UB Center for Clinical
Ethics and Humanities in Health Care

Ethics Committee Core Curriculum

Determination of Death
Consensus Conference

Consensus Guidelines Attachment A

GUIDELINES FOR DETERMINATION OF DEATH BY IRREVERSIBLE CESSATION OF ALL FUNCTIONS OF THE ENTIRE BRAIN, INCLUDING THE BRAIN STEM (AGE GREATER THAN ONE YEAR)

NOTE: All 9 items must be answered YES to declare brain death.

Have reasonable efforts been made to notify the patients' next-of-kin or other person closest to the individual that a determination of death based on cessation of brain function will soon be completed?
YES_______
NO________
Is the cause of the coma known and sufficient to account for the irreversible loss of all brain function? NOTE: Coma of unknown cause (e.g., no evidence of brain trauma, stroke, hypoxic/hypotensive injury) requires a diligent search for the cause of coma before brain death determination. Similarly, the magnitude of the brain injury must be commensurate with irreversible cessation of all brain function.
YES_______
NO________
Are CNS depressant drugs, hypothermia (<32 degrees C) and hypotension (MAP <55 mm Hg) excluded as reversible causes of brain failure and has any effect of neuromuscular blocking agents been excluded as contributing to the results of the neurologic exam? NOTE:

Specific levels of CNS depressants or neuromuscular blocking drugs are left to clinical judgment.
Brain death cannot be declared in the setting of hypothermia (<32.2 degrees C).
Shock, as defined as a mean arterial blood pressure less than 55 mm Hg, prohibits the declaration of brain death. Pressors to support arterial blood pressure may be used (mean BP = (2 * BP diastolic + BP systolic) / 3).
If levels of CNS depressants or neuromuscular blocking agents cannot be excluded as contributing to poor neurologic status but cerebral angiography demonstrates there is no intracranial blood flow, then proceed to item #4.

YES_______
NO________
Is all movement attributable to spinal cord function (i.e., there are no other spontaneous movements or motor responses)? NOTE: Posturing and shivering in the absence of neuromuscular blockade or learned movements in response to pain in any extremity or the head preclude the diagnosis of brain death. Deep tendon reflexes including stereotypic triple flexor responses in the lower extremities are compatible with brain death. These include spontaneous slow movements of an arm or leg. Bizarre movements of entirely spinal origin may sometimes occur in brain dead patients. Also, coordinated movements can occur with shoulder elevation and adduction, back arching and the appearance of intercostal muscle contraction without detectable tidal volumes. Finally, in a few patients, the "Lazarus sign" may develop when the ventilator is permanently disconnected; the head and torso may flex and for a few seconds rise from the bed with arms outstretched, then falls back and the dead body remains permanently flaccid in the supine position.
YES_______
NO________
Absent cough and/or pharyngeal reflexes?
YES_______
NO________
Absent corneal and pupillary light responses?
YES_______
NO________
Absent caloric responses to iced water after visual examination of the tympanic membranes?
YES_______
NO________
Has an apnea test of a minimum five minutes duration showed no respiratory movements with a documented PCO2 greater than 55 mm Hg with a pH of less than 7.40? NOTE: Extreme caution should be exercised in the performance of the apnea test. The apnea test should be conducted only after all other evaluations are completed. An apnea test should be performed in such a manner as to minimize the risk of hypoxia or hypotension. Delivering a high concentration of oxygen to the airway (4L/min) before and during the apnea test reduces the risk of hypoxic complications. If mean arterial blood pressure falls significantly during the performance of an apnea test, it should be discontinued with an arterial blood sample drawn to determine whether PaCO2 has either risen above 55 mm Hg or increased by more than 20 mm Hg from the level immediately prior to the test. If so, this validates the clinical diagnosis of brain death.
YES_______
NO________
Have one of the following four criteria (A,B,C, or D) been established?
YES_______
NO________

A.
Items 2 to 7 have been confirmed by two examinations separated by at least six hours, and item 8, the apnea test, validates the clinical diagnosis of death.
YES_______
NO________

B.
1.Items 2 to 7 have been confirmed as YES.
2.An EEG shows electrocortical silence.
3.A second exam at least 2 hours after the first, confirms items 2 to 7 as YES, and the apnea test validates the clinical diagnosis of death.
YES_______
NO________

C.
1.Items 2 to 7 have been confirmed as YES.
2.No intracranial blood flow is evident.
3.A second exam at least 2 hours after the first, confirms items 2 to 7 as YES, and the apnea test validates the clinical diagnosis of death.
YES_______
NO________

D.
In the event that any of the items 2 to 7 cannot be determined because the injury or condition prohibits evaluation, (e.g. extensive facial injury precluding caloric testing), then the following criteria apply:
1.ALL items which are assessable are YES.
2.No intracranial blood flow is evident.
3.A second exam at least 2 hours after the first, confirms all assessable items as YES, and the apnea test validates the clinical diagnosis of death.
YES_______
NO________

Having considered all the above, I hereby certify the death of:
________________________________________ Date: _________________
Time:________

Certifier:_______________________________________________ M.D.

Printed:______________________________________

Contemplation of Organ Donation

When organ donation is contemplated, the time of death must be certified by a second physician. Neither the physician who determines brain death nor the second physician who certifies the time of death can participate in the procedure for removing or transplanting the organ.

Second certifier: _________________________________________ M.D.