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Brain death is the irreversible cessation of all functions of the entire brain, including the brainstem. It is both a legal and medical definition of death in most countries and serves as the foundation for ethical organ donation.

The clinical diagnosis of brain death requires:

• Irreversible cause of coma established (e.g., TBI, hemorrhage, anoxia)
• Absence of confounding factors:
  1. Hypothermia (core temperature > 36°C)
  2. CNS depressants, sedatives, paralytics
  3. Severe metabolic or endocrine disturbances

• Complete neurological examination, including:
  1. No response to painful stimuli
  2. Absence of brainstem reflexes:
     1. Pupillary light reflex
     2. Corneal reflex
     3. Oculocephalic reflex (“doll’s eyes”)
     4. Oculovestibular reflex (cold calorics)
     5. Gag and cough reflexes
  3. Apnea test: No spontaneous respiration despite a rise in PaCO₂ above 60 mmHg or 20 mmHg over baseline

see Ancillary Confirmatory Tests for Brain Death

Depends on age and national regulation:

• Adults: some protocols require two independent exams, others accept one if criteria are unequivocally met
• In cases of uncertain prognosis (e.g., anoxia, hypothermia), a longer observation period and/or ancillary testing is recommended

• Must follow national standards (e.g., AAN [USA], ONT [Spain], AoMRC [UK])
• Documentation must include:
  1. Established irreversible coma
  2. Absence of brainstem reflexes
  3. Apnea test results
  4. Time of death declaration

Typically:

• Two licensed, independent physicians
• Must not be involved in transplant team
• Often includes neurologists, intensivists, or neurosurgeons

• Spinal movements postmortem: e.g., facial twitching, finger tremors, or the “Lazarus sign” (sitting up) – all mediated by the spinal cord
• False appearance of breathing: Ventilators may auto-trigger due to arterial pulsations or mechanical artifacts, not genuine respiration

Refers to the act or process of determining that a person is brain dead based on clinical and/or ancillary findings.

Examples:

• “The brain death diagnosis must comply with legal protocols.”
• “Diagnosis was confirmed following a complete exam and apnea testing.”

Refers to the clinical standards or protocol elements used to make the diagnosis.

Examples:

• “The patient fulfilled all brain death criteria.”
• “Protocols define the minimum criteria to establish brain death.”

While related, these terms describe different stages:

Describes the step-by-step clinical protocol:

• Neurological exam
• Apnea test
• Ancillary testing (if needed)
• Observation and legal documentation

Example: “Brain death determination includes all required confirmatory steps.”

Refers to the final legal declaration that the patient is dead based on the determination process.

Example: “Diagnosis of brain death was made at 08:22 by the attending physician.”

* Neurology. 2010 Jun 8;74(23):1911. doi:10.1212/WNL.0b013e3181e242a8

→ https://n.neurology.org/content/74/23/1911

• Brain Death Criteria
• Brain Death Determination
• Apnea Test
• Ancillary Confirmatory Tests for Brain Death
• The World Brain Death Project