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Brain Death

by Kenneth Maiese, MD

Brain death is the permanent loss of brain activity. As a result, people cannot breathe or maintain other vital functions on their own, and they permanently lose all awareness and capacity for thought.

Brain death means that the brain stops functioning. People do not respond to any stimuli. No treatment can help, and once the diagnosis is confirmed, a person is considered legally dead.

In the past, the idea of brain death was irrelevant because when the brain died, so did the rest of the body. That is, the person stopped breathing, and the heart stopped beating. However now, artificial means (such as ventilators and drugs) can temporarily maintain breathing and the heart’s beating even when all brain activity stops. But eventually, even with help from artificial means, all the body's organs stop working. Nothing can keep the heart beating indefinitely once brain death occurs.

Diagnosis

There are specific criteria for diagnosing brain death. Doctors identify some of them during the physical examination:

  • The person does not grimace, move, or otherwise react when doctors test specific responses and reflexes (such as the gag reflex, triggered by touching the back of the throat).

  • The eyes do not react to light.

  • The person makes no attempt to breathe.

Doctors also check certain other reflexes to confirm that the brain is not functioning. Doctors must also notify or attempt to notify the person's next of kin or a close friend.

In addition, doctors cannot diagnose brain death until they have checked for and corrected all treatable problems that could slow brain function and could thus be misdiagnosed as brain death. These problems include a very low body temperature, very low blood pressure, very high or very low levels of certain substances (such as sugar and sodium) in the blood, overdose of a sedative, and use of certain toxic drugs.

Doctors typically recheck the criteria 6 to 24 hours later to confirm the person's lack of response.

After confirming twice that the brain is not functioning and after checking for and correcting any problems present, doctors diagnose brain death. No additional testing is needed.

Occasionally, doctors use certain diagnostic tests to immediately confirm brain death. For these tests, rechecking results after 6 to 24 hours is not required. The tests are typically done to make organ donation possible—for example, after catastrophic head injuries (as may occur in car crashes). Otherwise, these tests are usually not needed. The tests include

Imaging tests include angiography, CT angiography, single photon emission computed tomography (SPECT—which uses a radioactive molecule called a radionuclide to produce images of blood flow), and transcranial Doppler ultrasonography.

Prognosis

No one who meets the criteria for brain death recovers. After brain death is confirmed, all life support is stopped. Family members may wish to be with the person at this time. They need to be told that one or more limbs may move when breathing assistance is ended or that the person may even sit up. These movements result from spinal reflex muscle contractions and do not mean the person is not really brain dead.