Brain Death Guidlines

Most organs come from donors that have died due to a neurological injury and have been declared brain dead. (Tissues and eyes can be recovered from patients who have been declared dead by either cardiac or brain death criteria). Brain death is irreversible and is death.

Frequently Asked Questions About Brain Death

Q: How does a physician determine if a person is brain dead?
A: A physician performs a series of tests to determine if brain death has occurred. These may include testing the person’s ability to breathe, testing reflexes, reactions to bright light and pain, and tests of activity in the brain. The doctor knows the person is dead when he or she:

• Cannot breathe without a machine,
• Has no pupil reaction to bright light, and
• Has no response to pain

Q: What does brain death mean?
A: When someone is brain dead, it means the person has died. It means there is no blood flow or oxygen to their brain and that their brain is no longer functioning in any capacity and never will again. The other organs, such as the heart, kidneys, or liver, may not have died yet because they may be able to function on mechanical support for a limited amount of time. Unless damaged by injury or disease, these vital organs may be used by another individual through an organ transplant.

Q: I have always understood that when a person dies, the heart stops beating. If a person is brain dead, why does the heart continue to beat?
A: The heart has its own natural pacemaker. It can work without receiving messages from the brain. As long as the heart has oxygen, it can continue to beat for a short time. Therefore, the brain can be dead and the heart continues to beat.

Q: What part does medication play in the body of a person who is brain dead?
A: Medications are usually continued after a person is declared brain dead if they are going to be an organ donor. These medications help keep the blood pressure and the heart rate under control, and some reduce swelling in the brain.

Q: Would removing the respiratory support equipment be the same as causing the death of a person or not giving him or her all possible chances?
A: Once a person is brain dead, he or she is dead. The brain will never recover. Since the person is already dead, you cannot cause death by removing respiratory support. The respiratory support equipment only provides oxygen, which keeps the heart beating. This gives the appearance that your family member is living.

Q: What is the recorded time of death for a brain dead patient…when the patient is declared brain dead or when the heart actually stops beating?
A: The recorded time of death is when the physician actually pronounces the patient dead. This is true, no matter how the person dies. Medically and legally, the official time of death is when the physician declares death, using either brain or cardiac criteria.

Q: Can the body of a person who is brain dead start to deteriorate even if the person is still on mechanical support?
A: Yes. Many organs begin to fail soon after brain death.

Q: Are there any documented cases when a person was declared brain dead and later restored to a normal life?
A: No. Brain death is permanent. There is no way to restore life to someone who is brain dead. Stories of individuals coming out of a “long deep sleep” are about people in a coma, not people who have suffered brain death.

Brain Death Guidelines

Brain death is the absence of clinical brain function when the proximate cause is known and irreversible.

Three cardinal findings of brain death

1. Unresponsiveness: no cerebral motor response to pain in all extremities (Nail-bed pressure and supraorbital pressure)
2. Absence of brain stem reflexes: Check for pupil response, ocular movement, facial motor response, pharyngeal and tracheal reflexes
3. Apnea: apnea test procedure

• Place on 100% oxygen and normalize CO2 to >35 mmHg
• Normalize core temperature to 36.5C or greater, systolic B/P 90 mmHg or greater
• Place on 100% T-piece (or 6 liters 02 cannula in the of ET tube)
• Observe for respiratory efforts
• Draw ABG at 5, 8 and 10 minutes, if needed until the PCO2 reaches 60 mmHg or greater
• The patient is considered apneic if there is no spontaneous respiratory effort after 10 minutes of after 3 minutes with a PCO2 of 60 or greater.

Pitfalls in the Diagnosis of Brain Death

a. Cervical spine fracture
b. Severe facial trauma
c. Preexisting pupillary abnormalities
d. Toxic levels of any central nervous system depressant
e. Presence of neuromuscular blocking agent
f. Severe electrolyte, acid-base or endocrine imbalance
g. Sleep apnea or chronic CO2 retention

Confirmatory Testing

In case of presence of any of the above pitfalls confirmatory testing such as angiography, transcranial Doppler ultrasonography, Technetium 99m brain scan, or EEG (not suitable for D. or F.) may be utilized to confirm brain death.

Documentation Needed for Brain Death

Documentation of brain death shall include the following entries:

1. Document the pronouncement of brain death
2. Document each diagnostic test performed as part of this procedure
3. Time and date of declaration of death

Reference: Practice Parameters for Determining Brain Death in Adults – Report of the Quality Standards Subcommittee of the American Academy of Neurology, Eelco F. M. Wijdicks, MD, 11/94.