SYNONYMS: Brain death, death by neurologic criteria, DNC, brain stem death, irreversible coma, whole brain death, neurological death, cerebral death, brain death determination, brain death testing, brain death evaluation, brain death protocol, brain death exam, BD evaluation, BD determination, BD testing, neurologic determination of death, NDD
SCOPE: Comprehensive evaluation and determination of brain death (death by neurologic criteria) in adults per AAN 2023 updated practice guideline. Covers prerequisites for testing, clinical examination (coma and brainstem reflex testing), apnea test protocol, ancillary testing indications and options, documentation requirements, family communication, legal/ethical considerations, organ procurement organization (OPO) notification, and donor management protocols. Excludes pediatric brain death determination (different age-specific criteria per AAP/CNS/SCCM guidelines), determination in neonates, and determination in patients on ECMO (requires institutional-specific protocols).
KEY DEFINITIONS:
Brain Death / Death by Neurologic Criteria (DNC): Irreversible cessation of all functions of the entire brain, including the brainstem (Uniform Determination of Death Act, 1981)
Clinical Examination: Assessment of coma (absence of consciousness) and brainstem areflexia (absence of all brainstem reflexes)
Apnea Test: Confirmatory test for absence of respiratory drive from the brainstem
Ancillary Test: Supplementary diagnostic test used when clinical examination or apnea test cannot be completed, or when confounders cannot be excluded
Confounder: Any condition that may mimic brain death findings and must be excluded before proceeding with determination
CRITICAL FRAMEWORK:
Brain death determination is a clinical diagnosis. The clinical examination (including apnea testing) is the gold standard. Ancillary tests are supplementary and used only when clinical testing is incomplete or confounders cannot be excluded.
LEGAL NOTE: Brain death determination requirements vary by state and institution. Clinicians must be familiar with local laws, institutional policies, and specific requirements regarding:
Number of examinations required (1 vs. 2)
Time interval between examinations
Qualifications of examining physicians
Mandatory ancillary testing requirements
Religious/conscientious objection accommodations (e.g., New Jersey)
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
Gold standard ancillary test; when clinical testing cannot be completed
Absence of intracerebral filling at the level of the carotid bifurcation or circle of Willis; external carotid filling may be present; delayed filling up to the proximal segments does NOT exclude brain death if no intracerebral filling
Contrast allergy; hemodynamic instability (relative — may require vasopressor support during procedure); renal impairment (acceptable if donation anticipated)
Radionuclide cerebral perfusion study; widely available; high sensitivity and specificity
"Hollow skull" phenomenon: Complete absence of intracranial tracer uptake; no perfusion to cerebral hemispheres or brainstem; scalp and facial blood flow present (external carotid territory)
None absolute; limited availability of isotope in some centers; patient must be transported to nuclear medicine (logistically challenging for unstable patients)
-
STAT
-
STAT
Technetium-99m pertechnetate cerebral blood flow study (CPT 78610)
Alternative radionuclide study; more widely available than HMPAO
Absence of intracranial blood flow on anterior and lateral views; "empty light bulb" sign; less sensitive for posterior fossa/brainstem than HMPAO-SPECT
Same as above; pertechnetate less specific than HMPAO for posterior fossa
-
STAT
-
STAT
EEG (electrocerebral inactivity) (CPT 95816)
Demonstrates electrocerebral inactivity (ECI); 16+ channel recording per ACNS guidelines
Electrocerebral inactivity (ECI): No electrical activity >2 μV over 30 minutes of recording; must use minimum 16 channels; interelectrode distances ≥10 cm; impedances 100-10,000 ohms; sensitivity 2 μV/mm; high-frequency filter ≤70 Hz; low-frequency filter ≤1 Hz
Does NOT assess brainstem function directly; can be confounded by sedatives, hypothermia, metabolic derangement; artifact from ICU environment; should NOT be sole ancillary test if brainstem assessment incomplete
-
STAT
-
STAT
CT angiography (CTA) — brain death protocol (CPT 70496)
Non-invasive vascular study; increasingly used; AAN 2023 acknowledges but notes variable sensitivity
Absence of opacification of cortical segments of MCA, cortical segments of ACA, and internal cerebral veins (7-point CTA scoring system); some protocols assess 4-point or 10-point systems
Contrast allergy; renal impairment; false negatives possible (sensitivity 85-95% depending on protocol and timing of image acquisition)
Non-invasive bedside study; can be repeated; useful for trending toward brain death
Cerebral circulatory arrest pattern: Reverberating (oscillating) flow pattern; small systolic spikes (<50 cm/s duration <200 ms); absent diastolic flow → absent flow in all assessed vessels; must assess bilateral MCA AND basilar artery
Operator-dependent; 10-15% of patients have inadequate temporal windows; not universally accepted as sole ancillary test; AAN 2023: acceptable if institutional protocol supports; cannot assess in presence of craniectomy defects
Assesses brainstem and cortical conduction; bilateral median nerve stimulation
Bilateral absence of N20 cortical response with preserved Erb point potential (peripheral nerve intact, cortex non-functional); does NOT assess brainstem directly
Peripheral neuropathy may confound; requires intact peripheral nerve; not widely available for acute bedside use
3A. Confounder Management (Prerequisites Before Brain Death Examination)¶
Treatment
Route
Indication
Dosing
Contraindications
Monitoring
ED
HOSP
OPD
ICU
Active rewarming
External/Internal
Hypothermia correction; core temperature must be ≥36°C before examination
Target ≥36°C :: External/Internal :: continuous :: Warm IV fluids 40-42°C; forced air warming blankets; warmed humidified ventilator gases; if severe hypothermia: peritoneal lavage, bladder irrigation, or extracorporeal rewarming; must achieve target before proceeding
None; must achieve target before proceeding
Core temperature continuous monitoring (esophageal, rectal, or bladder probe); target ≥36°C
STAT
STAT
-
STAT
Desmopressin (DDAVP)
IV
Diabetes insipidus treatment (common in brain death due to pituitary failure); maintain hemodynamic stability for valid examination
1-4 mcg :: IV :: q6-12h PRN :: 1-4 mcg IV q6-12h; titrate to urine output <200-300 mL/hr; may also give 10-20 mcg intranasally; onset IV: 15-30 min; adjust based on urine output and sodium
Volume resuscitation for hemodynamic stability; replace massive urine losses from DI; maintain adequate perfusion for valid examination
0.9% NaCl :: IV :: continuous :: Bolus 500-1000 mL for hypotension; maintenance 100-250 mL/hr; replace urine output mL-for-mL if DI present; avoid hypotonic fluids
Fluid overload; pulmonary edema (balance with organ preservation goals)
Vasopressor for hemodynamic support; neurogenic shock (loss of sympathetic tone) common in brain death; maintain MAP ≥60 mmHg for valid examination
0.1-0.5 mcg/kg/min :: IV :: continuous :: Start 0.05-0.1 mcg/kg/min; titrate to MAP ≥60 mmHg (or ≥70 for donor management); max 0.5 mcg/kg/min; consider adding vasopressin if escalating
Peripheral extravasation (central line required)
Continuous arterial BP monitoring; MAP target ≥60; assess for adequate organ perfusion; limit escalation if possible for donor management
STAT
STAT
-
STAT
Vasopressin
IV
Adjunct vasopressor; particularly useful in brain death (endogenous vasopressin deficiency from pituitary failure); hemodynamic support + DI treatment
0.01-0.04 units/min :: IV :: continuous :: Start 0.01 units/min; titrate to MAP ≥60 mmHg; max 0.04 units/min for vasopressor effect; also treats DI at higher doses; AAN/HRSA donor management: 1 unit IV bolus then 0.5-2.4 units/hr
High-dose may cause mesenteric ischemia; coronary vasoconstriction
Exclude metabolic confounders; sodium, glucose, pH, calcium must be within acceptable ranges
Per derangement :: IV :: PRN :: Correct sodium to 115-160 mEq/L range; glucose >54 mg/dL (D50 50 mL if needed); correct severe acidosis (NaHCO3 if pH <7.2); correct severe hypocalcemia (calcium gluconate 1-2 g IV); correct hypothyroidism
Overly rapid sodium correction (risk of osmotic demyelination — less relevant in brain death but important for organ preservation)
Serial electrolytes q2-4h; glucose q1-2h; ABG q4h; target physiologic ranges
Prevent hypoxia during apnea test; build oxygen reservoir
FiO2 1.0 :: Ventilator :: ≥10 min :: Pre-oxygenate with FiO2 1.0 (100% O2) for ≥10 minutes before disconnection; confirm PaO2 >200 mmHg on pre-apnea ABG
None
ABG after 10 min pre-oxygenation; SpO2 continuous; confirm PaO2 >200 mmHg
STAT
STAT
-
STAT
Step 2: Baseline ABG
Arterial
Establish PaCO2 baseline; must be 35-45 mmHg before starting apnea test
ABG draw :: Arterial :: once :: Draw ABG after pre-oxygenation; adjust ventilator to normalize PaCO2 if needed; if baseline PaCO2 chronically elevated (e.g., COPD), target must be ≥20 mmHg above chronic baseline AND ≥60 mmHg
If PaCO2 cannot be normalized to 35-45 (chronic hypercarbia), document chronic baseline and adjust targets accordingly
Apnea test initiation; remove external respiratory drive; observe for spontaneous respiratory effort
6-10 L/min O2 :: Intratracheal :: continuous :: Disconnect from ventilator; immediately place O2 cannula into trachea (or T-piece with CPAP at 5-10 cmH2O) delivering 6-10 L/min O2 at carina level; ensures oxygenation without ventilation
Severe ARDS with FiO2 >0.7 and PEEP >10 (may desaturate rapidly — consider ancillary test instead); hemodynamic instability (relative)
SpO2 continuous; arterial line continuous; direct observation for ANY respiratory movement (chest, abdomen)
STAT
STAT
-
STAT
Step 4: Observe for respiratory effort
Visual
Detect any spontaneous breathing; absence confirms apnea
8-10 min :: Visual :: once :: Observe 8-10 minutes (AAN 2023); watch for ANY chest or abdominal respiratory movements; look at proximal ETT for condensation/gas movement; if ANY respiratory effort observed → ABORT: patient is NOT brain dead
3C. Donor Management Protocol (After Brain Death Declaration — Organ Preservation)¶
Treatment
Route
Indication
Dosing
Contraindications
Monitoring
ED
HOSP
OPD
ICU
Vasopressin (donor management)
IV
Hemodynamic support and DI treatment; first-line vasopressor for brain-dead donors per UNOS/HRSA protocol
0.5-2.4 units/hr :: IV :: continuous :: HRSA protocol: 1 unit IV bolus then 0.5-2.4 units/hr; titrate to MAP ≥60 mmHg; also treats DI; preferred over catecholamines (less myocardial oxygen demand)
Mesenteric ischemia at high doses; coronary vasoconstriction
Hormone replacement therapy (HRT) for brain-dead donors; pituitary failure causes hypothyroidism; improves hemodynamic stability and organ function
20 mcg :: IV :: bolus then continuous :: HRSA protocol: 20 mcg IV bolus then 10 mcg/hr continuous infusion; alternative: T3 (liothyronine) 4 mcg IV bolus then 3 mcg/hr; improves cardiac output and donor hemodynamics
None in this context
TSH, free T4 q6-12h; hemodynamic response; cardiac function
Glycemic control during donor management; methylprednisolone and stress response cause hyperglycemia; tight glucose control improves organ preservation
1-10 units/hr :: IV :: continuous :: Regular insulin infusion; target blood glucose 120-180 mg/dL; start if BG >150 mg/dL; titrate per institutional insulin drip protocol; avoid hypoglycemia (<70 mg/dL)
Diabetes insipidus treatment; maintain euvolemia and sodium homeostasis for organ preservation; most brain-dead patients develop DI
1-4 mcg :: IV :: q6h PRN :: 1-4 mcg IV q6-12h PRN; titrate to urine output 0.5-3 mL/kg/hr; target sodium 135-155 mEq/L; may also give 10-20 mcg intranasally
Must be fully reversed before clinical examination; paralysis prevents assessment of motor and respiratory function
-
Active paralysis completely invalidates all clinical brain death testing
Train-of-four monitoring: must show 4/4 twitches before examination; sugammadex reversal for rocuronium/vecuronium if needed; wait for spontaneous clearance of cisatracurium
-
-
-
-
Atropine (diagnostic test — should NOT be administered as treatment)
-
Atropine is used as a diagnostic test during brain death examination (IV bolus → no heart rate increase confirms vagal nucleus non-function); NOT a treatment
-
Not used therapeutically in this context; used diagnostically: 1 mg IV → if NO heart rate increase >3% → confirms brainstem non-function
Document pre- and post-atropine heart rate; absence of response supports brain death
Notify attending physician and neurology/neurocritical care for brain death evaluation when clinical suspicion arises
STAT
STAT
-
STAT
Brain death determination requires qualified physician(s); AAN 2023: physician with training in brain death evaluation; most states require attending-level physician; some require neurologist/neurosurgeon
Verify institutional brain death policy and state law requirements before proceeding
STAT
STAT
-
STAT
Requirements vary: number of examinations (1 vs. 2); interval between exams (varies: 6h, 12h, 24h, or no minimum per AAN 2023); qualifications of examiners; mandatory ancillary testing; documentation forms
Contact Organ Procurement Organization (OPO) — REQUIRED by federal law when brain death is imminent or declared
STAT
STAT
-
STAT
Federal requirement (CMS Conditions of Participation): Hospitals must notify OPO of all imminent deaths (GCS 5 or less, ventilator-dependent); OPO determines donation suitability; OPO coordinates family approach for consent; do NOT approach family about donation without OPO involvement
Establish time of death as time of completion of brain death determination (final examination or ancillary test)
-
STAT
-
STAT
Time of death = time of completed clinical examination (or ancillary test); NOT the time of cardiac arrest or ventilator withdrawal; document precisely on death certificate
Ensure at least one independent qualified examiner for brain death determination
STAT
STAT
-
STAT
AAN 2023: Physician must be credentialed in brain death determination; most states: attending physician; some require neurologist, neurosurgeon, or intensivist; examiner must not be part of transplant team
Document all prerequisites, clinical findings, and apnea test results on institutional brain death determination form
-
STAT
-
STAT
Use standardized checklist/form; document: etiology, confounders excluded, core temp, drug clearance, each brainstem reflex result, apnea test results with ABG values, time of determination, examiner signature
Family meeting to explain prognosis, brain death concept, and planned evaluation process BEFORE beginning testing
URGENT
URGENT
-
URGENT
Use clear, direct language: "The brain has been severely and irreversibly damaged"; explain the difference between brain death and coma; avoid confusing terminology ("life support" when patient is dead); use interpreter services if needed
Provide family with explanation that brain death IS legal death in all 50 US states (with NJ religious exemption)
URGENT
URGENT
-
URGENT
Address common misconceptions: brain death ≠ coma, ≠ vegetative state, ≠ "pulling the plug"; the patient is dead; ventilator maintains organ function but the person has died; legal death with full legal death certificate
Social work and chaplain/spiritual care consultation for family support
URGENT
URGENT
-
URGENT
Grief counseling; cultural/religious sensitivity; some families need time to process (reasonable accommodation without indefinite ventilator use); address cultural differences in death acceptance; offer family presence during testing if appropriate per institutional policy
Palliative care consultation for family support and goals-of-care discussion if determination is delayed or contested
-
URGENT
-
URGENT
Particularly helpful when: family disputes brain death; religious objections (NJ exemption); cultural barriers; prolonged ICU course before determination; complex ethical situations
Communicate with OPO regarding family approach timing and strategy
-
STAT
-
STAT
OPO-trained requestors should approach family for organ donation; timing of approach (before or after declaration, per OPO protocol); physician should NOT be the one requesting organ donation (conflict of interest)
Provide family time with patient after brain death declaration and before organ recovery, if applicable
-
URGENT
-
URGENT
Allow family to say goodbye; arrange for religious/spiritual rituals if requested; coordinate with OPO for timing; if organ donation proceeding, ventilator continues until OR; if no donation, discuss timing of ventilator discontinuation
Complete institutional brain death determination checklist documenting all prerequisites and examination findings
-
STAT
-
STAT
Standardized documentation prevents legal challenges; include: etiology, confounders excluded (temp, drugs, metabolic), each brainstem reflex tested and result, apnea test results with ABG values, time of each examination, examiner credentials
Issue death certificate with time of death as moment of brain death declaration, NOT time of ventilator removal
-
STAT
-
STAT
Legal time of death = final brain death examination completion time; if two exams required, time of second exam; if ancillary test, time ancillary test interpreted; death certificate cause: underlying etiology (e.g., "Anoxic brain injury due to cardiac arrest")
Address religious/conscientious objections per state law (New Jersey Declaration of Death Act)
-
URGENT
-
URGENT
New Jersey: if family objects to brain death on religious grounds, physician must accommodate (patient remains legally alive on ventilator); no other state has this law; institutional ethics consultation recommended; reasonable accommodation in other states (varies by institution)
Ethics consultation if brain death determination is contested, delayed, or involves complex circumstances
-
URGENT
-
URGENT
Indications: family refuses to accept brain death; religious/cultural objections; medical uncertainty about confounders; disagreement between physicians; pregnant patient (may continue somatic support); medicolegal concerns
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SECTION B: SUPPORTING INFORMATION
═══════════════════════════════════════════════════════════════
Conditions That May Mimic Brain Death (Must Be Excluded)¶
Condition
Key Distinguishing Features
Tests to Differentiate
Severe hypothermia (<32°C)
History of exposure; core temperature <32°C; can cause fixed dilated pupils, absent reflexes, flat EEG; FULLY REVERSIBLE; "no one is dead until warm and dead"
Core temperature measurement; actively rewarm to ≥36°C before brain death examination; all clinical findings may normalize with rewarming
CNS depressant drug intoxication
History of overdose or recent sedative administration; barbiturates, benzodiazepines, opioids, propofol, alcohol; can mimic all brain death findings including flat EEG
Comprehensive toxicology screen; specific drug levels; wait ≥5 half-lives for clearance; if cannot wait, use ancillary testing (cerebral blood flow study NOT affected by drugs)
Severe metabolic derangement
Hepatic encephalopathy (ammonia >200); severe hyponatremia or hypernatremia; diabetic coma; severe uremia; hyperosmolar state
CMP; ammonia; osmolality; ABG; correct derangement and reassess; if uncorrectable, ancillary testing
Locked-in syndrome
Basilar artery occlusion/pontine stroke; patient is CONSCIOUS but appears unresponsive; preserved vertical eye movements and blinking; normal EEG
Ask patient to "look up" and "blink"; EEG shows normal alpha rhythm; MRI brainstem shows pontine lesion; brain death exam: pupils reactive, corneal reflex may be present
Intrathecal baclofen overdose can cause deep coma, areflexia, absent respiratory drive; REVERSIBLE
History of intrathecal baclofen pump; check pump function; CSF baclofen level; supportive care until clearance; EEG may show slowing but NOT electrocerebral inactivity; cerebral blood flow normal
Posterior fossa hemorrhage with brainstem compression
Acute cerebellar hemorrhage compressing brainstem; may present with absent brainstem reflexes; potentially surgically treatable
CT head: posterior fossa hemorrhage; neurosurgical evaluation for emergent decompression BEFORE declaring brain death; surgical evacuation may be life-saving
Severe hypothyroidism (myxedema coma)
Profound hypothermia, coma, hypoventilation, bradycardia; very slow reflexes may appear absent
TSH markedly elevated; free T4 very low; treat with IV levothyroxine and hydrocortisone; reassess after thyroid hormone replacement
Conditions Causing Irreversible Coma (NOT Brain Death)¶
Condition
Key Features
Brain Death Status
Persistent vegetative state (UWS)
Eyes open, sleep-wake cycles, no awareness; brainstem function INTACT
NOT brain death — brainstem reflexes present; breathing spontaneously
Minimally conscious state
Inconsistent but reproducible evidence of awareness; follows commands intermittently
NOT brain death — evidence of consciousness
Anencephaly
Congenital absence of cerebral hemispheres; brainstem present and functioning
NOT brain death — brainstem functions intact; different legal/ethical considerations
All patients undergoing brain death evaluation require ICU-level care; mechanical ventilation; continuous hemodynamic monitoring; arterial line; vasopressor support; hourly neuro checks; controlled environment for apnea testing
Continue ICU for organ donation
After brain death declaration with organ donation consent: continue ICU-level care for donor management (hemodynamic optimization, hormone replacement, organ preservation); OPO manages care; OR scheduling for organ recovery
Ventilator discontinuation
After brain death declaration WITHOUT organ donation: family notification → reasonable time for family to visit → ventilator discontinuation; patient is legally dead — ventilator removal is NOT "withdrawal of care"
Morgue/funeral home
After ventilator removal (non-donor) or after organ recovery (donor): standard post-mortem care; death certificate completed with time of brain death determination; autopsy per institutional/legal requirements
Delayed determination
If confounders cannot be excluded (e.g., recent sedative administration): continue ICU care; repeat evaluation after drug clearance (≥5 half-lives); consider ancillary testing if clearance uncertain or delayed
Contested brain death
If family contests: ethics consultation; social work; chaplain; legal counsel; reasonable accommodation; NJ religious exemption if applicable; continue ICU care during resolution
Transfer considerations
If institution lacks resources for ancillary testing: arrange transfer to facility with nuclear medicine, angiography, or neurophysiology capabilities; OPO may facilitate transfer
Established standardized clinical examination protocol; apnea test methodology; ancillary test recommendations; single examination sufficient if protocol followed
Updated DNC guidelines: minimum qualifications for examiners; checklist-based approach; core temperature ≥36°C; specific drug clearance guidance; expanded ancillary test options; legal/ethical framework
National Conference of Commissioners on Uniform State Laws
1981 (revised 2023)
Legal framework: death = irreversible cessation of circulatory/respiratory functions OR irreversible cessation of all brain functions including brainstem; adopted by all 50 states
No patient found to have different results on second brain death examination when confounders properly excluded in first examination
Supports AAN position that single examination is sufficient when properly performed; second examination is institutional/legal requirement, not clinical necessity
v1.1 (January 30, 2026)
- Standardized all treatment table dosing fields to use structured :: format across Sections 3A, 3B, 3C
- Added Route values for apnea test procedural steps (Section 3B) and mechanical ventilation (Section 3C)
- Renamed Section 4A header from "Essential Recommendations" to "Referrals & Consults" for cross-plan consistency
- Renamed Section 4B header from "Family Communication and Support" to "Patient/Family Instructions" for cross-plan consistency
- Renamed Section 4C header from "Legal and Documentation Requirements" to "Legal, Ethical & Documentation" for cross-plan consistency
- Improved "Active rewarming" dosing with structured format and Route designation
- Improved "Correction of metabolic derangements" dosing with specific agent doses (D50, NaHCO3, calcium gluconate)
- Improved "Goal-directed fluid therapy" dosing with structured rate and format
- Added structured dosing format to all 6 apnea test steps for clinical tool compatibility
- Checker validation: 50/60 → 56/60 (83% → 93%)
v1.0 (January 30, 2026)
- Initial template creation
- Comprehensive brain death evaluation protocol per AAN 2023 updated guidelines
- Full prerequisites, clinical examination, apnea test protocol
- Ancillary testing indications and options
- Donor management protocol (HRSA/UNOS hormone replacement therapy bundle)
- Family communication and legal/ethical framework
- Differential diagnosis of brain death mimics
- Documentation requirements and disposition criteria
APPENDIX A: Brain Death Clinical Examination Checklist¶
BRAIN DEATH / DEATH BY NEUROLOGIC CRITERIA — CLINICAL EXAMINATION
PREREQUISITES (ALL must be met before proceeding):
□ Known cause of coma established (imaging, clinical history)
□ Condition is irreversible (treatment options exhausted or not available)
□ Core temperature ≥36°C (96.8°F) — document: ____°C
□ Systolic BP ≥100 mmHg (or MAP ≥60 mmHg) — document: ____/____
□ No CNS depressant drugs at active levels (toxicology screen reviewed)
□ Drug screen results: ________________________
□ Last sedative/opioid given: _________ at _________
□ Drug levels (if applicable): ________________________
□ No neuromuscular blocking agents active (train-of-four 4/4 if given)
□ No severe electrolyte, acid-base, or endocrine derangement
□ Na: _____ Glucose: _____ pH: _____ Ca: _____
□ Not hypothermic (core temp ≥36°C confirmed)
CLINICAL EXAMINATION:
1. COMA
□ No eye opening to any stimulus (verbal, painful)
□ No motor response to central pain (nail bed, supraorbital, sternal)
□ Note: Spinal reflexes may be present and do NOT preclude brain death
(triple flexion, finger flexion, Lazarus sign are SPINAL reflexes)
2. BRAINSTEM REFLEXES — ALL must be ABSENT:
□ Pupillary light reflex — ABSENT bilaterally
□ Pupils: fixed, mid-position (4-9 mm) or dilated (>6 mm)
□ Direct light: No response R _____ L _____
□ Consensual light: No response R _____ L _____
□ Note: Round, oval, or irregular shape acceptable; mydriatic drops excluded
□ Corneal reflex — ABSENT bilaterally
□ Cotton wisp or saline drop applied to cornea directly
□ No blink response R _____ L _____
□ Oculocephalic reflex (Doll's eyes) — ABSENT
□ Rapid head turning side-to-side: Eyes remain midline (no movement)
□ Note: Do NOT perform if cervical spine injury suspected/uncleared
□ Oculovestibular reflex (Cold calorics) — ABSENT bilaterally
□ Head elevated 30°; inspect tympanic membrane (clear, no perforation)
□ 50 mL ice water irrigated into each ear canal
□ Observe 1 minute per ear; 5 minutes between ears
□ No eye deviation R _____ L _____
□ Gag reflex — ABSENT
□ Stimulate posterior pharynx with tongue depressor or suction catheter
□ No gag response _____
□ Cough reflex — ABSENT
□ Deep tracheal suctioning via ETT to carina
□ No cough response _____
□ Jaw reflex — ABSENT (optional per AAN 2023)
□ Atropine test — No heart rate increase (optional)
□ Atropine 1 mg IV → Heart rate change: ____
□ <3% increase = absent vagal response (consistent with brain death)
3. APNEA TEST
□ Pre-oxygenated with FiO2 1.0 x ≥10 min
□ Pre-test ABG: pH ____ PaCO2 ____ PaO2 ____
□ Ventilator disconnected; O2 catheter placed at carina (6-10 L/min)
□ Observed for ____ minutes (minimum 8-10 minutes)
□ No respiratory effort observed: □ TRUE □ FALSE
□ Post-test ABG: pH ____ PaCO2 ____ PaO2 ____
□ PaCO2 ≥60 mmHg: □ YES □ NO
□ PaCO2 rise ≥20 mmHg above baseline: □ YES □ NO
□ APNEA TEST RESULT: □ POSITIVE (absent drive) □ INCONCLUSIVE □ ABORTED
□ If aborted, reason: ________________________________
DETERMINATION:
□ Brain death / DNC confirmed
□ Time of death: ____:____ on ____/____/____
□ Examiner name: ________________________ MD/DO
□ Examiner credentials: ________________________
□ Second examiner (if required): ________________________
NOTIFICATIONS:
□ Family notified: Time ____:____
□ OPO notified: Time ____:____ Contact: ____________
□ Medical examiner/coroner notified (if applicable): Time ____:____
□ Attending physician notified: Time ____:____
APNEA TEST — COMMON PROBLEMS AND SOLUTIONS
PROBLEM: Patient desaturates (SpO2 <85%) during test
→ SOLUTION: Reconnect ventilator immediately
→ Ensure adequate pre-oxygenation (PaO2 >200 before disconnection)
→ Verify O2 flow rate at carina (6-10 L/min)
→ Consider T-piece with CPAP 5-10 cmH2O instead of open disconnection
→ If cannot maintain SpO2 >85% for 8-10 min: ANCILLARY TEST required
PROBLEM: Hemodynamic instability (MAP <60) during test
→ SOLUTION: Optimize vasopressors BEFORE test
→ Bolus vasopressin 1 unit IV before disconnection
→ Ensure adequate volume resuscitation
→ If unstable despite optimization: ANCILLARY TEST required
PROBLEM: Baseline PaCO2 elevated (chronic hypercarbia, e.g., COPD)
→ SOLUTION: Document patient's chronic PaCO2 baseline
→ Adjusted targets: PaCO2 must rise ≥20 mmHg above CHRONIC baseline
AND reach ≥60 mmHg absolute
→ May require longer observation period
→ AAN 2023: Acceptable to use chronic baseline as starting point
PROBLEM: PaCO2 target not reached after 8-10 minutes
→ SOLUTION: Continue observation up to 15 minutes if hemodynamically stable
→ Draw repeat ABG at 10 and 15 minutes
→ If still not reached: test is INCONCLUSIVE — need ancillary test
→ Note: CO2 typically rises 3-5 mmHg/min during apnea
PROBLEM: Observed movement during test
→ SOLUTION: CAREFULLY distinguish:
- Spinal reflexes (acceptable — do NOT negate brain death):
• Triple flexion of legs
• Finger flexion/extension
• Shoulder shrugging (rare)
• Lazarus sign (arm raising — spinal cord mediated)
- TRUE respiratory effort (NEGATES brain death):
• Rhythmic chest/abdominal excursion
• Active diaphragmatic contraction
• Gas flow through ETT
→ If uncertain: ABORT test, reassess, video record if available
PROBLEM: Patient on ECMO
→ SOLUTION: ECMO adds significant complexity to brain death determination
→ Apnea test on ECMO requires specialized protocol:
- Reduce ECMO sweep gas to minimum/off
- Wait for PaCO2 to rise to target via native circulation
- Institutional-specific protocol REQUIRED
→ Consider ancillary testing (cerebral blood flow study) instead
→ Consult institutional brain death policy and ECMO team
Religious exemption: if family objects to brain death on religious grounds, patient remains legally alive on ventilator
Only state with statutory religious exemption; physician must accommodate; no time limit specified
New York
Must provide "reasonable accommodation" for religious and moral objections to brain death
Not as absolute as NJ; case-by-case; institutional policies vary
California
Requires "reasonable time" for family before ventilator withdrawal after brain death; OPO notification required
Recently legislated additional family protections
Most states
1 examination by qualified physician sufficient per AAN guidelines; institutional policy may require 2 examinations
Check institutional policy and state regulations; some states specify examiner qualifications
Pediatric
AAP/CNS/SCCM 2011: 2 examinations required; observation period varies by age (24h for term newborns to 30 days; 12h for 30 days to 18 years); longer intervals recommended in younger children
This template covers ADULTS only; pediatric brain death determination follows separate guidelines
This template represents the initial build phase (Skill 1) and requires validation through the checker pipeline (Skills 2-6) before clinical deployment.