Brain death is the complete loss of brain function (including involuntary activity necessary to sustain life). It differs from persistent vegetative state, in which the person is alive and some autonomic functions remain. It is also distinct from an ordinary coma, whether induced medically or caused by injury and/or illness, even if it is very deep, as long as some brain and bodily activity and function remains; and it is also not the same as the condition known as locked-in syndrome. A differential diagnosis can medically distinguish these differing conditions.
Brain death is used as an indicator of legal death in many jurisdictions, but it is defined inconsistently and often confused by the lay public.  Various parts of the brain may keep functioning when others do not anymore, and the term "brain death" has been used to refer to various combinations. For example, although one major medical dictionary considers "brain death" to be synonymous with "cerebral death" (death of the cerebrum), the US National Library of Medicine Medical Subject Headings (MeSH) system defines brain death as including the brainstem. The distinctions are medically significant because, for example, in someone with a dead cerebrum but a living brainstem, the heartbeat and ventilation can continue unaided, whereas in whole-brain death (which includes brainstem death), only life support equipment would keep those functions going. Patients classified as brain-dead can have their organs surgically removed for organ donation.
Traditionally, both the legal and medical communities determined death through the permanent end of certain bodily functions in clinical death, especially respiration and heartbeat. With the increasing ability of the medical community to resuscitate people with no respiration, heartbeat, or other external signs of life, the need for another definition of death occurred, raising questions of legal death. This gained greater urgency with the widespread use of life support equipment, as well as rising capabilities and demand for organ transplantation.
Since the 1960s, laws on determining death have, therefore, been implemented in all countries with active organ transplantation programs. The first European country to adopt brain death as a legal definition (or indicator) of death was France, in 1968. In the United States, Kansas had enacted a similar law earlier.
An ad hoc committee at Harvard Medical School published a pivotal 1968 report to define irreversible coma. The Harvard criteria gradually gained consensus toward what is now known as brain death. In the wake of the 1976 Karen Ann Quinlan case, state legislatures in the United States moved to accept brain death as an acceptable indication of death. In 1981 a Presidential commission issued a landmark report – Defining Death: Medical, Legal, and Ethical Issues in the Determination of Death  – that rejected the "higher brain" approach to death in favor of a "whole brain" definition. This report was the basis for the Uniform Determination of Death Act, which has been enacted in 39 states of the United States. The Uniform Determination of Death Act in the United States attempts to standardize criteria. Today, both the legal and medical communities in the US use "brain death" as a legal definition of death, allowing a person to be declared legally dead even if life support equipment keeps the body's metabolic processes working.
In the UK, the Royal College of Physicians reported in 1995, abandoning the 1979 claim that the tests published in 1976 sufficed for the diagnosis of brain death and suggesting a new definition of death based on the irreversible loss of brain stem function alone. This new definition, the irreversible loss of the capacity for consciousness and for spontaneous breathing, and the essentially unchanged 1976 tests held to establish that state, have been adopted as a basis of death certification for organ transplant purposes in subsequent Codes of Practice. The Australia and New Zealand Intensive Care Society (ANZICS) states that the "determination of brain death requires that there is unresponsive coma, the absence of brain-stem reflexes and the absence of respiratory centre function, in the clinical setting in which these findings are irreversible. In particular, there must be definite clinical or neuro-imaging evidence of acute brain pathology (e.g. traumatic brain injury, intracranial haemorrhage, hypoxic encephalopathy) consistent with the irreversible loss of neurological function."
Natural movements also known as the Lazarus sign or Lazarus reflex can occur on a brain-dead person whose organs have been kept functioning by life support. The living cells that can cause these movements are not living cells from the brain or brain stem; these cells come from the spinal cord. Sometimes these body movements can cause false hope for family members.
A brain-dead individual has no clinical evidence of brain function upon physical examination. This includes no response to pain and no cranial nerve reflexes. Reflexes include pupillary response (fixed pupils), oculocephalic reflex, corneal reflex, no response to the caloric reflex test, and no spontaneous respirations.
Brain death can sometimes be difficult to differentiate from other medical states such as barbiturate overdose, alcohol intoxication, sedative overdose, hypothermia, hypoglycemia, coma, and chronic vegetative states. Some comatose patients can recover to pre-coma or near pre-coma level of functioning, and some patients with severe irreversible neurological dysfunction will nonetheless retain some lower brain functions, such as spontaneous respiration, despite the losses of both cortex and brain stem functionality. Such is the case with anencephaly.
Brain electrical activity can stop completely, or drop to such a low level as to be undetectable with most equipment. An EEG will therefore be flat, though this is sometimes also observed during deep anesthesia or cardiac arrest. Although in the United States a flat EEG test is not required to certify death, it is considered to have confirmatory value. In the UK it is not considered to be of value because any continuing activity it might reveal in parts of the brain above the brain stem is held to be irrelevant to the diagnosis of death on the Code of Practice criteria.
The diagnosis of brain death is often required to be highly rigorous, in order to be certain that the condition is irreversible. Legal criteria vary, but in general require neurological examinations by two independent physicians. The exams must show complete and irreversible absence of brain function (brain stem function in UK), and may include two isoelectric (flat-line) EEGs 24 hours apart (less in other countries where it is accepted that if the cause of the dysfunction is a clear physical trauma there is no need to wait that long to establish irreversibility). 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.
Also, a radionuclide cerebral blood flow scan that shows complete absence of intracranial blood flow must be considered with other exams – temporary swelling of the brain, particularly within the first 72 hours, can lead to a false positive test on a patient that may recover with more time.
Confirmatory testing is only needed under the age of 1. For children and adults, testing is optional. Other situations possibly requiring confirmatory testing include severe facial trauma where determination of brainstem reflexes will be difficult, pre-existing pupillary abnormalities, and patients with severe sleep apnea and/or pulmonary disease. Confirmatory tests include: cerebral angiography, electroencephalography, transcranial Doppler ultrasonography, and cerebral scintigraphy (technetium Tc 99m exametazime). Cerebral angiography is considered the most sensitive confirmatory test in the determination of brain death.
While the diagnosis of brain death has become accepted as a basis for the certification of death for legal purposes, it is a very different state from biological death - the state universally recognized and understood as death. The continuing function of vital organs in the bodies of those diagnosed brain dead, if mechanical ventilation and other life-support measures are continued, provides optimal opportunities for their transplantation.
When mechanical ventilation is used to support the body of a brain dead organ donor pending a transplant into an organ recipient, the donor's date of death is listed as the date that brain death was diagnosed.
In some countries (for instance, Spain, Finland, Poland, Wales, Portugal, and France), everyone is automatically an organ donor after diagnosis of death on legally accepted criteria, although some jurisdictions (such as Singapore, Spain, Wales, France, Czech Republic and Portugal) allow opting out of the system. Elsewhere, consent from family members or next-of-kin may be required for organ donation. In New Zealand, Australia, the United Kingdom (excluding Wales) and most states in the United States, drivers are asked upon application if they wish to be registered as an organ donor.
In the United States, if the patient is at or near death, the hospital must notify a transplant organization of the person's details and maintain the patient while the patient is being evaluated for suitability as a donor. The patient is kept on ventilator support until the organs have been surgically removed. If the patient has indicated in an advance health care directive that they do not wish to receive mechanical ventilation or has specified a do not resuscitate order and the patient has also indicated that they wish to donate their organs, some vital organs such as the heart and lungs may not be able to be recovered.
What is the legal time of death for a brain dead patient? The legal time of death is the date and time that doctors determine that all brain activity has ceased. This is the time that is noted on the patient’s death certificate.
2012 State Comparisons
Unless the individual expressed contrary intent, a hospital must take measures to ensure the medical suitability of an individual at or near death while a procurement organization examines the patient for suitability as a donor.
DNR will be honored. You can still be a tissue donor.
Anencephaly is the absence of a major portion of the brain, skull, and scalp that occurs during embryonic development. It is a cephalic disorder that results from a neural tube defect that occurs when the rostral (head) end of the neural tube fails to close, usually between the 23rd and 26th day following conception. Strictly speaking, the Greek term translates as "no in-head" (that is, totally lacking the inside part of the head, i.e. the brain), but it is accepted that children born with this disorder usually only lack a telencephalon, the largest part of the brain consisting mainly of the cerebral hemispheres, including the neocortex, which is responsible for cognition. The remaining structure is usually covered only by a thin layer of membrane—skin, bone, meninges, etc. are all lacking. With very few exceptions, infants with this disorder do not survive longer than a few hours or possibly days after their birth.Apnea
Apnea is the cessation of breathing. During apnea, there is no movement of the muscles of inhalation, and the volume of the lungs initially remains unchanged. Depending on how blocked the airways are (patency), there may or may not be a flow of gas between the lungs and the environment; gas exchange within the lungs and cellular respiration is not affected. Voluntarily doing this is called holding one's breath.Beating heart cadaver
A beating heart cadaver is a body that is pronounced dead in all medical and legal definitions, connected to a medical ventilator, and retains cardio-pulmonary functions. This keeps the organs of the body, including the heart, functioning and alive. As a result, the period of time in which the organs may be used for transplantation is extended. The heart contains pacemaker cells that will cause the heart to continue beating even when a patient is brain-dead. Other organs in the body do not have this capability and need the brain to be functioning to send signals to the organs to carry out their functions. A beating heart cadaver requires a ventilator to provide oxygen to its blood, but the heart will continue to beat on its own even in the absence of brain activity. This allows organs to be preserved for a longer period of time in the case of a transplant or donation. A small number of cases in recent years indicate that it can also be implemented for a brain-dead pregnant woman to reach the full term of her pregnancy. There is an advantage to beating heart cadaver organ donation because doctors are able to see the vitals of the organs and tell if they are stable and functioning before transplanting to an ailing patient.
This is not possible in a donation from someone pronounced dead.Brain Death (EP)
Brain Death is an EP released by thrash metal band Nuclear Assault, released in August 1986.Brainstem death
Brainstem death is a clinical syndrome defined by the absence of reflexes with pathways through the brainstem—the "stalk" of the brain, which connects the spinal cord to the mid-brain, cerebellum and cerebral hemispheres—in a deeply comatose, ventilator-dependent patient.
Identification of this state carries a very grave prognosis for survival; cessation of heartbeat often occurs within a few days although it may continue for weeks if intensive support is maintained.In the United Kingdom, the formal diagnosis of brainstem death by the procedure laid down in the official Code of Practice permits the diagnosis and certification of death on the premise that a person is dead when consciousness and the ability to breathe are permanently lost, regardless of continuing life in the body and parts of the brain, and that death of the brainstem alone is sufficient to produce this state.This concept of brainstem death is also accepted as grounds for pronouncing death for legal purposes in India and Trinidad & Tobago. Elsewhere in the world the concept upon which the certification of death on neurological grounds is based is that of permanent cessation of all function in all parts of the brain—whole brain death—with which the British concept should not be confused. The United States' President's Council on Bioethics made it clear, for example, in its White Paper of December 2008, that the British concept and clinical criteria are not considered sufficient for the diagnosis of death in the United States of America.Consciousness after death
Consciousness after death is a common theme in society and culture in the context of life after death. Scientific research has established that the mind and consciousness are closely connected with the physiological functioning of the brain, the cessation of which defines brain death. However, many believe in some form of life after death, which is a feature of many religions.Death
Death is the permanent cessation of all biological functions that sustain a living organism. Phenomena which commonly bring about death include aging, predation, malnutrition, disease, suicide, homicide, starvation, dehydration, and accidents or major trauma resulting in terminal injury. In most cases, bodies of living organisms begin to decompose shortly after death.Death – particularly the death of humans – has commonly been considered a sad or unpleasant occasion, due to the affection for the being that has died and the termination of social and familial bonds with the deceased. Other concerns include fear of death, necrophobia, anxiety, sorrow, grief, emotional pain, depression, sympathy, compassion, solitude, or saudade. Many cultures and religions have the idea of an afterlife, and also hold the idea of reward or judgement and punishment for past sin.Disorders of consciousness
Disorders of consciousness are medical conditions that inhibit consciousness. Some define disorders of consciousness as any change from complete self-awareness to inhibited or absent self-awareness and arousal. This category generally includes minimally conscious state and persistent vegetative state, but sometimes also includes the less severe locked-in syndrome and more severe but rare chronic coma. Differential diagnosis of these disorders is an active area of biomedical research. Finally, brain death results in an irreversible disruption of consciousness. While other conditions may cause a moderate deterioration (e.g., dementia and delirium) or transient interruption (e.g., grand mal and petit mal seizures) of consciousness, they are not included in this category.Eternal oblivion
In philosophy, eternal oblivion (also referred to as non-existence or nothingness) is the permanent cessation of one's consciousness upon death. This concept is often associated with religious skepticism and atheism.According to contemporary theories of consciousness, the brain is the basis of subjective experience, agency, self-awareness, and awareness of the surrounding natural world. When brain death occurs, all brain function permanently ceases. Many people who believe that death is a permanent cessation of consciousness also believe that consciousness is dependent upon the functioning of the brain. Scientific research has discovered that some areas of the brain, like the reticular activating system or the thalamus, appear to be necessary for consciousness, because damage to these structures or their lack of function causes a loss of consciousness.
Through a naturalist analysis of the mind (an approach adopted by many philosophers of mind and neuroscientists), it is regarded as being dependent on the brain, as shown from the various effects of brain damage.Flatline
A flatline is an electrical time sequence measurement that shows no activity and therefore, when represented, shows a flat line instead of a moving one. It almost always refers to either a flatlined electrocardiogram, where the heart shows no electrical activity (asystole), or to a flat electroencephalogram, in which the brain shows no electrical activity (brain death). Both of these specific cases are involved in various definitions of death.Heart transplantation
A heart transplant, or a cardiac transplant, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease when other medical or surgical treatments have failed. As of 2018, the most common procedure is to take a functioning heart, with or without transplanting one or both lungs at the same time, from a recently deceased organ donor (brain death is the standard) and implanting it into the patient. The patient's own heart is either removed and replaced with the donor heart (orthotopic procedure) or, much less commonly, the recipient's diseased heart is left in place to support the donor heart (heterotopic, or "piggyback", transplant procedure).
Approximately 3,500 heart transplants are performed every year in the world, more than half of which occur in the US. Post-operation survival periods average 15 years. Heart transplantation is not considered to be a cure for heart disease but a life-saving treatment intended to improve the quality of life for recipients.Human brain
The human brain is the central organ of the human nervous system, and with the spinal cord makes up the central nervous system. The brain consists of the cerebrum, the brainstem and the cerebellum. It controls most of the activities of the body, processing, integrating, and coordinating the information it receives from the sense organs, and making decisions as to the instructions sent to the rest of the body. The brain is contained in, and protected by, the skull bones of the head.
The cerebrum is the largest part of the human brain. It is divided into two cerebral hemispheres. The cerebral cortex is an outer layer of grey matter, covering the core of white matter. The cortex is split into the neocortex and the much smaller allocortex. The neocortex is made up of six neuronal layers, while the allocortex has three or four. Each hemisphere is conventionally divided into four lobes – the frontal, temporal, parietal, and occipital lobes. The frontal lobe is associated with executive functions including self-control, planning, reasoning, and abstract thought, while the occipital lobe is dedicated to vision. Within each lobe, cortical areas are associated with specific functions, such as the sensory, motor and association regions. Although the left and right hemispheres are broadly similar in shape and function, some functions are associated with one side, such as language in the left and visual-spatial ability in the right. The hemispheres are connected by commissural nerve tracts, the largest being the corpus callosum.
The cerebrum is connected by the brainstem to the spinal cord. The brainstem consists of the midbrain, the pons, and the medulla oblongata. The cerebellum is connected to the brainstem by pairs of tracts. Within the cerebrum is the ventricular system, consisting of four interconnected ventricles in which cerebrospinal fluid is produced and circulated. Underneath the cerebral cortex are several important structures, including the thalamus, the epithalamus, the pineal gland, the hypothalamus, the pituitary gland, and the subthalamus; the limbic structures, including the amygdala and the hippocampus; the claustrum, the various nuclei of the basal ganglia; the basal forebrain structures, and the three circumventricular organs. The cells of the brain include neurons and supportive glial cells. There are more than 86 billion neurons in the brain, and a more or less equal number of other cells. Brain activity is made possible by the interconnections of neurons and their release of neurotransmitters in response to nerve impulses. Neurons connect to form neural pathways, neural circuits, and elaborate network systems. The whole circuitry is driven by the process of neurotransmission.
The brain is protected by the skull, suspended in cerebrospinal fluid, and isolated from the bloodstream by the blood–brain barrier. However, the brain is still susceptible to damage, disease, and infection. Damage can be caused by trauma, or a loss of blood supply known as a stroke. The brain is susceptible to degenerative disorders, such as Parkinson's disease, dementias including Alzheimer's disease, and multiple sclerosis. Psychiatric conditions, including schizophrenia and clinical depression, are thought to be associated with brain dysfunctions. The brain can also be the site of tumours, both benign and malignant; these mostly originate from other sites in the body.
The study of the anatomy of the brain is neuroanatomy, while the study of its function is neuroscience. A number of techniques are used to study the brain. Specimens from other animals, which may be examined microscopically, have traditionally provided much information. Medical imaging technologies such as functional neuroimaging, and electroencephalography (EEG) recordings are important in studying the brain. The medical history of people with brain injury has provided insight into the function of each part of the brain.
In culture, the philosophy of mind has for centuries attempted to address the question of the nature of consciousness and the mind-body problem. The pseudoscience of phrenology attempted to localise personality attributes to regions of the cortex in the 19th century. In science fiction, brain transplants are imagined in tales such as the 1942 Donovan's Brain.Jahi McMath case
The Jahi McMath case involved a teenage girl who was declared brain dead in California following surgery in 2013 at age 13. This led to a bioethical debate engendered by her family's rejection of the medicolegal findings of death in the case, and their efforts to maintain her body using mechanical ventilation and other measures. Her parents considered these measures to constitute life support, while her doctors considered this to be futile treatment of a deceased person. In October 2014, the McMath family attorney made the unprecedented request that Jahi McMath's brain death declaration be overturned. The attorney later withdrew this request, saying he wanted time for the court-appointed medical expert and his own medical experts to confer. In March 2015, McMath's family filed a malpractice lawsuit against Children's Hospital Oakland and against the surgeon who performed McMath's surgery, indicating they were prepared to argue as part of the lawsuit that McMath is not dead, but profoundly disabled. The family lawyer stated that a preliminary second death certificate was issued on June 22, 2018, listing extensive bleeding relating to liver failure as the cause of death.Lazarus sign
The Lazarus sign or Lazarus reflex is a reflex movement in brain-dead or brainstem failure patients, which causes them to briefly raise their arms and drop them crossed on their chests (in a position similar to some Egyptian mummies). The phenomenon is named after the Biblical figure Lazarus of Bethany, whom Jesus raised from the dead in the Gospel of John.Legal death
Legal death is the recognition under the law of a particular jurisdiction that a person is no longer alive. In most cases, a doctor's declaration of death (variously called) or the identification of a corpse is a legal requirement for such recognition. A person who has been missing for a sufficiently long period of time (typically at least several years) may be presumed or declared legally dead, usually by a court. When a death has been registered in a civil registry, a death certificate may be issued. Such death certificate may be required in a number of legal situations, such as applying for probate, claiming some benefits or making an insurance claim, etc.Nuclear Assault
Nuclear Assault is an American thrash metal band formed in New York City in 1984. Part of the mid-to-late 1980s thrash metal movement, they were one of the main bands of the genre to emerge from the East Coast along with Overkill, Whiplash, Toxik, Carnivore, and Anthrax, where Nuclear Assault bassist Dan Lilker was a member from its formation in 1981 to 1984 (when he left the band and was replaced by Frank Bello). After releasing five full-length albums and touring relentlessly throughout the 1980s and early 1990s, Nuclear Assault split up in 1995. They briefly reunited in 1997 and then reunited permanently in 2002.
Nuclear Assault has released six studio albums to date, the latest being Third World Genocide (2005). Their most successful records are Survive (1988) and Handle with Care (1989), which peaked at #145 and #126 on the Billboard 200 chart respectively.Organ donation
Organ donation is when a person allows an organ of their own to be removed and transplanted to another person, legally, either by consent while the donor is alive or dead with the assent of the next of kin.
Donation may be for research or, more commonly, healthy transplantable organs and tissues may be donated to be transplanted into another person.Common transplantations include kidneys, heart, liver, pancreas, intestines, lungs, bones, bone marrow, skin, and corneas. Some organs and tissues can be donated by living donors, such as a kidney or part of the liver, part of the pancreas, part of the lungs or part of the intestines, but most donations occur after the donor has died.In 2017 Spain had the highest donor rate in the world at 46.9 per million people, followed by Portugal (34.0 per million), Belgium (33.6 per million), Croatia (33.0 per million) and the US (32.0 per million).As of February 2, 2018, there were 115,085 people waiting for life-saving organ transplants in the US. Of these, 74,897 people were active candidates waiting for a donor. While views of organ donation are positive, there is a large gap between the numbers of registered donors compared to those awaiting organ donations on a global level.Organ transplantation in Israel
Organ transplantation in Israel has historically been low compared to other Western countries due to a common belief that organ donation is prohibited under Jewish law. This changed with the passage of new organ donation laws in 2008. If two patients have the same medical need, priority will now go to the patient who has signed an organ donor card, or whose family members have donated an organ (though medical necessity still takes precedence). This policy was nicknamed don't give, don't get. The law also defines "brain death" as an indication of death for all legal purposes, including organ donation. Additionally the law provides financial reimbursement to living donors for medical expenses due to donation and lost time at work. Organ trafficking is explicitly banned. Health insurance plans can no longer reimburse patients who go abroad to receive transplants.
Currently, although the rate of organ donation is still relatively low, it is rising.Organ transplantation in Japan
Organ transplantation in Japan is regulated by the 1997 Organ Transplant Law which legalized organ procurement from "brain dead" donors. After an early involvement in organ transplantation that was on a par with developments in the rest of the world, attitudes in Japan altered after a transplant by Dr. Wada in 1968 failed, and a subsequent ban on cadaveric organ donation lasted 30 years. The first transplant after the Organ Transplant Law had defined "brain death" took place in February 1999.Due to cultural reasons and a relative distrust of modern medicine, the rate of organ donation in Japan is significantly lower than in Western countries.