Brain death

Brain death is defined as a complete and irreversible cessation of brain activity. Absence of apparent brain function is not enough. Evidence of irreversibility is also required. Brain-death is often confused with the state of vegetation.

Traditionally, death has been defined as the cessation of all body functions, including respiration and heartbeat. Since it became possible to revive some people after a period without respiration, heartbeat, or other visible signs of life, as well as to maintain respiration and blood flow artificially using life support treatments, an alternative definition for death was needed. In recent decades, the concept of "brain death" has emerged. By brain-death criteria, a person can be pronounced legally dead even if the heart continues to beat due to life support measures. The first nation in the world to adopt the brain death as the definition of legal death was Finland in 1971. In the United States, Kansas had made a similar law at an even earlier date. (Randell T. (2004) Acta Anaesthesiol Scand. 48(2): 139–44.)

A brain-dead individual has no electrical activity and no clinical evidence of brain function on neurologic examination (no response to pain, no cranial nerve reflexes (pupillary response (fixed pupils), oculocephalic reflex, corneal reflexes), and no spontaneous respirations). It is important to distinguish between brain death and states that mimic brain death (eg. barbiturate intoxication, alcohol intoxication, sedative overdose, hypothermia, hypoglycemia, coma or chronic vegetative states). Some comatose patients can recover, and some patients with severe irreversible neurologic dysfunction will nonetheless retain some lower brain functions such as spontaneous respiration, loss of both cortex and brainstem function. Thus anencephaly, in which there is no higher brain present, is generally not considered brain death, although it is certainly an irreversible condition in which it may be appropriate to withdraw life support.

Note that brain electrical activity can stop completely, or apparently completely (a "flat EEG") for some time in deep anaesthesia or during cardiac arrest before being restored. Brain death refers only to the permanent cessation of electrical activity. Numerous people who have experienced such "flat line" experiences have reported near-death experiences, the nature of which is controversial.

It is presumed that a permanent cessation of electrical activity indicates the end of consciousness. Those who view the neo-cortex of the brain as solely responsible for consciousness, however, argue that only electrical activity there should be considered when defining death. In many cases, especially when elevated intracranial pressure prevents blood flow into the brain, the entire brain is nonfunctional; however, some injuries may affect only the neo-cortex.

The diagnosis of brain death needs to be rigorous to ascertain whether the condition is irreversible. Legal criteria vary from place to place, but generally require neurologic exams by two independent physicians. The exams must show complete absence of brain function, and may include two isoelectric (flat-line) EEGs 24 hours apart. The proposed Uniform Determination Of Death Act in the United States attempts to standardize criteria. The patient should have a normal temperature and be free of drugs that can suppress brain activity if the diagnosis is to be made on EEG criteria. Alternatively, a radionuclide cerebral blood flow scan that shows complete absence of intracranial blood flow can be used to confirm the diagnosis without performing EEGs.

Most organ donation for organ transplantation is done in the setting of brain death. In some nations (for instance, Belgium, Poland, Portugal and France) everyone is automatically an organ donor, although some jurisdictions allow opting out from the system. Elsewhere consent from family members or next-of-kin is required for organ donation. The non-living donor is kept on ventilator support until the organs have been surgically removed. If a brain-dead individual is not an organ donor, ventilator and drug support is discontinued and cardiac death is allowed to occur.