Determination of Brain Death

The purpose of this guideline is to provide a summary of criteria for determination of brain death as well as sample documentation that is consistent with Jackson Health System policy and Florida statute. Jackson policy refers to the American Academy of Neurology guidelines regarding apnea testing and so the relevant portions of these guidelines are included below. Due to the frequency of updates to these policies, we highly recommend that clinicians review the most recent versions of the JHS Policy “Brain Death Determination in Adults” available in Jet Portal as well as the most recent AAN “Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline” prior to conducting formal brain death testing.

Two physicians licensed in the State of Florida should perform separate clinical examinations. Jackson policy states that one examiner should be the attending physician and the second may be a board-eligible or board-certified neurologist, neurosurgeon, internist, pediatrician, surgeon, or anesthesiologist. Neither physician may participate in any procedure or process for organ procurement or transplantation.

• Presence of a diagnosis that is compatible with the clinical diagnosis of brain death.
• Absence of any drug effect, including sedation and neuromuscular blockade, which would obscure the reliability of the clinical examination.
• Core temperature greater than or equal to 36° C (96° F).
• Systolic blood pressure greater than 90 mm Hg and PaO2 greater than 50.
• Exclusion of any complicating condition that would preclude the ability to perform a clinical examination (e.g., severe electrolyte or acid-base disturbances, sodium level greater than 160 mEq/L, endocrine dysfunction, severe facial injury, and cervical spine injury—e.g., high quadriplegia).

• If patient has recently received sedating medications, wait 5x the half-life prior to conducting clinical examination for brain death.
• If patient has received neuromuscular blockade, use train of four to confirm presence of four twitches prior to conducting clinical examination for brain death.
• Many patients with brain death require vasopressor support to maintain SBP > 90. Pressor requirement is not a contraindication to clinical examination for brain death.
• Many patients with brain death require warming measures such as Bair Hugger or Arctic Sun to maintain core temperature > 36° C. These warming measures are not a contraindication to conducting clinical examination for brain death.

• Coma or unresponsiveness – no cerebral motor response to pain in all extremities.
• Absence of brain stem reflexes.
• If the clinical examination is consistent with brain death (confirms coma/unresponsiveness and absence of brain stem reflexes), proceed to apnea assessment per American Academy of Neurology guidelines. (If unable to perform apnea test, document the reason ie hypoxia, arrhythmia, etc.)

GENERAL:
Patient lying in bed, unresponsive, connected to the ventilator, NO sedation since arrival, currently on the following drips ***

VITAL SIGNS:
HR:
RR:
Sat:
Temp:
BP:
GCS:

BRAIN STEM EXAMINATION:
Pupils
R: __mm fixed
L:  __mm fixed

Oculo-cephalic reflex: Absent (no motion of the eyes with head movement to each side)
Oculo-vestibular reflex: Absent (no deviation of the eyes with instillation of 30mL of iced saline on bilateral external auditory canal.  Interval of 5 min between examination of the two sides)

Facial motor response
Corneal reflex: Absent
Jaw reflex: Absent
Grimacing to deep pressure to superior orbit and nail bed: Absent

Pharyngeal and tracheal reflex
Gag reflex: Absent
Cough reflex: Absent

I have personally seen and examined this patient.  I have reviewed the medical record, laboratory workup and all available imaging.  I have discussed the case with the ICU team and with the consultants on record.  This patient’s examination is consistent with the diagnosis of brain death.

Plan:
Apnea test
Independent review by a second team to confirm diagnosis
Certification of terminal condition
Change of directives to DNR
Contact OPO strictly under institutional protocols

• Remove all clothing and blankets so that motion of any part of body can be observed.
• Start by checking for spontaneous breathing: set vent to PSV with backup off or simply disconnect vent from ETT.  Observe 30 sec for spontaneous breathing.  Sometimes vent will sense 10-20ml tidal volumes which are from cardiac impulse.
• For facial motor response, apply deep supraorbital and chin pressure.
• Check gag reflex by gently moving ETT within throat
• Check cough reflex by advancing suction catheter

• Patient is hemodynamically stable.
• Ventilator adjusted to provide normocarbia (PaCO2 35–45 mm Hg).
• Patient preoxygenated with 100% FiO2 for >10 minutes to PaO2>200 mm Hg.
• Patient well-oxygenated with a positive end-expiratory pressure (PEEP) of 5 cm of water.

• Provide oxygen via a suction catheter to the level of the carina at 6 L/min or attach T-piece with continuous positive airway pressure (CPAP) at 10 cm H2O.
  Disconnect ventilator.
• Arterial blood gas drawn at 8–10 minutes, patient reconnected to ventilator.
• Reasons to abort the apnea test include the following:
  1. Patient takes one or more spontaneous respirations OR
  2. Hemodynamic instability (defined by AAN as SBP<100 mmHg or MAP<75 mmHg in adults despite titration of vasopressors, inotropes, or fluids) OR a cardiac arrhythmia with hypotension OR progressive decrease in oxygen saturation below 85%.
• For patients known not to have chronic CO2 retention, apnea test is consistent with brain death/death by neurologic criteria if:
  1. No spontaneous respirations occur AND
  2. pH<7.3 AND PCO2 ≥60 mm Hg AND 20 mm Hg rise from pre-apnea test baseline value.

***AAN guidelines provide detailed instructions regarding patients with known or suspected chronic CO2 retention. For these patients, we recommend careful review of the AAN guidelines.***

• Confirmatory tests are not mandatory for all patients but may be used in patients for whom a clinical exam is inadequate, unreliable, or unsafe to perform such as those with cervical-spine injuries or cardiovascular instability.
• Use clinical judgement to determine if and when the following tests are to be conducted:
  1. Radionuclide Perfusion Scintigraphy
  2. Transcranial Doppler Ultrasonography (TCD)
  3. 4-Vessel Catheter Angiography

1. Etiology and irreversibility of condition
2. Absence of brainstem reflexes
3. Central apnea tests results, if performed
4. Confirmatory testing and results, if applicable
5. Absence of motor response to pain
6. Date and time of determination of brain death
7. Notification of next of kin/surrogate or attempt to notify if unable.

Jackson Health System Policy 400.087 “Death by Neurologic Criteria (Brain Death) Determination in Adults”. Revised 06/19/25.

Greer DM, Kirschen MP, Lewis A, Gronseth GS, Rae-Grant A, Ashwal S, Babu MA, Bauer DF, Billinghurst L, Corey A, Partap S, Rubin MA, Shutter L, Takahashi C, Tasker RC, Varelas PN, Wijdicks E, Bennett A, Wessels SR, Halperin JJ. Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline. Neurology. 2023 Dec 12;101(24):1112-1132. doi: 10.1212/WNL.0000000000207740. Epub 2023 Oct 11. Erratum in: Neurology. 2024 Feb 13;102(3):e208108. doi: 10.1212/WNL.0000000000208108. PMID: 37821233; PMCID: PMC10791061.