How to Determine Brain Death

It’s often the reality no one wishes to confront.  But after severe brain injury or extensive brain damage, the doctors will often say it:  he’s BRAIN DEAD.

What does brain death mean?

Brain death is the irreversible loss of function of the brain, including the area that controls life – the brainstem.  It is the end of all brain activity.

In the US, brain death is a legal indicator of death.  It is regarded the same as someone whose heart has stopped beating.

How do you determine brain death?

The doctors will perform careful tests before they can safely proclaim someone as brain dead.  Before they perform the exams, they will likely explain what they’re considering, and should tell you the results after.

Medical Criteria for Brain Death: the 3 Cardinal Findings:

1.  Coma or Unresponsiveness
2. Absence of Brainstem Reflexes
3. Absence of Breathing (Apnea)

Let us dissect each criterion.

1.  Coma. The person in a coma cannot be awakened by any stimulus.  He does not respond to pain or speech.

2.  Absence of Brainstem Reflexes. Brainstem reflexes include:

  • Pupillary reflex: Pupils do not react to light.  They are fixed and dilated
  • Corneal reflex: Loss of blink reflex
  • Cough & Gag reflexes: No reaction when the back of the throat is stimulated
  • Jaw reflex: The face does not move when the jaw is tapped

Tests the doctors will often perform:

  • Oculocephalic reflex or Doll’s Eyes reflex.  The doctor will rapidly turn the patient’s head 90 degrees to both sides.  A brain dead patient’s eyes will stay fixed at midline.
  • Vestibulo-ocular reflex.  Often called the caloric test, the doctor will instill 50ml of cold water into the patient’s ears.  A brain dead person’s eyes will have no reaction.

3.  Apnea. The doctors will disconnect the patient from the ventilator and check blood gas levels after.  A brain dead person will  NOT breathe on his own, and the carbon dioxide levels on his blood gas will be very high.

Other confirmatory tests that support brain death, but are not necessary to diagnose it:

  • EEG (Electroencephalogram): shows no electrical activity
  • Cerebral Angiography: shows no blood flow through the Circle of Willis
  • Transcranial doppler: shows high vascular resistance associated with greatly increased intracranial pressure
  • Cerebral blood flow & MRI: shows no cerebral perfusion



Can someone who’s brain dead still have reflexes?

Yes.  Often loved ones get excited when they see small movements from brain dead patients.  Sadly, they can just be reflexes that don’t necessarily come from the brain.

It’s confirmed.  Your loved one is proclaimed brain dead.  What now?

Then comes the painful decision to withdraw care.

A brain dead person is only kept alive by artificial means – the breathing machine (ventilator), and sometimes medication to keep their blood pressure and heart rate.  Once off, the body will not be able to keep itself alive.

These are painful times.  When agreeable, families are often asked about organ donation.  In most circumstances, the doctor will discuss the path with the family, give them time to say goodbye, and then withdraw care.

39 Comments Post a Comment
  1. Reena says:

    I wish I’ve read this before having to go through the exact scenario with my grandmum. The physician did not explain it as well, and we all thought it was just another condition. May granny rest in peace.

  2. Will Shirley says:

    My son is 36 and has been in a facility since his auto accident 10 years ago. Could you please include information on the two conditions “persistent vegetative state” and “locked in syndrome”? It would especially help to indicate the accepted means to differentiate between the two.

  3. Kath says:

    GREAT suggestion, Will! Persistent vegetative state & locked in syndrome are two very interesting / contradicting cerebral conditions. They are, however, not related to brain death (which means absence of whole brain function, not just parts of it). Will try to cover those topics in detail in a different post :)

    But as a tip, I always say:
    Persistent vegetative state = awake but not alert/aware
    Locked in syndrome = alert/aware but cannot move, like being “buried alive”

  4. Hi, My pal of mine thinks that I might have teeth grinding, what should I treat it with?

  5. lashawda hill says:

    my dad sufferd a stoke and is brain dead and has a gaingreen foot and no circulation in his leg.i know its time 2 let go but i am more prepared after reading the articles.i just been praying and bracing myself so depressed

    • Lucia Leslie says:

      I’m so sorry, these must be very difficult times for you and your family. My thoughts and prayers will be with you.

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  10. nancy beaupre says:

    my husband was in full cardiac arrest for about 40 mins he resussitated and placed in life support a ct scan showed brain swelling and nearly no activity on an eeg all the docs and nurses gave him 0 chance i took him off life support and he died 8 hours later was i wrong- my feeling of guilt is terrible

    • Shane Forster says:

      No, you was just giving him a peaceful death. He probably would of died in the end anyway. So sorry for your loss

    • Johnnie M. Hurt says:

      Never feel guilty about a decision like that. There was 0 chance and no one wants to be in that position to make those choices but there comes a time when we all have to face something like this. It would have hurt even more just seeing your love one there suffering. So Nancy you made the right decision, just pray about it and know that you are not alone. May God Bless You!

    • renee says:

      I saw your post about your husband and i was in the same situation but not my husband it was my mom,she was 49 and she went into cardiac arrest and the nurses panicked and put her on life support on feb 7,2013 my brother and i told them to withdraw all meds and withdraw dialysis and on feb 8 they shut off the machine she peacefully passed on the 11th,i have much regret and guilt and always question myself and when im alone i think about it more it is heartbreaking but when im down i pray and tell myself my mom is free and she is thanking me,i hooe one day that guilt eases up for you as well and goodluck

  11. Thanks for sharing of brain death.

  12. jo says:

    hey there, im wondering if a person is brain dead, can his / her mouth or jaw move?

    my grandma recently collapsed and her pulse and breathing stopped less than 5 mins, but was CPR by the doctors, after that doctors said she might be brain dead or brain death.

    but somehow when i call her name, her eyes will open, i even said if you can hear me, blink your eyes once though she did it but in a slow motion.

    and she can even close and open her mouth.

    im really prepared to hear the worst but lets hope for the better.

    thank you so much.

  13. steph says:

    my brother is 21 and we were told he is brain dead as of 6 yesterday they only did the eeg mri and caloric test tested all his reflex and all is pointing to brain death the didnt do the apnia test were they take him off the vent they said he isnt strong enough he would probably die and they wouldnt be able to get his organs i need advice tommorow their taken his organs i need to know should i chance him dieing during the test or let them take his organs please help

  14. Kee says:

    I’m really glad I read this article. Helped me out a lot.
    Thank you

  15. matthew says:

    my uncle is 36 he went into cardiac arrest 3 months ago, his heart was working at only like 20 % he is apperently brain dead currently , he rolls his eyes sometimes, sometimes even can show facial expressions like when your about to leave, but doesnt show any mouvement in any of his body parts sometimes is able to squeeze your hand, is there any chance for him ?

  16. Beth says:

    I would like to say that me and my family are going thru this right now with my step father. 2 nights ago he was in complete cardiac arrest for 55 minutes without any o2 to his brain. The doctors say that being without oxygen to the brain that long has caused brain damage. At this point we don’t know how much. After researching online the effects of no o2 to the brain I can see that he will have severe brain damage, possibly brain dead. However, I went into his room yesterday and it is very hard to accept this because his eyes are open and “blink”. He has some facial movement. I can see how it makes it very hard on people to let go. I too, along with anyone else who has gone through this wish we knew if he knows we are present. I just kept talking to him and comforted him. I pray that he is at peace and feeling no pain at this time. We are waiting on the rest of his family to come in to say good-bye. To keep him like this would be a very selfish act i believe. He needs to rest. Thanks for listening

  17. Donovan says:

    My best friend is 17 years of age and recently got in a car accident. He was driving on the free way drunk going 100 when he hit a sheriff. He is in critical state, and his brain is swollen. He is currently in a coma, however his brain is not responding. But he hasnt been diagnosed brain dead, or given any tests etc. (He just got in the hospital 3 hours ago). Is there ANY chance of survival? Is the possibility of him surviving slim? Or 50%? … if you dont understand anything im telling you his car crash was all over the news. Check it out. http://www.620wtmj.com/multimedia/photos/176743541.html#92875711

  18. Penny B says:

    I’ve just recently lost my son (17) after a freak accident where he was playing a pickup game of football during baseball practice (to get in their conditioning/running/exercise instead of just running laps, etc) and he went back to catch a pass, tripped in a rut, and fell, landing on the top/front of his head. Initially, it appeared that he strictly had a severe spinal cord injury due to a C5 fracture. He was awake and alert, talking and breathing well, but had no movement from nipple line down and only some sensation and a slight Babinski reflex left foot only. We were hoping that it was just a stinger or spinal cord trauma, but quickly saw on CT what a horrible fracture it was. (I am a nurse of many years, fwiw) I was able to be with him in the ER, thank GOD, and was talking with him when he suddenly became violently ill, vomiting without the diaphragmatic control or strength to do so, laying flat of his back in a high C collar. The neurosurgeon and I log rolled him and I suctioned him while he vomited and this continued to get worse. He was given 4mg of Zofran for the nausea, and became groggy, but within about 10 minutes, he was completely non-responsive and decompensating with his breathing terribly. This was all while we were wheeling him from ER to OR and by the time they got him intubated and vented, he was in traction with a beautifully reduced C spine fracture. Probably one of the most easily reduced and well aligned I’ve ever seen. He had surgery at that point to remove the shattered vertebrae, disc remnants and replace with cadaver bone and fuse to C4 and C6. The surgery went beautifully with very minimal bleeding and the aligment and hardware all looked great. The surgery was completed around 7:00 pm or a little bit later. He was brought back to an ICU suite to begin to wake on his own. This is a healthy, strapping 17 year old athlete with absolutely NO health problems that we are talking about. We went in to see him as soon as he came back and of course, was still asleep. However, as the night wore on, he was not awakening nor reacting to us at all. Neuro checks were “ok”….pupils reactive, responsive. At first we thought he was just extremely sensitive to the anesthesia, as he’d never had surgery or meds at all. The neurosurgeon called me and told me that he’d realized that there was not a CT of the head done, in all the excitement over the neck fracture, and he wanted to send him back to CT. Of course! Well, later in the night, the neuro and I were at the desk, talking over this case (my beautiful son, but me trying to be clinical) and he tells me that the vertebral arteries looked great on the CT, but that there is some opacity of the basilar. However, there were no signs at all of any infarct or bleed, so he just wanted to “watch it”. We looked at the imaging together and the brain looked great, I’ll admit. I had a niggling concern about the basilar opacity and why we weren’t pushing that, but this is a wonderful doc we’re talking about and I figured he knew best. He calls me sometime later and tells me that my son has developed hydrocephalus and he’s taking him back to surgery to place a shunt and ICP monitor. And we wait. By 6:00 the next morning, I knew something was different. His pupils were very sluggish and he was simply not responding at all to anything. Sternal stim, pin prick, light, girlfriend, nothing. I went out to the car to rest a bit after visiting and was soon called back by the nurse, telling me that there was a change….BP was bottoming and pulse was racing. We came back in and body temp was rising. I immediately knew we were looking at a brainstem stroke. Of course, it was worse than just that (if there is such a thing) and we were soon told that he was “locked in”. I almost lost it, because after taking care of patients in this condition, I felt that this was the most horrible situation anyone could be in. Soon after, both pupils were blown and he failed apnea testing miserably. I had already declined a feeding tube the day before, because of the ethical and legal issues involved and knowing my son’s wishes. He had also made the decision a year ago to be an organ donor, so I went ahead and told the doctor to begin preparations for that. He was stunned by this whole ordeal. This has only been 2 weeks ago for me, and I am so very lost without my son. This neurosurgeon has been in practice for 25 years and is a wonderful surgeon, with many awesome successes where none were expected. He told me that he had NEVER treated a case that progressed like this in his 25 years in practice. I begged them to sedate him while waiting for the organ donation process, because I could not bare the thought of him possibly actually having locked in syndrome (mother’s minds, you know) and being afraid or in pain with no way to let us know. They were gracious enough to comply with my request, but I still find myself scrounging for all the clinical information I can find to reassure myself that we made the right calls. I need to reassure myself that my child was ok and not in pain or fear, and this article is a great one. Please excuse the wordiness as this is still a very fresh pain for me and I guess I’m trying to “talk it through”. I’ve never hated being a nurse as much as I did through this ordeal, knowing what I was seeing and being so very helpless. Feel free to email me if you have any thoughts or comments. I’m grasping at straws right now. pblott@netzero.com

    • Enrique says:

      I’m so deeply sorry.

    • Angela says:

      Gosh that is awful. I’m also a nurse and this past Friday I lost my brother in law that I loved dearly. I found out he was in the hospital in ICU Tuesday night. I knew he had gone to the hospital Monday as I was getting off by running into some friends, but my sister cried wolf to manny times so I just went home not thinking of the worst. My daughter called me on Tuesday night that she had seen a picture of him on Facebook on a ventilator. I got so mad and called her and confirmed that he was critical. So I drove myself to the hospital and went in to see him. The ICU nurse informed me that he had gone into cardiac arrest 3 times was on 90% o2 BP was critical and kidneys were not working. The next morning the doctor told me he was getting a nephrologist to consult and go from there. His BP was stable and the dropped the o2 to 60% but heart rate was still in the 130-150. Nephrologist said to us in Tuesday that if on Thursday output was not better the temparery dialysis would be the next step. Thursday came and dialysis was performed and the nurse told me that sedation had been turned off but wait awhile because he could be sedative to the meds. At this point no gag reflex was responding, no sternal rub, nothing, I was during inside and also hated being a nurse at this point because I knew what was happening but I wasn’t ready to crush anyone’s hope yet. I waited for dialysis to be performed called at 1100 at night they told me pupils were still fixed and no gag reflex. Next morning got there early before family spoke to all 4 doctors and they confirmed what I was dreading. Of course my family doesn’t speak English on top of all things so I broke the news with the doctors in the room. I am so torn, I keep asking myself should we of held him on a ventilator a few more days. I know he was brain dead but keep questioning myself. I’m having a real hard time I can’t even imagine what you’re going through. God Bless

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  22. Eldhose says:

    I want to know that some patients having a kind ouf jerky movements
    after brain death what is it call.

  23. yolanda says:

    What does it mean when a doctor says the news is not good, I only see 10% of the brain functioning.

  24. Tim says:

    My best friend was in a bad motorcycle accident this past Friday
    He’s in a coma and on a vent. I know it’s very bad. For some reason the trauma doctor and neurologist were conflicted in performing the MRI and possibly relieving pressure. We all thought mike was gonna pull through this with no problem. He is 26 and built like an ox. We had just recently gotten home from a hard tour in Afghanistan. Mike was blown up by a massive bomb and still walked away with minor TBI injuries. He recieved a purple heart for his actions. Anyway the MRI produced results showing that on impact ( with full helmet) that his front lobe and brain shifted. There were also disconnections with the strings that connect his brain.? Neurons? I don’t know, I’m an infantryman not a doctor. So after the MRI the neurologist told his parents that there was a 60% chance he wasn’t going to wake up and if he did there was a 40% chance he would have brain damage. My mother was both an ICU and SICU nurse for over 30 yrs. she’s been telling me like I deserve to be told. That chances are very high mike will not make it. He had an EEG immediately following the MRI. And as per his parents, they are still sticking with their course of action to put a trach in this weekend and monitor swelling. I asked a nurse if his eyes were responsive to light and she flat out told me no last night. I’m not sure why the doctors are still planning to proceed with the plans for the trach and such. They haven’t given up hope, which means I can not either. But I was wondering if anyone knew a reason why they would still proceed, and if he isn’t reacting to light and has been showing multiple signs showed above in other comments, why we are still being led on like he can make a recovery. I don’t want to give up. He’s my best friend, but if anyone has some info please let me know. And please tell me like it is. I’m a man who’s been through more than any human should. Best regards

  25. MY uncle had a heart attack friday morning at 6:30 am . He has been unresponsive, he received some type of self induced coma to stop seizures he was experiencing after heart attack. They put him on dialysis as his organs were trying to shut down, but since then he has had urinated. Isn’t this a good sign? His CT Scan came back negative that night, but they are going to do another today. They have made it seem like he doesn’t have a chance but his kidneys ar now producing their own urine at a rate of 50 ccs to 100 ccs an hour. and altghough he has no cognitive repsonse yet his eyes were responsive to light. He was treated with a 12-24 cooling method and then a warming (heating method to bring his temp back up afterwards). What are the chances that seizures caused brain damaged during heating/cooling???? I am desperate to know if he has a chance to fully recover? I do believe so in my heart.

  26. Judy says:

    Im sorry. I don’t agree with brain dead being dead. My friend was in a coma for three months. He woke up and is a fully functional human being. He does have traumatic brain injury. But he lives alone works etc. I’m not a dr. So I don’t know. But I’m still praying for all. God is the almighty physician. Praying for all. God is good.

    • blargh says:

      Judy, your friend was never brain dead. That’s why he woke up. His brain was injured but still had a blood supply keeping it alive. If you lose your blood supply to the muscles and skin of your leg, you get gangrene and have to cut if off. If you lose blood supply to your intestines, you have to remove the parts that have no blood supply and sew it back together, and you may have to poop into a bag from the side of your body instead of sitting on the toilet. If you lose blood supply to your hip, you get avascular necrosis and you can remove the old hip and get a fake one. Unfortunately, with brain death you can’t just remove the dead bits, because brains simply don’t work that way.

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  28. [...] a coma alone. http://i2.cdn.turner.com/cnn/dam/ass…-story-top.jpg The way to tell brain death: How to Determine Brain Death | Saving the Brain The family seems to be assuming that the reflexes they showed came from the brain, but not all [...]

  29. Deidra Peets says:

    My mom had a stroke Feb. 4th 2014, she has not woke up yet. At first she was responding to simple commands , (two fingers, thumbs up…) then she had an infection in the fluid from the drain.since then she doesn’t do any commands. She does open her eyes on occasion, she moves her right arm alot , looks like purposely movements ( she will scratch her head , rub her eyes, she also will yawn) Are these good signs that she will wake up soon? Will she rememer me? Never been through this before :(
    The doctors keep saying it will take time.
    LookIng for some reassuring,

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