The concept of brain death developed because ventilators and drugs can perpetuate cardiopulmonary and other body functions despite complete cessation of all cerebral activity. The concept that brain death (ie, total cessation of integrated brain function, especially that of the brain stem) constitutes a person’s death has been accepted legally and culturally in most of the world.
Diagnosis of Brain Death
Serial determination of clinical criteria
Apnea testing
Sometimes electroencephalography (EEG), brain vascular imaging, or both
For a physician to declare brain death, a known structural or metabolic cause of brain damage must be present, and use of potentially anesthetizing or paralyzing drugs, especially self-administered, must be excluded.
If hypothermia is present, a core temperature < 35° C must be increased slowly to > 36° C, and if status epilepticus is suspected, EEG should be done. In adults, after all complicating medical conditions have been excluded and a comprehensive neurologic examination with the required testing has been done, brain death can be confirmed. Some states advise clinicians to do two separate examinations separated by at least 48 hours in children; this approach is not consistently recommended or required for adult patients (see table Guidelines for Determining Brain Death (in Patients > 1 Year) Guidelines for Determining Brain Death (in Patients > 1 Year*)† 
).
Examination includes
Assessment of pupil reactivity
Assessment of oculovestibular, oculocephalic, and corneal reflexes
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. They are indicated when apnea testing is not hemodynamically tolerated and when only one neurologic examination is desirable (eg, to expedite organ procurement for transplantation).
Prognosis for Brain Death
The diagnosis of brain death is equivalent to the person’s 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. Spinal motor reflexes may occur during terminal apnea; they include arching of the back, neck turning, stiffening of the legs, and upper extremity flexion (the so-called Lazarus sign). Family members who wish to be present when the ventilator is shut off need to be warned of such reflex movements.
