Dr Pamela Prince Pyle

Brain Death Criteria

A child has a traumatic brain injury caused by a stray bullet. Parents clutch the child with an awareness of warmth that will soon fade away. An entry and exit wound quickly assessed by paramedics and reported to receiving trauma center. A solemn response is heard from a disembodied voice in return. It is the exchange of knowing the fragility of life.

Initial assessment pointed to the likelihood of impending brain death. Doctors give prognoses based on medical probabilities and intuition gained from experience. Until certain criteria are met, nothing can be stated with absolute certainty. Thus, it was the correct decision to have a painful discussion about potential organ donation with a grieving family. Time is of the essence. In the midst of unimaginable grief, a family choose life for others as they expect to lose life themselves. 

Yet, what happened that day was beyond explanation. Some wonder if statistical abnormality, or a miracle? 

All the initial assessments and intuitions proved to be wrong. Breath begins driving machine rather than machine driving breath. Such glimmers of hope would not and could not have been if she were medically brain dead. Those who meet the strict criteria for brain death show no such signs. 

Her case reveals while there is consensus in the medical community about the criteria for brain death, there is not always consistency in how these criteria are assessed and applied in different real-life situations. Therefore, we hear stories on a semi-regular basis about patients being declared dead only to revive in the morgue, or accounts of patients suddenly emerging from comas after having spent years in what the experts had deemed a hopeless vegetative state. 

We do not know when a stray bullet or a car accident or a fall through the ice will invite these questions. Therefore, wisdom becomes more important than knowledge. Keep the information below as a source of knowledge and wisdom and hope that you never need it.

  • Familiarize yourself with the accepted medical criteria for brain death.
  • Prerequisites
    • Clinical or neuroimaging evidence of an acute central nervous system (CNS) catastrophe (e.g., traumatic brain injury, subarachnoid hemorrhage)
    • Exclusion of complicating medical conditions that may confound clinical assessment (no severe electrolyte, acid-base, endocrine, or circulatory [i.e., shock] disturbance)
    • No drug intoxication or poisoning, including any sedative drug administered in hospital, which may confound the clinical assessment
    • Core temperature >36°C (97°F)
    • Systolic blood pressure >100 mmHg; vasopressors may be required
  • Examination Findings
  • Coma
  • Absent brain-originating motor response, including response to pain stimulus above the neck or other brain-originating movements (e.g., seizures, decerebrate or decorticate posturing)
  • Absent pupillary light reflex: pupils are mid-position (3.5 to 4 mm)
  • Absent corneal reflexes
  • Absent oculocephalic (doll’s eyes) and oculovestibular reflexes (caloric responses)
  • Absent jaw jerk
  • Observation Period
  • At least 6 hours; longer time periods recommended in children and for certain conditions such as after cardiac arrest
  • Seek multiple medical opinions before drawing any definitive conclusions or making any decisions. Consult all available end-of-life specialists, especially those in the fields of brain trauma (intensivists, neurologists, and pulmonologists). If I had a family member in this situation, I would want any examiner to be familiar with the 2010 American Academy of Neurology (AAN) Criteria for adults and the 2011 AAN Criteria for pediatrics. If your doctor is not, it is your right as a family member or healthcare proxy to request one who is. 
  • Insist that all necessary examinations (neurologic and apnea tests, etc.) be performed and all recommended observation periods be followed. 
  • Know that the clinician determining brain death should not be the attending physician and should not be a member of any organ transplant team. 
  • Understand that once a patient is declared brain dead, that patient is no longer legally living. Brain death is death. This has been determined by Part 2 of the Uniform Determination of Death Act (UDDA). This “extends the common law basis for determining death—total failure of the cardiorespiratory system…to include the new procedures for determination of death based upon irreversible loss of all brain functions.” 

 Young, G. B. (2021, April 21). Diagnosis of Brain Death. UpToDate. Retrieved February 20, 2022, from https://www.uptodate.com/contents/diagnosis-of-brain-death#H2 

 Wijdicks EF, Varelas PN, Gronseth GS, et al.” Evidence-based guideline update:  Determining Brain Death in Adults:  Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010; 74:1911. 

  Nakagawa T, Ashwal S, Mathur M, et. Al.” Guidelines for the Determination of Brain Death in Infants and Children:  An Update of the 1987 Task Force Recommendations; From the American Academy of Pediatrics Clinical Report; Pediatrics Sep 011 Vol 128/Issue 3

 Nakagawa T, Ashwal S, Mathur M, et. Al.” Guidelines for the Determination of Brain Death in Infants and Children:  An Update of the 1987 Task Force Recommendations; From the American Academy of Pediatrics Clinical Report; Pediatrics Sep 011 Vol 128/Issue 3

 The Uniform Determination of Death Act, retrieved 19 June; http://www.law.upenn.edu/bil/archives/ulc/fnact999/1980s/udda.htm

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