17 Brain Death

Abstract

Brain death, legally recognized as death, is defined as irreversible loss of all brain function. The clinical assessment should reveal irreversible coma, loss of brainstem reflexes, and apnea. In the presence of confounding variables, or when the apnea test cannot be performed or completed, ancillary tests are needed to confirm the diagnosis. However, due to their variable accuracy, physicians should understand the limitations of each test. Given the legal and ethical implications of the diagnosis, physicians should have a solid understanding of the approach to brain death, using evidence-based guidelines, taking into consideration hospital policies and state laws. The medical team should provide psychological and emotional support to the grieving loved ones, following a consistent approach, taking into consideration their religious beliefs. Unlike in adults, the declaration of brain death in pediatrics requires two examinations by two different physicians. Legally, hospitals are obliged to involve organ procurement agencies. Early involvement is essential; however, the discussion should not proceed until death is declared. The time of death is when the arterial blood gas (ABG) reveals a PaCO₂≥ 60 mm Hg or a rise in PaCO₂of more than 20 mm Hg from the baseline, with lack of respiratory movement, or when the results of the ancillary tests have been officially reported. Organ donation after brain death could save many lives. It is essential to understand and treat the physiologic derangement that follows the catastrophic brain injury and can lead to worsening organ function.

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