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  • Print publication year: 2008
  • Online publication date: October 2009

13 - Brain death


Mr. L is a 35-year-old man who has a sudden, excruciating headache and collapses in his chair at dinner. At the emergency department, a CT scan reveals a subarachnoid hemorrhage. Mr. L is admitted to the intensive care unit for monitoring and supportive measures aimed at controlling the intracranial pressure. The next morning he is noted to be unresponsive, with non-reactive, mid-position pupils.

A 3½-year-old boy, M, is playing near the backyard pool under supervision of his babysitter. The caretaker goes into the house to answer the telephone. Upon returning, she discovers the child face down in the pool. The paramedic team arrives and finds the child's vital signs are absent. Basic life support is started, and the boy is taken to the hospital. He is resuscitated with intubation, ventilation, and intravenous epinephrine injection. The minimum documented duration of absent vital signs is 30 minutes. He is comatose and unresponsive, with spontaneous breathing, reactive pupils and intermittent generalized seizures.

What is brain death?

Medicine and society continue to struggle thoughtfully with the definition of death, particularly with the progression of sophisticated life-support systems that challenge traditional concepts. The questions of when a disease is irreversible, when further treatment is ineffective, or when death has occurred are of great consequence. These questions are independent of, and galvanized by, the practice of organ donation.

Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death (1968). A definition of irreversible coma. JAMA 205: 337–40.
American Academy of Neurology (1995). Practice parameters for determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 45: 1012–14.
Bernat, J. L. (2006). Are organ donors after cardiac death really dead?J Clin Ethics 17: 122–32.
Canadian Council for Donation and Transplantation (2005). Public Survey. Ottawa: Canadian Council for Donation and Transplantation (
Capron, A. (1995). Legal issues in pronouncing death. In Encyclopedia of Bioethics, revised edn, ed. Reich, W. T.. New York: Simon and Schuster Macmillan, pp. 534–9.
Dosemeci, L., Cengiz, M., Yilmaz, M., and Ramazanoglu, A. (2004). Frequency of spinal reflex movements in brain-dead patients. Transplant Proc 36: 17.
Gervais, K. G. (1995). Death, definition and determination: philosophical and theological perspectives. In Encyclopedia of bioethics, revised edn, ed. Reich, W. T.. New York: Simon and Schuster Macmillan, pp. 540–8.
Hornby, K., Shemie, S. D., Teitelbaum, J., and Doig, C. (2006). Variability of hospital based brain death guidelines in Canada. Can J Anes 53: 613–19.
Lagiewska, B., Pacholczyk, M., Szostek, M., Walaszewski, J., and Rowinski, W. (1996). Hemodynamic and metabolic disturbances observed in brain dead organ donors. Transplant Proc 28: 165–6.
Medical Consultants on the Diagnosis of Death to the President's Commission (1981). Guidelines for the determination of death. JAMA 246: 2184–5.
Mollaret, P. and Goulon, M. (1959). Le coma dépassé. Rev Neurol (Paris) 101: 3–15.
Olick, R. S. (1991). Brain death, religious freedom, and public policy: New Jersey's landmark legislative initiative. Kennedy Inst Ethics J 1: 275–92.
Pallis, C. and Harley, D. H. (1996). ABC of Brainstem Death, 2nd edn. London: BMJ Publishing, pp. 8–12.
Powner, D. J. and Bernstein, I. M. (2003). Extended somatic support for pregnant women after brain death. Crit Care Med 31: 1241–9.
Powner, D. J., Hernandez, M., and Rives, T. E. (2004). Variability among hospital policies for determining brain death in adults. Crit Care Med 31: 1284–88.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1981a). Defining Death: A Report on the Medical, Legal and Ethical Issues in the Determination of Death. Washington, DC: The President's Commission.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1981b). Defining death. JAMA 246: 2184–6.
Royal College of Physicians Working Party (1995). Criteria for the diagnosis of brain stem death. J R Coll Physicians Lond 29: 381–2.
Saposnik, G., Bueri, J. A., Maurino, J., Saizar, R., and Garretto, N. S. (2000). Spontaneous and reflex movements in brain death. Neurology 54: 221–3.
Shemie, S. D., Doig, C., Dickens, B., et al. (2006). Severe brain injury to neurological determination of death: Canadian forum recommendations. CMAJ 174: S1–12.
Sperling, D. (2006). Management of Post-mortem Pregnancy: Legal and Philosophical Aspects. Aldershot: Ashgate.
Task Force for the Determination of Brain Death in Children (1987). Guidelines for the determination of brain death in children. Arch Neurol 44: 587–8.
Taylor, R. M. (1997). Reexamining the definition and criteria of death. Semin Neurol 17: 265–70.
Truog, R. D. and Robinson, W. M. (2003). Role of brain death and the dead-donor rule in the ethics of organ transplantation. Crit Care Med 31: 2391–6.
Wertheimer, P., Jouvet, M., and Descotes, J. (1959). A propos du diagnostic de la mort du système nerveux dans les comas avec arrêt respiratoire traités par respiration artificielle. Presse Med 67: 87–8.
Wijdicks, E. F. M. (2002). Brain death worldwide: accepted fact but no global consensus in diagnostic criteria. Neurology 58: 20–5.
Young, B., Shemie, S. D., Doig, C., and Teitelbaum, J. (2006). Brief review: the role of ancillary tests in the neurological determination of death. Can J Anes 53: 620–7.