Determination

of
Brain Death

Thomas A. Nakagawa, M.D, FAAP, FCCM
Professor of Anesthesiology and Pediatrics
Wake Forest University School of Medicine
Pediatric Critical Care Medicine
Brenner Childrens Hospital at Wake Forest University Baptist Medical
Center
Winston-Salem, North Carolina

Objectives

n

Review specic recommendations from the AAN

adult brain death guidelines and
recommendations from the SCCM/AAP/CNS
guidelines for the determination of brain death in
infants and children

Discuss important issues that can impact the

diagnosis of brain death in adults and children

Characteristics of irreversible coma

A patient in this state appears to be in deep coma. The condition
can be satisfactorily diagnosed by points 1,2, and 3 to follow. The
electroencephalogram (point 4) provides confirmatory data, and
when available it should be utlized.
1. Unreceptivity and unresponsitivity
2. No movements or breathing
3. No reflexes
4. Flat electroencephalogram

2 Defining Death
To embody these conclusions in statutory form the
Commission worked with the three organizations which had
proposed model legislation on the subject. the American Bar
Association, the American Medical Association, and the
National Conference of Commissioners on Uniform State
Laws. These groups have now endorsed the following
statute, in place of their previous proposals:
Uniform Determination of Death Act
An individual who has sustained either (1) irreversible
cessation of circulatory and respiratory functions, or (2)
irreversible cessation of all functions of the entire brain,
including the brain stem, is dead. A determination of death
must be made in accordance with accepted medical
standards. The Commission recommends the adoption of this
statute in all jurisdictions in the United States.
Overview of the Report
Traditionally, the cessation of heartbeat and of breathing were
regarded by the lay and. medical communities alike as the
definitive signs of death. The law, through the judgments of
courts in deciding individual cases, articulated this general
view. In the oft-quoted words of Black's Law Dictionary, the
common law mirrored the physician's "definition" of death "as
a total stoppage of the circulation of the blood, and a
cessation of the animal and vital functions consequent
thereon, such as respiration, pulsation, etc."1

Criteria for determining death

162 Defining Death: Appendix F
The Criteria for Determination of Death
An individual presenting the findings in either section A (cardiopulmonary) or section
B (neurologic) is dead. In either section, a diagnosis of death requires that both
cessation of functions, as set forth in subsection 1, and irreversibility, as set forth in
subsection 2, be demonstrated.
A. AN INDIVIDUAL WITH IRREVERSIBLE CESSATION OF CIRCULATORY AND
RESPIRATORY FUNCTIONS IS DEAD.
1. CESSATION IS RECOGNIZED BY AN APPROPRIATE
CLINICAL EXAMINATION.
2. IRREVERSIBILITY IS RECOGNIZED BY PERSISTENT
CESSATION OF FUNCTIONS DURING AN APPROPRIATE
PERIOD OF OBSERVATION AND/OR TRIAL OF THERAPY.
B. AN INDIVIDUAL WITH IRREVERSIBLE CESSATION OF ALL FUNCTIONS OF
THE ENTIRE BRAIN, INCLUDING THE BRAINSTEM, IS DEAD.
Defining Death. A Report on the Medical, Legal and Ethical Issues in the Determination of Death
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and
Behavioral Research 1981

Criteria for determining death

162 Defining Death: Appendix F
The Criteria for Determination of Death
C. Children
The brains of infants and young children have increased
resistance to damage and may recover substantial
functions even after exhibiting unresponsiveness on
neurological examination for longer periods than do
adults. Physicians should be particularly cautious in
applying neurologic criteria to determine death in
children younger than five years.
Defining Death. A Report on the Medical, Legal and Ethical Issues in the Determination of Death
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and
Behavioral Research 1981

Brain death is a clinical diagnosis

A.Etiology and irreversibility of condition
B.Absence of brainstem reflexes
C.Absence of motor response to pain
D.Absence of respiration with PCO2 60 mm Hg

IV. Confirmatory laboratory tests (Options)

Brain death is a clinical diagnosis. A repeat
clinical evaluation 6 hours later is recommended,
but this interval is arbitrary. A confirmatory test is not
mandatory but is desirable in patients in whom specific
components of clinical testing cannot be reliably
performed or evaluated. It should be emphasized that
any of the suggested confirmatory tests may produce
similar results in patients with catastrophic brain
damage who do not (yet) fulfill the clinical criteria of
brain death.

CMAJJAMC
March 14, 2006, Vol. 174, No. 6; (suppl):S132
Brain arrest: the neurological determination of
death and organ donor management in Canada
Severe brain injury to neurological
determination of death:
Canadian forum recommendations
Sam D. Shemie, Christopher Doig, Bernard Dickens, Paul Byrne, Brian Wheelock, Graeme
Rocker, Andrew Baker, T. Peter Seland, Cameron Guest, Dan Cass, Rosella Jefferson,
Kimberly Young, Jeanne Teitelbaum, on behalf of the Pediatric Reference Group and the
Neonatal Reference Group

Crit Care Med 2011;29:2139-2156

Pediatrics 2011;128:e720-e740

National and International Endorsements

Adult

Pediatric

Society of Critical Care Medicine

American Academy of Neurology

American Academy of Pediatrics

Child Neurology Society

Child Neurology Society

Neurocritical Care Society

American Association of Critical

American College of Radiology

The Radiologic Society of North

America

Care Nurses

National Association of Pediatric

Nurse Practitioners

Society for Pediatric Anesthesia

Society of Pediatric Neuroradiology
World Federation of Pediatric

Intensive and Critical Care Societies

*American Academy of Neurology

arms the value of the manuscript

The adult and pediatric brain death guidelines

emphasize the important point that brain death is a
clinical diagnosis based on the absence of
neurologic function with a known irreversible
cause of coma

Clinical examination criteria to determine

brain death
n
n
n

Clinical neurologic examination and apnea testing are the

cornerstone of brain death determination.
Deep, unresponsive coma
Absent respiratory effort
(apnea)
Loss of all motor responses,
excluding spinal reflexes
Loss of all brain stem
reflexes, including
n
n
n
n

Absent gag reflex

Absent cough reflex
Absent corneal reflex
Absent oculocephalic and
oculovestibular reflexes
Fixed and dilated pupils

Wijdicks EFM. The diagnosis of brain death. N Engl J Med 2001;344:1215-1221

Determination of brain death

Brain death can be determined in infants > 37

weeks gestational age to adults

Specied the age of pediatric and adult patients

Acknowledged special sub groups of pediatric patients
Pediatric trauma patients
The committee recognizes dierences in age criteria for
pediatric trauma patients(37 weeks gestational age to 18 years
of age)
Special Considerations for Term Newborns (37 weeks Gestation) to
30 Days of Age
No recommendations were made for neonates < 37 weeks


gestation because of insucient data

Testing for brain death must occur with

appropriate physiologic parameters

Additional parameters to determine

absence of neurologic function
n
n
n

The patient should not be hypotensive (based on age)

The patient should not be hypothermic
Sedatives, analgesics or neuromuscular blocking agents
should not have been recently administered
Conditions capable of imitating brain death must be ruled
out
n

Severe metabolic disturbances including electrolyte and

glucose abnormalities capable of causing a potentially
reversible coma
Clinically significant drug intoxications including alcohol,
barbiturates, opiates, and sedative agents
n

Low to mid therapeutic levels of anticonvulsants, sedatives, and

analgesic agents should not preclude the clinical diagnosis

 This update sought to use evidence-based methods to

answer 5 ques8ons historically related to varia8ons in brain
death determina8on to promote uniformity in diagnosis
Are there pa8ents who fulll the clinical criteria of brain death
who recover brain func8on? (Level U)
What is an adequate observa8on period to ensure that
cessa8on of neurologic func8on is permanent? (Level U)
Are complex motor movements that falsely suggest retained
brain func8on some8mes observed in brain death? (Level C)
What is the compara8ve safety of techniques for determining
apnea? (Level U)
Are there new ancillary test that accurately iden8fy pa8ents
with brain death? (Level U)

Evidence based medicine guidelines

EBM ranks evidence based on the eectiveness of treatment or
interventions
Level 1:
Level 11-1:
Level 11-2:

Level 11-3:


Level 111:

Evidence obtained from at least one properly designed randomized controlled trial
Evidence obtained from well-designed controlled trials without randomization
Evidence obtained from well-designed cohort or case-controlled analytic studies

preferably from more that one center or research group
Evidence obtained from multiple time series with or without the intervention.
Dramatic results in uncontrolled trials might also be regarded as this type of

evidence.
Opinions of respected authorities, based on clinical experience, descriptive

studies, or report of expert committee.

Levels of evidence (Oxford Centre for Evidence-based Medicine)

Level A: Consistent randomised controlled clinical trial, cohort study, all or none clinical

decision rule validated in dierent populations
Level B: Consistent retrospective cohort, exploratory cohort, ecologic study, outcomes

research, case-controlled study, or extrapolations from level A studies
Level C: Case-series study or extrapolations from level B studies
Level D: Expert opinion without explicit critical appraisal, or based on physiology, bench

research or rst principles

 6 specific recommendations were made

Determination of brain death in term newborns, infants,
and children is a clinical diagnosis
Insufficient data in the literature to make recommendations for
preterm infants < 37 weeks gestational age

Hypotension, hypothermia, and metabolic disturbances should

be treated and corrected and medications that can interfere
with the neurologic examination and apnea testing should be
discontinued allowing for adequate clearance before
proceeding with these evaluations

 Two examinations, including apnea testing with each

examination separated by an observation period, are
require
An observation period of 24 hours for term newborns (37 weeks
gestational age) to 30 days of age and 12 hours for infants and
children (> 30 days to 18 years) is recommended.

Apnea testing to support the diagnosis of brain death must

be performed safely
Ancillary studies are not required to establish brain death
and are not a substitute for the neurologic examination
Death is declared when these criteria are fulfilled

Grading of Recommendations, Assessment,

Development and Evaluation (GRADE)
GRADE is a recently developed standardized methodologic
consensus-based approach used to make recommendations for
the updated guidelines
GRADE allows panels to evaluate evidence and opinions and
make recommendations using 5 domains to judge the balance
between the desirable and undesirable effects of an intervention.
A GRADE score was produced by each committee member for the
strength of evidence linked to a specific recommendation
Based upon these scores, specific recommendations were made
based upon available literature at the time of publication

 Ques%on: Are there pa8ents who fulll the

clinical criteria of brain death who recover
brain func8on?
Conclusion:
In adults, recovery of neurologic func8on has not been
reported aIer the clinical diagnosis of brain death has
been established using the criteria in the 1995 AAN
prac8ce parameter

Crit Care Med 2011;39:1538-1542

Guidelines for the determination of brain death

in infants and children
Cerebral protective therapies such as hypothermia

may alter the natural progression of brain death and

their impact should be reviewed as more information
becomes available. The clinician caring for critically ill
infants and children should be aware of the potential
impact of new therapeutic modalities on the
diagnosis of brain death.

IV. Confirmatory laboratory tests (Options)

Brain death is a clinical diagnosis. A repeat clinical
evaluation 6 hours later is recommended, but
this interval is arbitrary. A confirmatory test is
not mandatory but is desirable in patients in
whom specific components of clinical testing
cannot be reliably performed or evaluated. It
should be emphasized that any of the suggested
confirmatory tests may produce similar results in
patients with catastrophic brain damage who do not
(yet) fulfill the clinical criteria of brain death.

 Ques%on: What is an adequate observa8on period to

ensure that cessa8on of neurologic func8on is
permanent?
There are no detailed studies on serial examina8ons in
adults who have been declared brain dead
Conclusion:
There is insucient evidence to determine the minimally
acceptable observa8on period to ensure that neurologic func8ons
have ceased irreversibly.

 Prac8cal (Non-evidenced based) guidance for

determina8on of brain death
Many of the details of the clinical neurologic examina6on to
determine brain death cannot be established by evidence-based
methods. The detailed brain death evalua6on protocol that
follows is intended as a useful tool for clinicians. It must be
emphasized that this guidance is opinion-based. Alterna6ve
protocols may be equally informa6ve

Perform 1 neurologic examina%on (sucient to pronounce

brain death in most US states)
If a certain period of 6me has passed since the onset of the
brain insult to exclude the possibility of recovery (in prac6ce,
usually several hours), 1 neurologic examina/on should be
sucient to pronounce brain death. However, some US state
statutes require 2 examina/ons.

Guidelines for the determination of brain death

in infants and children
Recommendation 3

Two examinations, including apnea testing with each
examination separated by an observation period, are
required. Examinations should be performed by dierent
attending physicians. Apnea testing may be performed
by the same physician.
Observation period
24 hours for term newborns (37 weeks gestational age) to
30 days of age
12 hours for infants and children (> 30 days to 18 years)

Criticisms of the revised pediatric

brain death guidelines
Observation periods between examinations
2 examinations to determine brain death
2 separate attending physicians are needed to

declare death
Recommendation for an arterial line

Why two examinations separated by

an observation period for children?

75,976 adults
11,020 children
1,264 children < 1 year of age
OPTN data 2/2012

The importance of two examinations separated

by an observation period
The first examination determines
the patient meets

n

criteria for brain death. The second examination

confirms that the patients neurologic status remains
consistent with the diagnosis of brain death throughout
the observation period

Fulfills criteria for irreversibility from the Presidents

commission
n

The Criteria for Determination of Death

A diagnosis of death requires that both cessation of
functions, as set forth in subsection 1, and irreversibility, as set forth
in subsection 2, be demonstrated.
1. CESSATION IS RECOGNIZED BY AN APPROPRIATE
CLINICAL EXAMINATION.
2. IRREVERSIBILITY IS RECOGNIZED BY PERSISTENT
CESSATION OF FUNCTIONS DURING AN APPROPRIATE
PERIOD OF OBSERVATION AND/OR TRIAL OF THERAPY.

Guidelines for the determination of brain death

in infants and children
Recommendations
Examinations should be performed by dierent attending
physicians
The guidelines list appropriately trained individuals who should be
competent to perform the neurologic examination
State and local guidelines will determine whether physicians trained in
the neurosciences are required to perform at least one of the
examinations.

Apnea testing must be performed in conjunction with each

neurologic examination
Apnea testing should be performed by the physician managing the
ventilator (Apnea testing can be performed by the same physician)

Guidelines for the determination of brain death

in infants and children
Recommendation 3

Assessment of neurologic function after
cardiopulmonary resuscitation or other severe acute
brain injuries should be deferred for 24 hours if there
are concerns or inconsistencies in the examination

1,229 adult and 82 pediatric patients were studied over a 2.5 year period
Mean brain death interval between the 2 examination was 19.2 hours
Hospitals with fewer beds had longer intervals between testing
Consent for organ donation decreased from 57% to 45% as the brain
death declaration interval increased
Refusal of organ donation increased from 23% to 36% as the brain death
interval increased
166 patient (12%) sustained a cardiac arrest between the 2 examinations
or after the second examination

We demonstrated a significant delay in the diagnosis of brain death

as a result of a second examination resulting in negative
consequences of organ donation and procurement of organs. The
mean observation period between the 2 brain death examinations
was substantially longer than the 6 hours proposed in the New York
State Guidelines. In several patients, a second brain death
examination was performed more than 1 to 2 days after the first
examination.
Regrettably, 116 patients sustained a cardiac arrest while awaiting a
second brain death examination, and an additional 50 patients
arrested after the second brain death examination following the brain
death interval. Cardiac arrest was a direct result of the requirement of
a second clinical examination and observation period.

 Importance of this publica8on

Con8nues to add important informa8on about
brain death in children and adults reinforcing that
when the diagnosis of brain death is properly
made, recovery of neurologic func8on does not
occur

 Important considera8ons for children

Limited number of children in this study
Of the 82 pediatric pa8ents, 15 children < 5 years of
age with no children < 2 years of age reported in this
study

 RegreVably, 116 pa8ents sustained a cardiac

arrest while awai8ng a second brain death
examina8on, and an addi8onal 50 pa8ents
arrested aIer the second brain death
examina8on following the brain death
interval. Cardiac arrest was a direct result of
the requirement of a second clinical
examina/on and observa/on period.

Important considerations when determining

brain death
n

Diagnosing brain death should never be rushed or

take a priority over the needs of the patient and
family
Patients should continue to be supported until a
diagnosis of brain death is made or a decision to
withdraw life-sustaining medical therapies is
decided upon
If there is any uncertainty about the examination or
ancillary study, the observation period should be
prolonged

Apnea testing
To determine brain death, coma and apnea must coexist
Apnea testing must be performed safely
Apnea testing should only be pursued after the patient has met
established prerequisite and clinical criteria (complete loss of
brain stem reexes) for brain death testing
Specic recommendations regarding apnea testing are made in
the adult and pediatric brain death guidelines
Patients should be adequately preoxygenated to minimize
complications and ensure the greatest chance of successfully
completing this test
Patients should be removed from mechanical ventilation to
reduce any chance of false triggering of the ventilator

Guidelines for the determination of brain death

in infants and children
Apnea testing
Apnea testing must be performed safely
The apnea test should be aborted if oxygen saturations
fall below 85%, if hemodynamic instability occurs, or if a
PaCO2 level of 60 mm Hg cannot be safely achieved. In
this instance, the patient should be placed back on
ventilator support with appropriate treatment to
restore normal oxygen saturations and a normal carbon
dioxide level.
Care should be taken if tracheal insuation of oxygen is used
to prevent barotrauma and CO2 washout

 Ques%on: Are there new ancillary test that

accurately iden8fy pa8ents with brain death?
Conclusion:
There is insucient evidence to determine if newer
ancillary tests accurately conrm the cessa8on of
func8on of the en8re brain.

Considerations when selecting a neurodiagnostic

study to assist with determination of brain death
n

4 vessel angiography remains the gold standard

n

Electroencephalography (EEG)
n
n

Dicult to accomplish in small infants and requires technical

expertise which may not be available at every center
May require transport of a critically ill child to the angiography
suite

Remains an accepted means to determine brain death

EEG is inuenced by factors such as sedative agents and
hypothermia

Radionuclide cerebral blood ow (CBF) study

n
n

May not be available at every institution

May require transport of a critically ill patient to the nuclear
medicine suite unless a portable gamma camera is available

Neurodiagnostic (Ancillary)testing
n

EEG and radionuclide

CBF are the two most
widely available and
useful ancillary studies
to assist with the
diagnosis of brain
death in children
Radionuclide CBF
study have been used
extensively with good
experience. This study
is becoming a standard
in many institutions.

Is one test better than the other?

n

Each test is considered

acceptable as an
ancillary study
Some believe that EEG
may be more specific,
although less sensitive
than radionuclide CBF
testing
n

EEG testing evaluates

cortical and cellular
function
Radionuclide CBF
evaluates flow and
uptake into brain tissue

 Are there new ancillary test that accurately

iden8fy pa8ents with brain death?
MRI and magne8c resonance angiography
CT angiography
Somatosensory evoked poten8als
Bispectral index
Conclusion:
Because of a high risk of bias and inadequate sta8s8cal
precision, there is insucient evidence to determine if
any new ancillary tests accurately iden8fy brain death.

Guidelines for the determination of brain death

in infants and children
Recommendations for ancillary studies
Ancillary studies are not mandatory and are not a substitute for
the neurologic examination
EEG and CBF studies remain accepted ancillary studies to assist
with making the diagnosis of brain death. 4 vessel angiography
can be pursued if available.
Ancillary studies may be used to assist the clinician in making the
diagnosis of brain death
When components of the examination or apnea testing cannot be
completed safely as a result of the underlying medical condition of the
patient
If there is uncertainty about the results of the neurologic examination
If medication eect may be present
To reduce the interexamination observation period

Neurodiagnostic (Ancillary) testing in

infants and children
n

The following ancillary studies have not been

sufficiently studied in children and cannot be
recommended as ancillary studies to assist with the
determination of brain death in children at this time
n
n
n

n
n
n
n

Transcranial doppler study

Computed tomography angiography
Computed tomography perfusion using arterial spin
labeling
Nasopharyngeal somatosensory evoked potential studies
Magnetic resonance imaging
Magnetic resonance angiography
Perfusion magnetic resonance imaging

Differences between pediatric and adult brain

death guidelines
Adult

18 years of age and older

111

111

> 37 weeks gestational age to 18

years of age

> 60 mm Hg or > 20 mm Hg above

baseline

the clinical diagnosis of brain

death

Rather than ordering ancillary tests, physicians

may decide not to proceed with the declaration of
brain death if clinical ndings are unreliable.

Acceptable ancillary studies

EEG
Nuclear scan
Cerebral angiogram

Ancillary studies: not required

unless physical exam and apnea

test cannot be completed

EEG
Nuclear scan
Cerebral angiogram

> 60 mm Hg and > 20 mm Hg above

baseline

Acceptable ancillary studies

*Preferred tests

* Trauma population

Apnea testing

Ancillary studies: not needed for

Pediatric

Apnea testing

Differences between pediatric and adult brain

death guidelines
Adult

Number of examinations
1 examination

Pediatric

Number of examinations
2 examinations

Some states may

require 2 examinations

2 dierent attending
physicians must perform the
examination

Observation period: none

specied

Observation period based on age

24 hours for infants less than 30 days
12 hours for children 31 days of age or
older

James Fackler, MD, Brahm Goldstein, MD,

Crit Care Med 2011(39)2197-2198

We strongly suggest that this checklist be

incorporated into the patients medical
record as it will guide clinicians during a
high-stress period and provide definitive
documentation of the specific steps and
timeline followed for determination and
declaration of brain death for clinical and
medical legal purposes.

Guidelines for the determination of brain death

in infants and children
Terminology
Dierent terms for one clinical state
Brain death
Neurologic death
Total brain failure
Irreversible coma
Brain infarction
Brain arrest

Communicating with families

Communication should be in simple terminology
allowing parents and family members to understand
their loved one has died
Avoid terms such as brain death
Your loved one has suffered a severe injury that has caused
the brain to stop working
Your loved one has died

Allow families to be present during the examination

and apnea test
Families may become confused or angry if
discussions regarding withdrawal of support or
medical therapies after declaration of death are
entertained.
It should be made clear that once death has occurred,
continuation of medical therapies is no longer an
option, unless organ donation is planned.

Cyanotic heart lesion and brain death

You are treating a patient with cyanotic heart disease

who has a baseline saturation of 70-75%. Can you

determine brain death in this patient? In a normally
saturated patient, based on the revised pediatric
guideline, the apnea test should be terminated when
oxygen saturations fall below 85%.

There is no published reports on how to approach a cyanotic patient

The patient is in a desaturated state which is dierent from

desaturating
If the patient desaturated, how low would you allow the saturations to
drop before terminating the apnea test?
In this instance, an ancillary study would likely need to be pursued to
assist with the determination of death

Hypothetical adolescent trauma

patient
Car accident, 3 teenagers ages 16, 17, 18 years
No brainstem reexes with apnea noted 12 hours

later
Bed A: 16 y, SCCM/AAP/CNS guidelines
Wait and do a second exam, cardiac arrest

Bed B: 17 y, SCCM/AAP/CNS guidelines

Wait and do a second exam, family devastated, they want

closure and do not want to wait. Family denies organ

donation

Bed C: 18 y, AAN Guidelines

One exam is performed and organ donation occurs

Hypothetical adolescent trauma

patient (cont)
Is there a dierence in the physiology of these three

patients?
Should these patients be treated under the pediatric
or adult brain death guidelines?
Should one examination and an apnea test be
performed or should 2 examinations and apnea tests
be performed?
The committee recognizes dierences in age criteria
for pediatric trauma patients

Where are we today?

n
n

n
n

Brain death remains a clinical diagnosis based upon the

absence of brainstem and hemispheric function
Apnea testing is essential to the determination of brain death
and should be performed in conjunction with the clinical
examination
Brain death can be diagnosed in infants < 7 days of age
n The younger the child, the more cautious one should be in
determining brain death
Care must be taken when the patient has sustained an anoxic
insult or has undergone cardiopulmonary resuscitation
Ancillary studies can assist in making the determination of
brain death when the clinical examination criteria and apnea
testing cannot be completed and documented
If there is any concern regarding declaration of death, the
observation period should be extended and additional
examinations or use of ancillary studies should be pursued to
make the appropriate diagnosis

Future directions
n

Further information is needed before we can state that

a single neurologic examination is sucient to declare
brain death in infants and children
Further research into validity of newer ancillary tests is
warranted to see how they compare and if they are
more accurate and reliable than currently available
tests
We must work with national medical societies and
organizations to achieve a uniform approach to
declaring brain death that can be incorporated into all
hospital policies while understanding that dierences
in children and adults exists

Working to standardize the determination of

brain death in infants and children
n

SCCM is currently working on a toolbox

n Online resource for medical providers tasked
with determining brain death in children
n Full guideline
n Examination criteria
n Brain death checklist
n Tables, appendices
n Training video demonstrating the neurologic
examination

Implications for donation and

transplantation
n

The OPO coordinator will face greater challenges and

must continue to rely on their ability to perform a
brain death examination
The OPO must verify that the patient meets criteria for
brain death prior to organ recovery
This increased responsibility can have profound social
and political implications for families and physicians in
the ICU setting

The diagnosis of brain death still requires the thoughtful,

mature judgment of a knowledgeable physician who takes all
the facts into careful deliberation in each case.
The diagnosis of brain death should remain a clinical one to
be made at the bedside by knowledgeable physicians who,
in concert with grieving families, make the most agonizing
of all lifes events (the death of a child) as bearable as
possible for all concerned.

Freeman JM, Ferry PC

New brain death guidelines in children: further confusion.

Pediatrics. 1988;81:301-303.35

Thomas A. Nakagawa, M.D., FAAP, FCCM

Wake Forest University School of Medicine
Department of Anesthesiology
tnakagaw@wakehealth.edu
(336) 716-7194