria. […] Since 1995, the American Academy of Neurology has provided guidelines for brain death determination (revised in 2010), but nationwide adherence to these guidelines has been incomplete. […] These guidelines stated that brain death has occurred when the irreversible loss of function of the brain, including the brain stem, has been determined by the demonstration of complete loss of consciousness (coma), brain stem reflexes, and the independent capacity for ventilatory drive (apnea) in the absence of any factors that imply possible reversibility. […] Despite the 2010 update, significant variability remains in hospital policies across the United States.

• #86 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  In practice, diagnosis of BD/DNC is essential to organ transplantation, particularly cardiac, in that brain dead donors are the only accepted source for cardiac transplant in the United States. However, importantly, declaration of BD/DNC is an important and separate medical diagnosis that should be made independent of the need for organ transplantation. […] The first and most widely accepted is the whole brain formulation which asserts that brain death is equivalent to catastrophic injury to all the major structures of the brain including the hemispheres, diencephalon, brainstem, and cerebellum. In this view, confirmation of complete and permanent damage to the whole brain should be confirmed before BD/DNC is ultimately declared. […] The clinical determination of BD/DNC is detailed and can be daunting even to experienced critical care providers and neurologists. Correct diagnosis is of utmost importance, and the minimum clinical criteria and examination involves many steps.

• #87 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM

  https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know

  In the United States, the legal basis for brain death stems from the UDDA, the Uniform Determination of Death Act, which was enacted in 1981 in the United States. It states that an individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brainstem, is dead. […] What the panel decided and what has been written into the guidelines is that you have a duty to inform families that you are going to proceed with a brain death evaluation. However, you do not need to obtain consent for doing the evaluation, that we have an obligation as clinicians to know whether the patient who we are taking care of in front of us is alive or dead. […] There are a variety of ancillary tests that are permissible by the guidelines. The first is four-vessel conventional angiography. There is nuclear medicine-based cerebral blood flow and perfusion studies. Then there is transcranial Doppler. […] I think we need to think of this in a variety of action items. Hospitals need to take the guidelines and they need to revise their institutional protocols to be consistent with the guidelines, keeping in mind state and local laws and regulations that also need to be adhered to.

• #88 Brain Death | National Kidney Foundation

  https://www.kidney.org/kidney-topics/brain-death

  Before brain death is confirmed, everything possible to save an individual’s life is done. After the diagnosis of brain death is made there is no chance of recovery. […] Once the diagnosis of brain death is made, an individual is pronounced legally dead. This is the time that should appear on the death certificate. […] No. When someone is dead, there is no feeling of pain or suffering.

• #89 Brain Death: What It Is, Stages & Criteria

  https://my.clevelandclinic.org/health/diseases/brain-death

  Healthcare providers with special training in brain death do several tests. They may do tests more than once to confirm their initial diagnosis. […] If you have a catastrophic brain injury, you cant breathe on your own and rely on mechanical ventilation (ventilators). In an apnea test, providers briefly stop ventilator support to see if you take a breath on your own. […] First, your healthcare providers will share and explain test results with your family, including that a brain death diagnosis means death. […] No, people dont recover from brain death. Healthcare providers follow strict guidelines about assessing and testing for potential brain death. If tests indicate brain death, the person is clinically dead. […] No, you cant because you may not be able to prevent any of the serious illnesses or injuries that lead to brain death. In some cases, immediate medical care may keep brain death from happening if you have a serious illness or an injury that affects your brain. […] Brain death is different from the way we usually die. For most of us, death is when our physical body stops working. […] Providers who diagnose brain death understand that. Theyll always take time to explain the careful steps they take before concluding someone is brain dead.

• #90 Brain death | Better Health Channel

  https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/brain-death

  Brain death occurs when a critically ill person dies sometime after being placed on life support. […] In some cases, a person who is brain dead may be a candidate for organ donation. […] Brain death is not the same as coma, because someone in a coma is unconscious but still alive. […] Brain death occurs when a critically ill patient dies sometime after being placed on life support. […] Brain death differs from other states of unconsciousness in important ways. […] Brain death means the person has died. […] It is important for the medical staff members to fully explain that brain death is final, and that the person is dead and has no chance of ever regaining consciousness again. […] In some cases, a person who is brain dead may be a candidate for organ donation.

• #91 ‘Brain death’: should it be reconsidered? | Spinal Cord

  https://www.nature.com/articles/3102107

  To evaluate whether current clinical criteria and confirmatory tests for the diagnosis of brain death satisfy the requirements for the irreversible cessation of all functions of the entire brain including the brainstem. […] We present four arguments to support the view that patients who meet the current operational criteria of brain death do not necessarily have the irreversible loss of all brain (or brainstem) functions. […] The stated definition of brain death (the complete cessation of all functions of the entire brain) is now acknowledged even by supporters of the concept of brain death to be only an approximation. […] The conclusion of the above analysis is that somatic survival is feasible, for various periods of time, even in the presence of a totally destroyed brain; therefore, the destruction of the brain cannot be equated with the human death.

• #92 Controversy over the definition of brain death : Shots – Health News : NPR

  https://www.npr.org/sections/health-shots/2024/02/11/1228330149/brain-death-definition

  When can a person be declared dead? The question can be hard to answer. […] The debate is focused on the Uniform Determination of Death Act, a law that was adopted by most states in the 1980s. The law says that death can be declared if someone has experienced „irreversible cessation of all functions of the entire brain.” […] The second method, brain death, can be declared for people who have sustained catastrophic brain injury causing the permanent cessation of all brain function, such as from a massive traumatic brain injury or massive stroke, but whose hearts are still pumping through the use of ventilators or other artificial forms of life support. […] For years, doctors have declared brain death using a series of tests to determine four main criteria: whether a person has a profound and irreversible coma, has permanently lost the capacity to breathe, has permanently lost all reflexes controlled by the brainstem, and whether all potentially reversible conditions, such as a drug overdose, have been ruled out.

• #93

  https://link.springer.com/article/10.1007/s12028-009-9231-y

  Since the establishment of the concept of declaring death by brain criteria, a large extent of variability in the determination of brain death has been reported. […] There are no standardized practical guidelines, and major differences exist in the requirements for the declaration of brain death throughout the USA and internationally. […] The American Academy of Neurology published evidence-based practice parameters for the determination of brain death in adults in 1995, requiring the irreversible absence of clinical brain function with the cardinal features of coma, absent brainstem reflexes, and apnea, as well as the exclusion of reversible confounders. […] Ancillary tests are recommended in cases of uncertainty of the clinical diagnosis. […] Every step in the determination of brain death bears potential pitfalls which can lead to errors in the diagnosis of brain death. […] These pitfalls are presented here, and possible solutions identified. […] Suggestions are made for improvement in the standardization of the declaration of brain death.

• #94 Diagnosis of brain death – UpToDate

  https://www.uptodate.com/contents/diagnosis-of-brain-death

  Diagnosis of brain death […] Brain death implies the permanent absence of cerebral and brainstem functions. […] Brain death signifies the complete, irreversible cessation of brain function, including the capacity for the brainstem to regulate respiratory and vegetative activities. […] While most countries have a legal provision for brain death, institutional protocols for diagnosis are not universal and are often absent, particularly in lower-income countries and in those without an organized transplant network. […] Even among countries with an organized diagnostic protocol, there is substantial variation in the criteria that are used. […] In most adult series, trauma and subarachnoid hemorrhage are the most common events leading to brain death.

• #95 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12

  It is critical for brain death diagnosis to be accurate. […] A determination of death must be made in accordance with accepted medical standards. […] The American Academy of Neurology has since established and reaffirmed standards for determination of brain death. […] Nevertheless, confusion exists among physicians regarding definitions of and distinctions among brain death, coma, persistent vegetative state, and minimally conscious state. […] In a survey of physicians who perform brain death examinations, only 25% reported compliance with current practice guidelines. […] The team informed the family that the patient was not brain dead. […] A clinical diagnosis of brain death was not possible because a number of the brain stem reflexes and other responses were not testable. […] In addition to the patient not meeting prerequisites for determination of brain death, there were 2 contraindications to apnea testingparenchymal lung disease/CO2 retention and high cervical spinal cord injury.

• #96 Inconsistency in Brain Death Determination Should Not Be Tolerated | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/inconsistency-brain-death-determination-should-not-be-tolerated/2020-12

  The variability found in the 2008 study prompted an update to the AAN practice parameters in 2010 in hopes of bringing about more uniformity in brain death determinationor at least in the protocols for such. […] A follow-up study in 2016 reviewed 492 US hospital policies on brain death declaration. […] Notably, this paper found that only 43.1% of policies specifically required an attending physician to make the diagnosis of brain death. […] Variability in the diagnosis of brain death has the potential to lead to misdiagnosis. […] If the medical profession cannot achieve rigorous, disciplined brain death testing in accordance with accepted guidelines for the determination of brain death on a national scale, confusion and doubt may ensue, leading to erosion of public trust. […] Efforts are underway to outline the differences that exist in brain death determination both in the United States and worldwide and to develop clearer and more unified practice parameters to ensure correct determination as close to 100% of the time as possible. […] Ensuring that proper determination of brain death is occurring will require in-depth and meticulous efforts by hospitals.

• #97

  https://link.springer.com/article/10.1007/s44202-024-00183-w

  Receiving a diagnosis of brain stem death poses significant challenges for families. […] The aim of this review is to explore the experiences of families facing brain stem death. […] The review underscores the pervasive lack of understanding among families regarding the diagnosis and process of brain stem death, as well as the short- and long-term distress it can engender. […] There is a clear imperative to establish national or international protocols for brain stem death, ensuring more effective and consistent support for affected families. […] As a result of the lack of universal standard of method for BSD diagnosis, the practise surrounding brain death can vary across countries. […] Prior to testing for BSD, proof is required to confirm that there is irreversible structural brain damage, and that all possibility of a reversible cause of coma can be excluded.

• #98

  https://link.springer.com/article/10.1007/s44202-024-00183-w

  Some components of the formal neurological examination and diagnostic criteria that follows are: apnoea testing, absence of corneal reflex, absence of vestibulo-ocular reflex, demonstration of no motor response to pain, no pupillary response to light and no gag reflex tests. […] Countries will utilize not only different tests, but they also require these tests to be conducted by different professionals with varying expertise. […] The findings highlight the importance of staff input on families experience and understanding of BSD and need for better family support provision and training for clinical staff. […] The review also highlighted the resulting difference between people understanding and accepting BSD. […] Many people were pleased to have been present for the testing and to have had the choice and said they would recommend it to future families.

• #99

  https://link.springer.com/article/10.1007/s44202-024-00183-w

  However, without clarification of its purpose and what it would entail, it left some family members further confused. […] Families that were not aware of BSD testing were negatively impacted by additional confusion, stress and grief. […] Given the families unique experience of grief, and the apparent confusion and uncertainty surrounding official announcement of BSD, families in this situation require specific grief support to help navigate them throughout this incredibly difficult time. […] This review highlights the psychological impact of a relative’s diagnosis of brain stem death (BSD) on families.

• #100 ‘Brain death’: should it be reconsidered? | Spinal Cord

  https://www.nature.com/articles/3102107

  To evaluate whether current clinical criteria and confirmatory tests for the diagnosis of brain death satisfy the requirements for the irreversible cessation of all functions of the entire brain including the brainstem. […] We present four arguments to support the view that patients who meet the current operational criteria of brain death do not necessarily have the irreversible loss of all brain (or brainstem) functions. […] The stated definition of brain death (the complete cessation of all functions of the entire brain) is now acknowledged even by supporters of the concept of brain death to be only an approximation. […] The conclusion of the above analysis is that somatic survival is feasible, for various periods of time, even in the presence of a totally destroyed brain; therefore, the destruction of the brain cannot be equated with the human death.

• #101 Controversy over the definition of brain death : Shots – Health News : NPR

  https://www.npr.org/sections/health-shots/2024/02/11/1228330149/brain-death-definition

  „The law says: You’re not dead until all the functions of your entire brain have stopped every single function of the entire brain,” Pope says. „Well, there is a function of your brain that may continue, and we’re still going to say that you’re dead.” […] Critics point to rare cases like Jahi McMath, a 13-year-old girl who was declared brain dead in 2013. […] But many other neurologists, bioethicists and others argue that there’s no way to make sure every neuron in the brain has ceased functioning. […] „They do not have any hope for meaningful recovery or any hope for regaining of consciousness or brainstem function,” says Dr. David Greer, chair of neurology at the Boston University Chobanian Avedisian School of Medicine. […] „There has never, ever been a case of a person correctly diagnosed as brain dead where that person has recovered any degree of consciousness,” agrees Dr. Robert Truog, a Harvard University professor of bioethics, anesthesiology and pediatrics.

• #102 ‘Brain death’: should it be reconsidered? | Spinal Cord

  https://www.nature.com/articles/3102107

  Therefore, according to the above arguments, the assumption that all functions of the entire brain (or those of the brainstem) in brain-dead patients diagnosed according to all proposed criteria have ceased, is invalidated. […] Not one of the various confirmatory tests has the necessary positive predictive value (100%), for the pronouncement of human death. […] Therefore, it follows that no form of neurophysiologic testing currently available has 100% positive predictive value (the chance of having a disease given a positive test result) in the diagnosis of brain death, which is necessary for the pronouncement of human death.

• #103 Controversy over the definition of brain death : Shots – Health News : NPR

  https://www.npr.org/sections/health-shots/2024/02/11/1228330149/brain-death-definition

  The American Academy of Neurology proposes putting into law only three specific criteria for the determination of death by neurologic criteria. […] Some doctors and advocates would like to do away with brain death entirely. Others call for additional testing to rule out functioning of the hypothalamus. […] But eliminating brain death or requiring additional testing could significantly reduce the number of people who would be eligible for organ donation at a time when organs for transplantation remain in severely short supply. […] „I don’t think the [Uniform Determination of Death Act] should be revised. It’s working, and revisions I think can only lead to lack of conformity throughout the United States,” says Peter Langrock, a Vermont attorney who serves on the Uniform Law Commission. […] „I think it would be much better to bring the law into accord with contemporary clinical practice,” says David Magnus, a professor of medicine and bioethics at Stanford University School of Medicine.

• #104 Controversy over the definition of brain death : Shots – Health News : NPR

  https://www.npr.org/sections/health-shots/2024/02/11/1228330149/brain-death-definition

  The American Academy of Neurology proposes putting into law only three specific criteria for the determination of death by neurologic criteria. […] Some doctors and advocates would like to do away with brain death entirely. Others call for additional testing to rule out functioning of the hypothalamus. […] But eliminating brain death or requiring additional testing could significantly reduce the number of people who would be eligible for organ donation at a time when organs for transplantation remain in severely short supply. […] „I don’t think the [Uniform Determination of Death Act] should be revised. It’s working, and revisions I think can only lead to lack of conformity throughout the United States,” says Peter Langrock, a Vermont attorney who serves on the Uniform Law Commission. […] „I think it would be much better to bring the law into accord with contemporary clinical practice,” says David Magnus, a professor of medicine and bioethics at Stanford University School of Medicine.

• #105 Confirmatory Tests for Brain Death

  https://www.verywellhealth.com/confirmatory-tests-for-brain-death-2488871

  Brain death is one of the most serious diagnoses a neurologist can make. Unlike severe forms of coma, a diagnosis of brain death means there is no coming back. Medically, brain death is death. […] If the diagnosis is made properly, it can be done just by ensuring the patient is in a coma of a known and irreversible cause, and that certain physical exam findings are absent, including brainstem reflexes and any effort to breathe during an apnea test. […] There are no well-documented cases of a diagnosis of brain death is carefully made in which the patient then had a meaningful recovery. […] However, there are times when meeting all the technical qualifications for brain death is impossible. […] In these cases, additional testing is called for. […] Furthermore, because the diagnosis of brain death is so serious, many families prefer to have additional testing done before making decisions about stopping mechanical ventilation or considering organ donation.

• #106 Clinical testing for neurological determination of death | Deranged Physiology

  https://derangedphysiology.com/main/required-reading/organ-and-tissue-donation/Chapter-612/clinical-testing-neurological-determination-death

  Clinical testing for neurological determination of death is a Level 1 topic from Section 2.1.15 in the CICM Syllabus for the Second Part Examination (2nd ed), where all the topics are Level 1 topics. […] The ANZICS statement reports that there has never been a documented case of anybody who fulfilled the above brain death criteria, and the preconditions for brain death, who has ever recovered any brain function. […] Definition of brain death: Unresponsive coma, Absence of brain stem reflexes, Absence of respiratory centre functions, Clinical setting which suggests that these findings are IRREVERSIBLE. […] Preconditions for clinical brain death testing: Evidence of sufficient intracranial pathology to deteriorate to loss of all brain function, AND all of the following: Normothermia ≥35 C, Normotension: SBP ≥90 or MAP ≥60, Exclusion of effects of sedative medications, Absence of severe electrolyte, metabolic or endocrine disturbances, Absence of acute liver failure or decompensated chronic liver disease, Absence of neuromuscular-blocking drugs, At least one intact ear and one intact eye, Enough spinal cord function to assess the motor response in the facial nerve (VII) to painful stimulus in the upper limbs and to assess the motor response in the upper limbs to painful stimulus in the trigeminal (V) sensory region, Ability to perform apnoea testing.

• #107 Learning Center

  https://www.neurocriticalcare.org/NCS-Learning-Center/Learning-Center/Results/Details/brain-death-determination-course

  While there exists a legal provision for brain death, or death by neurologic criteria (BD/DNC), institutional protocols for diagnosis are not universal and are often absent; no specific criteria for diagnosis is mandated. […] The Brain Death Determination on-line course, presented by the Neurocritical Care Society, aims to standardize the process of brain death diagnosis. […] Highlighting the necessary steps that must be taken to determine brain death. […] Reviewing meticulous examination methods, including apnea testing, understanding the role of ancillary testing, and discussing proper documentation. […] Describing common pitfalls and barriers that may arise during the determination process.

• #108 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12

  The case illustrates a series of errors that led to a false determination of brain death. […] Although the diagnosis of brain death and prognosis of neurological recovery after brain injury are well-defined in the literature, hospital policies in the United States for the determination of brain death are highly variable and often not in line with current practice guidelines. […] Without the safety net of standardized guidelines, false diagnoses of brain death are more likely to occur. […] The Neurocritical Care Society provides a brain death determination course to standardize brain death diagnosis.

• #109 Brain Death – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK538159/

  Brain death, both a legal and clinical term, has been present in medical literature and texts for many years and was defined by the Uniform Determination of Death Act (UDDA) in 1981. […] The course primarily focuses on three core areas: the etiology and progression to brain death, distinguishing brain death from other states such as coma or vegetative state, and the comprehensive criteria and protocols for the diagnosis of brain death. […] This course explores the latest standards and practices in diagnosing brain death, emphasizing clinical assessments, brainstem reflex testing, and the uses of ancillary tests. […] AAN’s recent position statement on brain death endorses UDDA’s death definition as „irreversible cessation of all functions of the entire brain, including the brainstem, has been determined by the demonstration of complete loss of consciousness (coma), brainstem reflexes, and the independent capacity for the ventilatory drive (apnea), in the absence of any factors that imply possible reversibility.”

• #110 Brain Death – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK538159/

  In 2012, the World Health Organization (WHO) partnered with an international forum to endorse brain death as the official diagnosis of death. […] Distinguishing the term „brain death” from „coma” to the public is essential, as coma may imply a limited form of life. […] Differentiating brain death from other forms of severe brain damage, including vegetative state and minimally responsive state, is crucial. […] Once the decision to proceed with the brain death determination has been made, three conditions must be present: coma, the absence of brainstem reflexes, and apnea. […] If the above conditions are present and there is an identified cause of coma and complete lack of brainstem reflex, you may proceed with apnea testing. […] If the above list is completed, and coma, the absence of brainstem reflexes, and a positive apnea test are present, the diagnosis of brain death can be made.

• #111 Learning Center

  https://www.neurocriticalcare.org/NCS-Learning-Center/Learning-Center/Results/Details/brain-death-determination-course

  While there exists a legal provision for brain death, or death by neurologic criteria (BD/DNC), institutional protocols for diagnosis are not universal and are often absent; no specific criteria for diagnosis is mandated. […] The Brain Death Determination on-line course, presented by the Neurocritical Care Society, aims to standardize the process of brain death diagnosis. […] Highlighting the necessary steps that must be taken to determine brain death. […] Reviewing meticulous examination methods, including apnea testing, understanding the role of ancillary testing, and discussing proper documentation. […] Describing common pitfalls and barriers that may arise during the determination process.

• #112 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM

  https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know

  Host Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, welcomes Matthew Kirschen, MD, PhD, FAAN, FNCS, to discuss what critical care professionals need to know about determining brain death/death by neurologic criteria (BD/DNC). In October 2023, a revised consensus practice guideline for the determination of brain death in both children and adults was published in Neurology (Greer DM, et al. Neurology. 2023;101;1112-1132). The guideline integrated guidance for adults and children to provide a comprehensive, practical way to evaluate patients with catastrophic brain injuries to determine whether they meet the criteria for brain death. […] The big thing in this set of guidelines is that we amalgamated the adult criteria and the pediatric criteria into one document. […] The fundamental definition of brain death has not changed over the past 10 years. You still need to have a catastrophic brain injury. That brain injury needs to be permanent, such that you observe the patient for a period of time and ensure that there is no recovery of any clinical brain function. Then you have to evaluate the patient for brain death, and they need to be comatose and unresponsive to all stimuli. They need to have brainstem areflexia, and they need to not breathe with an appropriate CO2 and acidotic challenge after you have excluded relevant confounders. That definition has maintained the same in this revision of the guidelines.

• #113 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM

  https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know

  Host Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, welcomes Matthew Kirschen, MD, PhD, FAAN, FNCS, to discuss what critical care professionals need to know about determining brain death/death by neurologic criteria (BD/DNC). In October 2023, a revised consensus practice guideline for the determination of brain death in both children and adults was published in Neurology (Greer DM, et al. Neurology. 2023;101;1112-1132). The guideline integrated guidance for adults and children to provide a comprehensive, practical way to evaluate patients with catastrophic brain injuries to determine whether they meet the criteria for brain death. […] The big thing in this set of guidelines is that we amalgamated the adult criteria and the pediatric criteria into one document. […] The fundamental definition of brain death has not changed over the past 10 years. You still need to have a catastrophic brain injury. That brain injury needs to be permanent, such that you observe the patient for a period of time and ensure that there is no recovery of any clinical brain function. Then you have to evaluate the patient for brain death, and they need to be comatose and unresponsive to all stimuli. They need to have brainstem areflexia, and they need to not breathe with an appropriate CO2 and acidotic challenge after you have excluded relevant confounders. That definition has maintained the same in this revision of the guidelines.

• #114 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM

  https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know

  Host Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, welcomes Matthew Kirschen, MD, PhD, FAAN, FNCS, to discuss what critical care professionals need to know about determining brain death/death by neurologic criteria (BD/DNC). In October 2023, a revised consensus practice guideline for the determination of brain death in both children and adults was published in Neurology (Greer DM, et al. Neurology. 2023;101;1112-1132). The guideline integrated guidance for adults and children to provide a comprehensive, practical way to evaluate patients with catastrophic brain injuries to determine whether they meet the criteria for brain death. […] The big thing in this set of guidelines is that we amalgamated the adult criteria and the pediatric criteria into one document. […] The fundamental definition of brain death has not changed over the past 10 years. You still need to have a catastrophic brain injury. That brain injury needs to be permanent, such that you observe the patient for a period of time and ensure that there is no recovery of any clinical brain function. Then you have to evaluate the patient for brain death, and they need to be comatose and unresponsive to all stimuli. They need to have brainstem areflexia, and they need to not breathe with an appropriate CO2 and acidotic challenge after you have excluded relevant confounders. That definition has maintained the same in this revision of the guidelines.

• #115 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM

  https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know

  One of the things that we did is we added recommendations for special situations, for example, evaluating pregnant persons for brain death, doing the apnea test, and the rest of the evaluation in patients supported on VA and VV ECMO. […] For pediatrics, again, the fundamental criteria have not changed from the prior guidelines 10 years ago to the guidelines now. We provide a little bit of additional clarity in terms of doing the neurologic examination. […] In adults, one exam and one apnea test are required. We recommend that a second exam can be done, which will help decrease the likelihood of a false-positive brain death determination. […] One of the things that we emphasize in the guidelines that were published at the end of last year is that practitioners who perform the evaluation should be adequately trained and competent in performing the evaluation.

• #116 Learning Center

  https://www.neurocriticalcare.org/NCS-Learning-Center/Learning-Center/Results/Details/brain-death-determination-course

  While there exists a legal provision for brain death, or death by neurologic criteria (BD/DNC), institutional protocols for diagnosis are not universal and are often absent; no specific criteria for diagnosis is mandated. […] The Brain Death Determination on-line course, presented by the Neurocritical Care Society, aims to standardize the process of brain death diagnosis. […] Highlighting the necessary steps that must be taken to determine brain death. […] Reviewing meticulous examination methods, including apnea testing, understanding the role of ancillary testing, and discussing proper documentation. […] Describing common pitfalls and barriers that may arise during the determination process.

• #117 Inconsistency in Brain Death Determination Should Not Be Tolerated | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/inconsistency-brain-death-determination-should-not-be-tolerated/2020-12

  The variability found in the 2008 study prompted an update to the AAN practice parameters in 2010 in hopes of bringing about more uniformity in brain death determinationor at least in the protocols for such. […] A follow-up study in 2016 reviewed 492 US hospital policies on brain death declaration. […] Notably, this paper found that only 43.1% of policies specifically required an attending physician to make the diagnosis of brain death. […] Variability in the diagnosis of brain death has the potential to lead to misdiagnosis. […] If the medical profession cannot achieve rigorous, disciplined brain death testing in accordance with accepted guidelines for the determination of brain death on a national scale, confusion and doubt may ensue, leading to erosion of public trust. […] Efforts are underway to outline the differences that exist in brain death determination both in the United States and worldwide and to develop clearer and more unified practice parameters to ensure correct determination as close to 100% of the time as possible. […] Ensuring that proper determination of brain death is occurring will require in-depth and meticulous efforts by hospitals.

• #118 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12

  It is critical for brain death diagnosis to be accurate. […] A determination of death must be made in accordance with accepted medical standards. […] The American Academy of Neurology has since established and reaffirmed standards for determination of brain death. […] Nevertheless, confusion exists among physicians regarding definitions of and distinctions among brain death, coma, persistent vegetative state, and minimally conscious state. […] In a survey of physicians who perform brain death examinations, only 25% reported compliance with current practice guidelines. […] The team informed the family that the patient was not brain dead. […] A clinical diagnosis of brain death was not possible because a number of the brain stem reflexes and other responses were not testable. […] In addition to the patient not meeting prerequisites for determination of brain death, there were 2 contraindications to apnea testingparenchymal lung disease/CO2 retention and high cervical spinal cord injury.

• #119 Difficulties in Defining and Detecting Brain Death – Knowledge Base – Justpoint

  https://justpoint.com/knowledge-base/difficulties-in-defining-and-detecting-brain-death/

  The term brain death has been used for more than 40 years to describe a complete cessation of all cognitive activity. […] This makes brain death diagnosis more complicated. […] Legally, a brain-dead individual has been declared dead. […] Misdiagnosis of brain death or a delay in diagnosis accounts for one-third of all malpractice cases resulting in death or permanent disability. […] A correct diagnosis is not always straightforward, and misdiagnosis may prevent the actual condition from improving. […] To determine if a child is receiving adequate treatment, it is helpful to understand this common problem. […] Resuscitating patients who have suffered cardiac arrest and are unconscious should be thoroughly examined for signs of brain death. […] If the medical profession cannot achieve rigorous, disciplined brain death testing by accepting official guidelines for determining brain death on a national scale, confusion and doubt may ensue, leading to erosion of public trust.

• #120 Brain Death – Neurologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/neurologic-disorders/coma-and-impaired-consciousness/brain-death

  Brain death should not be declared or considered and brain death assessment should not be done if the patient is breathing spontaneously, can be aroused, is not in coma, or has intact brain stem reflexes. […] Clinicians who evaluate brain death need sufficient training and must be credentialed. Brain death assessment should not begin until at least 24 hours after a brain injury capable of causing brain death. […] Examination includes assessment of pupil reactivity, assessment of oculovestibular, oculocephalic, and corneal reflexes, and apnea testing. […] Sometimes EEG or tests of brain perfusion are used to confirm absence of brain activity or brain blood flow and thus provide additional evidence to family members, but these tests are not usually required. […] The diagnosis of brain death is equivalent to the persons death. No further treatment can prevent death. […] After brain death is confirmed, all supporting cardiac and respiratory treatments are ended. Cessation of ventilatory support results in terminal arrhythmias.

• #121 Difficulties in Defining and Detecting Brain Death – Knowledge Base – Justpoint

  https://justpoint.com/knowledge-base/difficulties-in-defining-and-detecting-brain-death/

  For brain death testing to be effective, the guidelines must be followed. […] This is precisely why brain death testing is important. Lack of compliance with the Brain Death Guidelines can lead to inaccurate determination of death. […] The three most significant clinical signs of brain death are irreversible and unresponsive convulsions and the absence of brain stem reflexes. […] If you or your loved one fall into the categories listed above, it is advisable to see a brain death misdiagnosis immediately. […] Brain death (BD) should be the ultimate clinical expression of a brain catastrophe characterized by a complete and irreversible neurological stoppage, recognized by irreversible coma, absent brainstem reflexes, and apnea. […] The sign of such loss of brain functions, that is to say, BD diagnosis, are thoroughly reviewed.

• #122

  https://link.springer.com/article/10.1007/s44202-024-00183-w

  However, without clarification of its purpose and what it would entail, it left some family members further confused. […] Families that were not aware of BSD testing were negatively impacted by additional confusion, stress and grief. […] Given the families unique experience of grief, and the apparent confusion and uncertainty surrounding official announcement of BSD, families in this situation require specific grief support to help navigate them throughout this incredibly difficult time. […] This review highlights the psychological impact of a relative’s diagnosis of brain stem death (BSD) on families.

• #123

  https://journals.lww.com/neur/fulltext/2018/66020/brain_death_revisited.5.aspx

  The exact incidence of brain death is not known. […] Brain death is usually a result of severe head injury, aneurysmal subarachnoid hemorrhage, and intracerebral hemorrhage. […] Variability in documentation of brain death has been reported. […] The process implies that once a person is brain dead, it is unethical to continue treatment. […] In India, there is no legal definition of death. […] The declaration of brain death must be recorded in the medical notes with the date and time. […] Once an unequivocal diagnosis of brain death has been made, most medical and legal authorities agree that continuing treatment is not in the interest of the patient or is ethically permissible. […] Brain death has created a new class of dead people that does not conform to the society’s expectations of normal death and dying. […] It is imperative that all neurosurgeons and neurologists fully understand the intricacies of brain death so that they can discuss in detail with the family, the implications of continuing treatment and its repercussions.

• #124 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  In practice, diagnosis of BD/DNC is essential to organ transplantation, particularly cardiac, in that brain dead donors are the only accepted source for cardiac transplant in the United States. However, importantly, declaration of BD/DNC is an important and separate medical diagnosis that should be made independent of the need for organ transplantation. […] The first and most widely accepted is the whole brain formulation which asserts that brain death is equivalent to catastrophic injury to all the major structures of the brain including the hemispheres, diencephalon, brainstem, and cerebellum. In this view, confirmation of complete and permanent damage to the whole brain should be confirmed before BD/DNC is ultimately declared. […] The clinical determination of BD/DNC is detailed and can be daunting even to experienced critical care providers and neurologists. Correct diagnosis is of utmost importance, and the minimum clinical criteria and examination involves many steps.

• #125 Inconsistency in Brain Death Determination Should Not Be Tolerated | Journal of Ethics | American Medical Association

  https://journalofethics.ama-assn.org/article/inconsistency-brain-death-determination-should-not-be-tolerated/2020-12

  The variability found in the 2008 study prompted an update to the AAN practice parameters in 2010 in hopes of bringing about more uniformity in brain death determinationor at least in the protocols for such. […] A follow-up study in 2016 reviewed 492 US hospital policies on brain death declaration. […] Notably, this paper found that only 43.1% of policies specifically required an attending physician to make the diagnosis of brain death. […] Variability in the diagnosis of brain death has the potential to lead to misdiagnosis. […] If the medical profession cannot achieve rigorous, disciplined brain death testing in accordance with accepted guidelines for the determination of brain death on a national scale, confusion and doubt may ensue, leading to erosion of public trust. […] Efforts are underway to outline the differences that exist in brain death determination both in the United States and worldwide and to develop clearer and more unified practice parameters to ensure correct determination as close to 100% of the time as possible. […] Ensuring that proper determination of brain death is occurring will require in-depth and meticulous efforts by hospitals.

• #126

  https://journals.lww.com/neur/fulltext/2018/66020/brain_death_revisited.5.aspx

  The exact incidence of brain death is not known. […] Brain death is usually a result of severe head injury, aneurysmal subarachnoid hemorrhage, and intracerebral hemorrhage. […] Variability in documentation of brain death has been reported. […] The process implies that once a person is brain dead, it is unethical to continue treatment. […] In India, there is no legal definition of death. […] The declaration of brain death must be recorded in the medical notes with the date and time. […] Once an unequivocal diagnosis of brain death has been made, most medical and legal authorities agree that continuing treatment is not in the interest of the patient or is ethically permissible. […] Brain death has created a new class of dead people that does not conform to the society’s expectations of normal death and dying. […] It is imperative that all neurosurgeons and neurologists fully understand the intricacies of brain death so that they can discuss in detail with the family, the implications of continuing treatment and its repercussions.

• #127 Brain death: a clinical overview | Journal of Intensive Care | Full Text

  https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00609-4

  The exact extent of the effect of these confounders is unclear for the individual patient, given variation in target temperature, medication use and variable evidence of end-organ injury. […] In conclusion, the concept of brain death has grown, been refined, and increasingly accepted by the scientific community and the public since its original conception in the 1950s.

• #128 Brain Death: What It Is, Stages & Criteria

  https://my.clevelandclinic.org/health/diseases/brain-death

  Healthcare providers with special training in brain death do several tests. They may do tests more than once to confirm their initial diagnosis. […] If you have a catastrophic brain injury, you cant breathe on your own and rely on mechanical ventilation (ventilators). In an apnea test, providers briefly stop ventilator support to see if you take a breath on your own. […] First, your healthcare providers will share and explain test results with your family, including that a brain death diagnosis means death. […] No, people dont recover from brain death. Healthcare providers follow strict guidelines about assessing and testing for potential brain death. If tests indicate brain death, the person is clinically dead. […] No, you cant because you may not be able to prevent any of the serious illnesses or injuries that lead to brain death. In some cases, immediate medical care may keep brain death from happening if you have a serious illness or an injury that affects your brain. […] Brain death is different from the way we usually die. For most of us, death is when our physical body stops working. […] Providers who diagnose brain death understand that. Theyll always take time to explain the careful steps they take before concluding someone is brain dead.

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