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Brain death

Key sources
The following summarized guidelines for the evaluation and management of brain death are prepared by our editorial team based on guidelines from the Congress of Neurological Surgeons (CNS/AAN/SCCM/AAP 2023) and the American Heart Association (AHA 2023).


1.Diagnostic investigations

General principles: follow the standardized process in this guideline for the determination of BD/death by neurologic criteria unless otherwise legislated by local, regional, or federal authorities.
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  • Consent acquisition

  • Prerequisites for evaluation (etiology)

  • Prerequisites for evaluation (timing)

  • Prerequisites for evaluation (hypothermia)

  • Prerequisites for evaluation (hypotension)

  • Prerequisites for evaluation (drugs and metabolic derangements)

  • Prerequisites for evaluation (neuroendocrine function)

  • Neurological evaluation (numbers of examinations)

  • Neurological evaluation (components)

  • Apnea testing

  • Ancillary testing (indications)

  • Ancillary testing (tests)

  • Determining time of death

2.Specific circumstances

Pregnant patients
Recognize that pregnancy in and of itself is not a contraindication to BD/death by neurologic criteria evaluation. Assess and diagnose pregnant patients with catastrophic, permanent brain injuries for BD/death by neurologic criteria.
Educate and discuss with surrogate decision-makers the risks and benefits to the fetus of continuing maternal organ support, assisted by clinicians knowledgeable in maternal-fetal medicine, child neurology, and neonatology as needed, after determining BD/death by neurologic criteria in a pregnant patient.

3.Patient education

Family support
Provide support and guidance for families as they face difficult end-of-life decisions for their loved one who has sustained a catastrophic brain injury. Ensure that communication is clear, concise, and supportive and includes simple terminology that families can understand. Provide appropriate emotional support for the family.
Ensure that hospital policies include consideration of providing a reasonable period to accommodate families after the death of a family member and provide a process to resolve disagreements when families do not agree with the medical team about the initiation of the BD/death by neurologic criteria evaluation and/or termination of organ support after determination of BD/death by neurologic criteria.

4.Follow-up and surveillance

Organ donation: consider discussing organ donation in all patients resuscitated from cardiac arrest and meeting neurological criteria for death.

5.Quality improvement

Health professional training: ensure that attending clinicians performing BD/death by neurologic criteria evaluation are appropriately credentialed members of the hospital medical personnel and adequately trained and competent in the evaluation of BD/death by neurologic criteria in pediatric or adult patients, as applicable (such as intensivists, neurologists, neurosurgeons) and in accordance with local laws and institutional standards.
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  • Avoidance of conflict of interest