Forensic Science, 11 (1978)2f~2 -.

212 20I"
Elsevier Seqaoia.S.A., Lausanne -- Printed in the. Netherlands. ":
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PROBLEMS:IN BR~IN:DEATH DETERMINATION

MICHAEL JASTRFAMSEI,* DAVID:PbwNERI jJ~IvIESSI~.[rDEI~,.

JAN SMITH and:
AKE GRENVIK
. . . , - .

Departrae~zt of ~4nesth'e~iology/Critieal Cam Medicine, Unive~tyof .Pitfsburgh School of

Medieine and" Presbyterian University .Hospital, Pittsburgh, Pefmsylvania. 15213.. eU:.S.A.).:
(Received March 20, t 9 7 8 ; accepted May 10, 1978)

Summary
During the las~ decade there has been philosophical acceptance of the eoncep~ that
the state of brain death is equivalent to total patient death, The applica~,ion of this con-
cept to clinical medicine has been as~ciated with .~'|~or problems in both the diagnosis
of brain death and the. medical managetaent of the brain dead patient. In our experienc e
with 176 consecutive cases of suspected brain death over a seven-year period, we have
found ~hat a standardized protocol applied by experienced c.]inicians will minimize these
prohlems.

"A human being may be dying. He is never-dead. If he is dead, he is

no more a human being. Death is Ln itselfnothing.: But it:leaves a dea'd body
behind perceptible .to our senses and,. in addition, among those nearby a
feeling that something imperceptible has gone." (G. Bi!Srck)

~ntroduction
. , . . . , , .

Recent advances in re.~iuscitation, artificial life s,ujp.port, !and organ trans-

plantation have necessitated a re-examination o f t h e medical, mo~al, :and...
legal definitions of death, The capability of the medic~] profession to :recover.
or support cardiopulmonary functic4~ presently exceeds its abili~y to. resusci~
tate the.brain in some unfortunate patients. During:the last d~cade, there has
been increasing acceptance o f the concep t o f brain death, defined as a state
of irreversible cessation of ~l brain function, as equivalent t,a!.to~al patient
death [1 - 5]. Acceptmlce of this basic premise permi!~; the physician to.dis.
continue mea_ning~ess life suppor~ when b!min function h$'s ce$eed: Ln.1968 a
committee of clinicians, lawyers, philosophers, and Clergymen established a
well-defined set of criteria for the diaguosi s of brain death based o n accep~d
i :

i " " ' ' " '

. . . . . . . - . . . . . ..
. , .. - .. . . . . . .

.'Addm-~s reprint, requests to: Michael Jastromski, M.D., Director, Intensive Care
Unit, SUNY, Upstate Medical C~.nter,SyracuSe, N Y 13~10 (U.S,A.)..
,
~. : .. . ..' . . . "
202 ,

scientific knowledge and :e~mpatible with locai legal and eth.ical :St~mdard~ to
be used at Presbyterian Univemity Hospital of the University:of Pittsburgh
[.61. T h e ~ criteria became.the basis o f a~protocol:~or:thei:cer~fficati0m:;aud
managemen~ of brain death that has been used in 176 consecutive case,,~ of
su.'~ected brain d e a t h o v e r a period of seven yeare'. It:is not tile purpose of
thfs paper t o a r g u e the relative merits'of the Various Criteria fO~ brain dei~th.
These have been published and reviewed elsewhere [ 7 - 15]. Lusteadi: ~ve w~sh
to present our experience with the practical problterns ass0ciated With the
implementation and use o f sucl~ a protocol.

TABLE I
Brain dead patients

E~iology No. (%) Age (years) Cardio- Diahe~,es Spinal

vascular insipidus reflexes
, I~,ge Mean irmtabflity
No. (%) No. (%)
No. (%)

Cecebrai bleed 70 (39.8) 1tt - 76 44 30 (42.8) 4 (5.7) 9 (12.8)

Trauma 58 (32.9) ll.-,B5 30 29 (50:0) 10 (17.2) 9 (15.5)
Post-resuseitati~,n 20 (11.4) 17-89 48 7 (,~5.0) --
Vascular occlusion 14 (8.0) 18 - 76 ~4 6 (42.9) --
Tumor 6 (3.4) 2,'! - 62 48 3 (50.0) -- 1 (16.6)
Miscellaneous 8 (4.5) 1{1~-54 43 5 (62.5) 1 (12.5) --
176(100) 1]L-S9 43 80 (45.5) 15 (85) ]9 (10,1~)

Materials and methods

Patients
Table I summariz~ s the important characteristics of the 176 patient.,;
studied. Most of them were relatively young people who had died from
cerebral vascular events or trauma. A patient was n o t eligible for brain death
evaluation until appropriate diagnostic studies had demonstrated a cent~rat
nervous system lesion capable of causing brain death, All patients were m-
patients on the medical or surl~c~d services and were maintained in t:he
hospital's multidi~ciplh~ary Intensive Care Un~t until the dia~u~os~s of bin,An
death was confirmed or rejec:Led. T~'e ECG, arteria~ blood pressure, urine
output, and central venom: or pulm.on~:ry artery pressure were contin,u o u d y
monitored or, all patients. A smat~ number of patients also had cerebral
ventricular catheters or subdural hollow bolts for continuous mon~to~ng of
intracranial p~essure. Therapy with s~anda~ ~e-support techniques-including
mechanical ventilation,, fluid replacement, pressor .,agents, a~,d ~u~i,arrhy~hm:ic
drugs was conl;inued during the evaluation process:. "
 :2O3

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~ : :.,~ 1~.m3.,...~ m c z m d ~ a = m,..m'b ~ p a r f ~ = ~ x b :~l~: .-..

.-5"'~ " " ~ ' t ~ ~=~nor ~ ~ ~ ~ r ti~o.fir~l:..
..- .-:. _--- . . % . - . , . . : . . .,: ..-,. ,..

., - . . . . .

A. ~ ~:~u~e~ ~ d = ~ ~ e ~ c , , o~ " ..-: oh~:6~ ~-::' '" '""~ " . . . . " : : '
c~,=,l. ~ ~#,~x~:~an~ dx~s; :.~ .. .Ti~*~ O f ~ : . . . . ...:-...- --- - - : . i .'
: bl(xxt ~t:hoil~l l.~s~l or .ixixi~l~y .s~:reen " : l ' ~ u ~ . . " " .'. . "....
~.a.obtminl.v~ if indicae,~,-lixty'tl~,~x~Ellt:~: should . . ..' .' ; ~ "
. - .. .

I . ~y T~crature-: _ ~ .:
2. Ethanol' Level: . . . .
3. Toz.&~loqy S~uQy:
B. .,/~m_rali-~_~le.'laccidL~.y,., n o s ~ - n ~ . " mu~ular m~n~,
and 11o ~"idth%~ ,~: ~ t d / a % ~&~;J.%'i~ OT f~i~trt~rl~%@ Inll i n
am'.m~:e o m,z..~le z ~ 2 a x a n t s ] : ...

C. Cranial Nerve ~..flexe~ and l~s~onses=

i. Pup1s d~./nted and li~ht-1xes:

2. Ab3e~t ~ r n ~ a ! r~fl~m~:

3. th%respc~i~ar~-ss to inten=eb.{ vainf~l stimuli e.J.,

s%~raorblta! p~cssure: ---

4~ ~nt ~.sraon~l t o 'uF2per and : ~ e r aLrway st,zl~lation,

~.g. t ~ z ~ ' y n g e a ~ ~ e-~oEracJ~e~ s@c~ioning: . ___

6, Ahse-nt ocula= r e s ~ n ~ to irr'.gat~on of t.he o!~rs with

I0-2~mI$ ,Dr iec w a r . o r ( n o , I ~ r m=~ement):

D. ~ b s ~ C ~ O spo~tmm~o~ / = ~ t h i ~ j r~xants for 3 :~nutas(in

ahsemec of h~=~carbia and t ~ s l e rel~ts) :
PaCO 2 a~ ,c~ of agne~t t.x~st;=~ - _

E. An ~soelectric cle~,mcuei'ICC'l:~"i,fi.l~9~'rl L't,r.<i'(k:d ii~ p a r . = ~ t . f u ~ l ~'~*in:

I ; m ~ arf3 ~ of .t.v.~=.':Lr~':

F. i~mmp'.~ -...~=

~ 2.:.,'r'r..F.t~2".T.E~
~avii~ c~mllldczod r / ~ alxa~ fllillnge~, ~ ~..c,~rt:i~y the '~eath 0:

not t , ~ ~ i a r m of a ~ v.~an z~cipt~mt, . ...... . - } ; . . ; . .

/Corm l ~ t 9~0 5/77

. -. . . .,

Fig. 1. Brain death evaluat}on fo=Ta.

..

Brain deaNz eveIuation

AH br~/n death deLe~m.ma,ions were performed by ~he Critical ,~8/e ~
Medicine staffusing a prep~n%ed form(Fig. I)%o ensure ~hat each .evalua%ion
was done in a s1~ndaz~ized :f~shi.on.When %he.his%ory or .cli~c~ findings
su~ges%ed that the pa~ient,scoma might.b e due %o a metabolic derangemen'~
or a %oxic.~oenL,. appropriaLe ]abora%ory S~udie:;includi~ng'blood g]ucose~
BUN, .liver-function tests, Spec~flc.dr~g leVe~s "(e.g.. ethanol, barbitural~),
an d toxice]o~c, screens.of ~/~/ne,b~0od~ and.g'-,~tricconten~s were IobLained
before b ~ n death:. evs/uation ':~V~s.sL~r~ed.l~tien~s w h o mighthave hs~[.
, . . . .
204-
., ,.

. induced hypotlnermiawere, warmed" t o > 35 "'Cbef0re'being.evaluated:,.for .

brain death. . . . . . ::. . . . . . . . . : . . ....... . ?" , '
Our cl~teria for brain d e a t h w e r e a singleisoelectric.EEG..and complefle.
;absence of cerebral and bz'ain~stem activity';:0n: t w o .Clinical.exzmiinatio6s~
peff0rme/l a t ~east .two hours apart.' The ~,EG w~ r e c 0 r d e d i n the Intensive
Care u n i t t,sing standardized technical guidelines [ !6]. I t was .Usually )b,
rained in t h e interval between the first. .a n d second.:clinical examiriatio-n.
Neuromusculax blockade with succinylcholine, pancuronium.brom!de ~ o r
curare, was occasionally used to abolish muscle artifacts which interfered
with ,the EEG tracing. The ~Wo elements to the clinical assessment wet~ a
neurologic exeznination of cranial nerve and m o t o r activity using s~andaxd
techniques o~ physical diagnosis and a three-minute apnea ..test to detect
sponta~eou~ breathing. Any patient who had received neuromuscular
paralyzing drugs was tested with a muscle stimulator before the clinical
examination ~o ensure that their effect was no longer presenL Prior to the
apnea test, the patient was ventilat~;d with 100% oxyg~" to prevent hypoxia
during the ~hree minu~,es of apnea. It was sometimes necessary t e decrea,,;e
the m~nute ventilation or add mechanical deadspace to the ventilator circuit
to raise the a~.~rial pC,:)~_ to the normal range (40 - 50 Tort) before the test
for apnea. Afl~er arterial blood gas a~alysis confirmed adequate oxygenation
and a normal pCO~, the patient, was disconnected from the ventiIator and
closely observed for three minutes. If no respiratory efforts were detected
during the th~'ee minu~es of observation a second set of arterial blood gases
was obtained and the patient recon~ected to the ventilator. The apaea test
was considered valid only if the arterial pCO~ was above 45 Tort .after three
minutes of apnea, thus representing the absence of ,any ventilatory response
to a physiologic hypercarbic challenge.
When a patient fulfilled these criteria for brain death h e w a s certified
dead by two ],icensed physiciaz~s. The time of patient death was the ~Lmeo f
bra~n death c~.*rtification and ~ t the time of cessation of ca~liac activity.
After the family had been informed of the .rlea~h, mecha,uical:ventilation
was discontinued and thr, body kept in the Laten~ive Care Unit until cardiac
activity ceased. ]:f organ removal for transplantation purposes was t o be per-
formed, such brain dead organ donors received continued cardiopulmonary
support until ~he donated organ~; were removed in the operating room. As
soon as this h~: been co.mple~:edL, all ca.,~liopulmonzasr support ~as discon-
tinued and the body kept ~n the operating room until cardiac activ,~ty s~opped.

IllusLrative case ..a~esenL~tions

Case 1
Thi~ 35-yea~-~,Idman was admitt(~dto ~he emergency room early one morn~.ngafter
.shooting himself i~ the ~igh't~emPlewi~;ha 38-caliber revoh~er. Vital s~ns::were: pulse 96.,
blood pressure 2921110, rc~:~cati0n 28. The bullet could be pa:tpa.ted ~ubcutaneou~|y.i]~
the ]ef~ temporal ~ a . Them Was papilledema bilateralIy: ]~.e was thrashing ehou~ and"
mumbling incohe~e~,tiy,bu~d:fd not respond t~ verbal ~timuIL:i-Ie moved both axm~and
 :,20~ :
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. ..,,

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..hh.left leg spontaneously and. in.resp0nse.t~ pain. Slcull..X-ray:.ShOwed bullet".fragments.

in.ilthe.:hypothalaraus",:i.m!d~brain,_:left
;p arietallqobdi"and-le.ft'~
te.rnp~,ralis.,
muscle..'..iS!SO.rtly.?
.dfter admissidn~ .-both.l~pils.bec"a~ne',fixed .ai~dVdilatedani~..he ddwloided '.decdi~brate.-.
15osturing.:He was then intub~tted:and .trmlsferred.tO:theiIntlmsiw.,Care unit/for,Supper- -.:,
t~ve care..Twelve .',ibUrsafter".adrai~ssion'
he.developed .d.iabete!~:ii~il~idUsland,e~e'rthe'.nex~ ~.:
60 hout~ he prodt~ccd.13400ml~of:urinean~ required 2000 xnl ofp!asmahat~ and .ii.3001":
ml .of..cr~sta~loid~to.maint~fin~.:centrnl..venous..pressure"'.b~ 5 -:.'H):'m.H20..The ..initial-
diuresis Cai~s0d a marke~i potassium 1Oss,iwhich'required 3i~0:m~equivs .of:ipotar~iumin..Y
the next 12 hour~ .to.mai~tain normolealemia. l~ight~er~..hou~.afteradmis~ion,ihebe~:ame
apncic~ flaccid,by pothcrinic,,and "hypotensive....The. hypotension,reSl:iond~d :to.a. rapid
infusion of 500 ral Of halt-normal saline and 1.200 ml Ofe0il~id~.0n.the: da~? ~fteradrais-.
sion .a forma~ .braindeath!evaluation .vca~initi~t~d.T w o .e~i~ilca!exami~a~!0p~ipe:~formed-
at 3~ and 37 .~a.~r~.~ after adraission d~d fiot.reveal"any evi.deaceof cerebral"functi0n..;ind
an E E G recorded betweenG~c ~,Y~oexaminationswas.isoelectl~ic.The.patient was certified
brain dead and permission was obtained [or kidney do~ati0n'...By.this.time his mean
arterial pressure hsd fallen to 55 tdrr with a central..venouspressure~of ~ .i.'raH20, so a.
doparalne i ~ f . , s i o n w a s . ~ t a r t e d s t 6 .~zg p e r k g p e t " r a i n t o ~ , ~ a i r ~ t a i n ~ ; e n a l . 1 6 e r . ~ n s ~ b n . ' F o r t y -
eight hours after admission, s h o r t ~ , y before ~ kid~ey..re~iovai Wa.~ S ~ . h e c i u l c d , b e ' w a s
noted to ha-~e spontaneous move:hents Of all four ex~r~.mities,resembling decerebrate
posturing. ~'hese movements could also be induced by pair~fulstimuli. Because of this.
organ donation was. cancelled and his .neurologicalstatus.n~.~eased. He remained apneic
with no detce~able crafting-nerveactivity.Asccond EEG.~IFig. 2) was g~so isoeleetric
during the raovements. His blood alcoholievel wag 0 and..tberewas .n0 detectable barb|- "
turate, phcnothiazide, salicylath,araphetamine, morphine~ cocaine,,raethad ne .orquinine
in his urine. His heart rate .did not.increase foU0wing:i-rag of intravenous atropin6..An
isctope flow study with technetium.stannous .DTPA (diethylenetriamineperttaaceticacid)
did not detect any circulatidn.toeither t,h(eanterior oJrmiddleeereh~aI arteries,-interpreted
as obstruction to all flow through ,both internalcarotids. Cereb:ral::angi0g~mphydemon-
strated that there was nO f e w through the.leftvertebralar.te.ryto.ihe..p0steirio~"fossa"and
only minimal sluggish flow to severa! branches .of.theriglitan~iol ..and.middle cerel~ra]
arteries.Intracranialpressure was. measured :by..the.hoi}.owlbolt"tecb'niclu~,.~;d:Wasf~und
to .he.above theraean-~irterialpres~ttre..iAsecond,formal bra[n'death-ev~lu'ation:wasidbne'
after these.studies were. corapleted. Clix~!cal:exarn~riatio,.n.S
at .68:and 72 ho..ulis.afteradm.is:,
sion revealed no cranial nerve,activity.:Athlrd'EF.G ree0rded between th~se:tw0 exper-
|meats was ~so isoelectricThe pa'tient@as theta,certifiedbr.'tin.dead"a.Se~end time and
cardiopulmonary suppo.rt,discontinued. Cardiac acti~ty...stoppe,~several ~.~inute~.later...
The kidneys'were not used bccau.~e0f.rdfractoryhypotenS]0~i"dndoligui-ia:du~irig'~he last
five hours before finalbrain death certlficiafion.

Case 2
This 18-yea:~o|d white raale..~ustainedraultip~einj~rie,~ine m,~toz~.ve!~ic~eaccident.
On adrai.~ion to an outlying hospital,his blood p~esst~r~was,8~I/~~pulse 96 and respira-
tion '"labored".There was blood drainin~ from both ea~s.Rhorrchi were heazd k)veCboth
lungs. The heart, abdoraen, and extrern!tieswere norrnal. On'neuro~ogice~::am!nation,he
was noted to be unconscious ",. nd.unresponsive. There ~as a.~ight .Bal#ingkis~gn, d~ep
tendon reflexes ~verv absent, the..eyes,were deviated to the rightwith con~i~ic~ed,puI~i|s
which reacted sluggishly.~o the light. Skull.X-ray xarninati~n.was negative, but chest :
X-ray showed fractures of ribsl.3- !} on the right and 4 ."9.0n ~he lea ~ithno:app~a~ent
hcrao- or pneuw,0thorax. He was admittedire the.lntens~.veC a m Unit.w,'~,ere..treatmenl;
consisted of ~iasotrachealintubati0n and c0ntr~!led mec!~anical venti[atio.nui~ingdinZe-
pare and curare, volurdereplacem~n~.witb 2000 nil of crys~dl0id andltwo.~/iz~its0f whole.
blood, and dex~u~ethasone and fu::oseraide'for.'cerebral'edema. Twel;ehours after the
accident, he remained, unresPbnsi~o~.and hypoi~ensiveand w ~ oliguric.Hispavettts Were
told.that he.was brain de'nO.andDerrnissi0n we.-sobtained'to i:em0ve hi,,i'.i~idneys
for trans-. "
plantation. " " . . . . . . ' " : ". . . . " ' ' :' ". . . .
206

'.~ 0
 1:2o7 ... ' , ' .

:i,
. ' The ..patient was transferred to. thePrel~l~y~rian.:Uni,)erslty...Hospit;al, for lthe s01e
purpose, o f organ'd0nation, i On ar~'ival ..in"0ur' emergency room; his bl00dpregsure.wa~
60/0 ,With""apulseiof i40 a:nd'i~)eca~ional::.i~l,?n~aneous:/esiii'ratorYe~fforts~ Blo0d:~ind
.:~rebrospinal"flUid were draii~il~g!from both '~,~si"Tl~e/c~w~::e~t~ive eervi~l:isub~uta'-.
i~eou~ ernphysema~ He did not.raa~:~~o n0xi0ti~i~t.~r~Uii~ ~u~ did ~ave.~nat|"reactive}~up~l~ ~
Wi~h:.an.-intaCt eiliospinal. ~flex.,;.spontaneods faeia[igfimacing; and~pontaneou~:resl~ira:
tion..After, resuscitation with.vigorous velum(i, lrePlacemen[;aud.tube-thor~m0stor~ies:.:for ~
bilateral hem0thoraces, his biood pressure, ineileas~d, and.Urine output retuzned;.W[th' ~he
~xnprovement of hemodynamic status, his ne~=~oIogic"statu~ ~lsv::improved and hebegan.
to have spontaneous move:rnez|~Oall h is extremities, He Was.placed in Cr~ztchfield to ia2~
because of a possible C-7 frac'~iure disiocati0nan;d the n:.transI~erted tb: theintensive'Cars
Unit, A caxotid angiogram was normaI.' His.near01ogiestatus.improved.rapidlY alter l~is
other injuries were treated .apI~.ropriately and he was transfer~.~d to a rehabilitation Center
57 days after the injury with his only residual neurologic deficit being a right hemip.aresi,-:
and slight imp~rn~ent of higher cognitive f t m e t i o n s . .
. .. '. , . ' .

Results

As shown in Table t, 72% of thepatients became brain dead as .a result

of an in~racerebral hemorrhage or trauma. The me~m age :of these pafien%s
was 44 years h~. the group with cerebral bleeds and 30 years, in ~he ~ u p
wi~h trauma, Thus mo~t of the patients ,~n our"series were ~,.~an age range
to make them suitable organ.donors. '.
Cardiovascular instability, defined a s a systolic blood pressure.of le.q~
than 100 tort for more than one h o u r or the presence o f a p.otentially f a t ~
atvhythmia, occurred in 45% of these patients. Cardiovascular instability
was not significantly associated w i t h a n y one etiology 'of :br~hndeafln...
Diabetes insipidus was present in 8,5% Of the: patients. Al~solute inumbers.
were too small to make any significant associations with an et[c:]ogy; although
it did seem to b e a bit more.common in those patient~ wh0 suffd~di:frauma.
Persistent spinal cord reflexeswere.present in :10.8% 0f :the: pa~ie.nts,: . . . .
Spontaneous hypothermia i s a Characteristic 'vfbr~n' deatl~ :~d:i.in ;our
series of patients the mean body temperatvyeat the thnd.0f brain.death.was
34 C with a range from"27 to 40 C. Only seven patients," all infected; had
body temperatures greater than 37 C a t t h e time brain death wa/:~.ertifiedi.
' . . . . ''...

Discussion

Diagr~osis of brain death

The need for a careful, standardized approach to ~he evaluatio:nt of brah~
death is exemp!ified by Case 2. I t is essential both to demonsl~ate .an irre-
versibIe central nervous system Ies~on With the potential of car.sing brain
death and to normalize cardiopulmonary and metabbl~c status b e [ o r e certifi-
cation of brain death is undertaken. After these prerequisites hmre been met,
certification of brain death should only b eundeztat;en:.by physici~ms wit2~
experience in this axea Using a standardized checldist; to minimize the possi..
bil~ty of errors.of omission. . ' ::.: ". ;
 .: ,:lit:is::necessaryto rely o n .cranial nerve, and, not spinal:.cotxlrefldxes .in
thei :diagnosis".of:"brain death because the spinal'cord.,neurons .cAn '.~emain
'viable'a~ter:brain function h ~ ceasedLThe.somat~c-imO~or movements f~rn
ii)~rsistent.spinal reflexactiv.ity .~hat.wereseen in!..iO~8%iOfl..our ~p.~tients"ilare
in..agreement ~ith. t h e 9% incidence .reported. by others [i0]~ Mos~ could be.
easily"recogni:,:ed a.,~ being of.spinal reflex: ori~,~n; :..e.g.; .tapping. the patellar
tendon causing contraction of the quadriceps muscle. T w o patients,:including'
Cas el, had c e m p l ~ integrated movements of mu]itiplemuscle group~i Which
Were difficultI~o ascribe to spinal reflexes on clinicalgrounds. An isoelectric
B E G duriug the movement and multiple studies idocumenting"al)sence of
cerebral perfusion make it very unhkely that ~Ly cerebral activityproduced
these movement. In the occasional patient w h o does havesuch complex
muscle movements additional tests to document the absence of cerebral
blood flow should be considered before certification of brain death. How-
ever, it should be noted that a test of cerebral blood flow, as a single study,
does not confirm the presence or absence of brain death.
Spontaneous muscle fasciculations may interfere with the recording of
the E E G (Fig. 3), It is acceptable and often necessary to use neuromuscular
p,arMysi~ to abolish muscular artifacts during th,2 recording of the E E G as
long as a neuromascu.lax stimulator is used to insure that the dru~i effee~ is
gone before the next elhlical examination is performed, Neurc~muscu.lar
paralysis may also be necessary for abdomina]l relaxation, at the time of
removal of donated organts from brain dead palfients with pelrsis~entspinal
reflexes.
Several hm:azcls may be a~sociated with a test for apnea. Because hypo-
earbia may induce apnea [17], the pCO should not be below normal at i;he
st'art of the apnea test. However, since h y p o c ~ b i a .can also cause a marked
decrease in ceJ~eb~al blood flow. and intracranial pressure, many of th,ese
patients will be intentionally hyperventilated to manipulate Jntracrauial
pressure, and blood flow [18]. We have observed dramatic increases in intira-
cranial pressure when the pC'02 was allowed to lgse to norma!levels .for an
apnea b~st, demonstrating rite .potential four fu~.~her, compromise of br~fin
function during this test. We therefore requh'e that all other clinical critel:ia
be satisfied before the apnea tet;t is performed!. Clearly, the apnea test should
not be used in the routine ~s.essment of a cornato~e patient.
Another potential ha',,.ard of discontinuing mechanical ventilation
during ~u apne~a test is hyp,oxia. This probl~m can be eliminated in most
patients ,by p,~e,oxygenatio~ with 100% oxysen or passive apneic diffusion
oxygenahon dt~:fing ~he period of disconnection J~rom the ventilator using a
5 - 7 1/m~n flow of oxygen through a small catheter passed down the endo-
t~acheal tube. Some patiem~,S with preexisting chronic .hypercarbia require a
h~zpoxic stimulus to breathe and will not breathe in response to an increase
in the pCOs. Such patiant,J must be allowed to become hypoxic during the
apnea test to insure that they have .received a valid physiologic stimulus.
The validity of our .~nethod of apnea testing was confirmed when the
p~:tients were certified b].',~Jn dead and disconnected.from ~he ventilator,
 i.~ ' . 2 ( ] 9

" ' ' . "ii.i . i . . . ' ' . . i ~',

"210

since none of them exhibited any spontaneous '.respiratory efforts ~ith much
longer periods of apnea.

Problems in systemic support

. The 45% incidence of cardiovascular instability in this series almost
certainly underestimates the ~ t u a l incidence of cardiovascular instability
.in brain death, since there wa~: a large subset of patients who were not in-
eluded in:this series because t h e y sustained a ca~ztiac arrest before t h e y could
be officially certified brain, dead. Because cardiovascular collapse may cause
revemible cessation of cerebral a,~ivity~ as Case ~: dramatically ~.~lustrates, any
hemodynamie derangements should be corrected before brain death is
ce.~ified, It is our experience that most of l;hese patients are relatively
hypovolemic from generalized vasodilation w~th low central ven,,:~us and
pulmonary artery occlusion pre~.,sures. igorous fluid replacement tc~ restore
cardiac filling pressures to no,final will often be sufficient to res'~gre %he
blood pressure and urine outp,Jt. If hypctension and/or oligm~[a persist after
adequate volume re~)acement, dopam~ne is tit;rated to give '.an aeceptabIe
blocd pressure a~d adequate, urine output. Since, many of these patients are
potential kidney donors, vasoconstricting agents such as no,epinephrine or
high doses of dopamine should be avoided.
A wide variety of mThythmias was encountered in this patient group.
Most responded to conventional therapy. Iqo~ever, it ~s important to realize
that bradyarrhythmias will not respond to afro,pine because their etiology
is noL increased vagal activit:r, tn fact, an incre~sed heart rate after atropine
in a presumed brain dead pal;ient negates the dia~nosis, as the atropine test is
a sensitive indicator of brain stem function [ 19]. Therefore, an agent with a
direc~ chronotropic effect, such as isoprotereno]!, sholfld be utilized in the
treatment o f bradyarrhythmias in such patients.
Diabetes insipidus occurred in 8.5% .of our patients. Large losses of
fluids and electrolytes, especially potassium, may occur rapidhj if '~his syn-
drome ~ not recognized. Frequent measurement of urinary electroiytes and
volun~:es is necessary to adequately maintain optim~ fluid balance. Aqueous
pitres~;in in doses of 3 - 5 un:~ts subcutaneous.~y, repeated as needed on the
basis of urine volume and specific gravity, has proven helpful in the fluid
management of these patients.
A pmgnan~ brain dead patient was encountered once in this se:des. Ob-
viously, s u p p o r t of v:~tal organ systems must be. continued after maternal
brain death if the fetus is to be saved. The fetal he',~ should be mc.nitored
con%~,nuou~ly and f2tal matur~t:y assessed by amniot~c fluid mmlysis. The
inf.'at should be delivered by cesarean section as soon as it has a zeasonabte
chance of survival. The use of oxytocin to induce labor should probably be
avoided because of the potential for maternal cardiovascular collapse during
the ]process. Arrangement.~ for emergency cesarean section and infant resus-
citation should be made in advance with equipment available at the bedside,
thus permitting this p~ocedu~e to be per~0rmed at. the first sign of fetal
distress or maternal cm'd~ova~euk.x co~lapse.
 :211
. . . . . '. . . . - . - .. . . . .,

ForensiciSocia~'andeconomi~.co~isideratior~s?. .... :i.. i ; : : : , : : : :::" ::

: : T o : avoid confusion concerning the :legal :time::of death, ou~:prot0col
specifie~, that :the :official time o f death occurs 'at the ifime.of braifi:death.cer-
tification .and' riot':at :the :time o f ceiiSation o f : c ~ i a c aCtivi~."It reqt~LreScon-
tinuing .education ::of involved: pecz~nnel .to: prevent~:miS~ders~andings' about
this Concept, In coroner's cases that axe' Organ donoi~s~ the physician 'should
inform the coroner ofthedeath certification and obtain his permissidn before
organ removal to aVOidpossible leg~I problems. In Cases of'organ donation,
death is certified immediately prior, to transfer from ~bheIntensive Care Unit
to the operating room. After the donated organs have been removed; cardio-
pulmonary support is discontinued and the corpse is kept in the operating
room ~ttfl cardiac activity ce~es. When this has hai)pened, the body is then
transferred to the morgue and :~houtd not be returne~ to the Intensive Care
Unit.
The concel~t of brain death ar.td our s'~rict protocol f o r t h e diagnosis of
brain death are carefully exp~air~ed to the rele~ives before actually discon-
tinuing cardiopulmonary support. "]?herelativeshave usually understood and
accep'~ed the concept of bra~ death and are often :relieved to k n o w that
their loved one ~II not be maintained in a vegetative state. Only one fea~ily
absolutely refused to accept the fact tha~ their relative could be dead if h~s
heart w ~ still beating, and it was felt prudent to continue ve~tflatory
support f~n this patient until a cardiac arrest ensued fi~'e days later, How~et,
it should be emphasized that the decla~ation of brain death is based on
medical .criteria only and does not requi[re permission of: the next of kin.
We would advise that the relatives not be present du:dng~the tinge between
disconnection of the ventilator and cessation of cardiac activitY, Since we
have had one patient who devetol~ed reflex m.vn movement whenever the
artetda! pO= fell below 23 Tort. :
A protocol that allows for d~scontinuance of meaningless caxdiopu!-
monary .rapport after bran death has been certified should result in con-
siderable financial savings. Based on an ave~rage daily cost of: $:1000 ~n our
Intensive Care Unit [2~3] and assm~aing that each of our bzah~ dead patients
would have survived an additional 4 8 hours if they had not been certified
dead and disconnected :from ventilator support, ap~roximately $359 00(}
have been Saved in the se~vea years this brain death prc~tocol has been in use.
More widely applied, the~ p~tential for decreashag the na'Cional health-care
budget ~s significant. Wider appl~cafion is appropriate in that the money is
otherwise spent on heart-beating cadavers with no hope for recovery.

Conclusion

The state of brain death can be reliably diagnosed wilfl~the knowledge

a n d techniques currently available. ~ y center caringfor cr~tical!y ).I1patients
should feel obligated to adopt a st~mdardized sys~;emat~c approach to this
condition and to the diagnos~s of b r ~ death. The mah'~Lproblems associate~l
212

with the implementation of such a.protocol will be:educati0n of involved

personnel,: communication With relatives,use.of the diagnostic.Criteriafor
brain .death,..andmanagement .10f..themedical complications ass~ciated:with
the brain deed state..The:benefits of such a careful-systematicapproach to
the brain.de~patient are multiple, It Clecreases:fatileintensivecare,spares
family member, the physical aud emotional drain of a prolonged death
watch, .provideseconomic benefitsboth for the relativesand society,facili-
tates the procurement of healthy donor organs for transphntation and,.,most
importantly, minimizes the possibility of death certifica$ion.when brain
function rem~s..

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