Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project

David M. Greer, Sam D. Shemie, Ariane Lewis, Sylvia Torrance, Panayiotis Varelas, Fernando D. Goldenberg, James L. Bernat, Michael Souter, Mehmet Akif Topcuoglu, Anne W. Alexandrov, Marie Baldisseri, Thomas Bleck, Giuseppe Citerio, Rosanne Dawson, Arnold Hoppe, Stephen Jacobe, Alex Manara, Thomas A. Nakagawa, Thaddeus Mason Pope, William SilvesterDavid Thomson, Hussain Al Rahma, Rafael Badenes, Andrew J. Baker, Vladimir Cerny, Cherylee Chang, Tiffany R. Chang, Elena Gnedovskaya, Moon Ku Han, Stephen Honeybul, Edgar Jimenez, Yasuhiro Kuroda, Gang Liu, Uzzwal Kumar Mallick, Victoria Marquevich, Jorge Mejia-Mantilla, Michael Piradov, Sarah Quayyum, Gentle Sunder Shrestha, Ying Ying Su, Shelly D. Timmons, Jeanne Teitelbaum, Walter Videtta, Kapil Zirpe, Gene Sung*

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

309 Scopus citations


Importance: There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. Objective: To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. Process: Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. Evidence Synthesis: Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. Recommendations: Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability. Conclusions and Relevance: This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries..

Original languageEnglish (US)
Pages (from-to)1078-1097
Number of pages20
JournalJAMA - Journal of the American Medical Association
Issue number11
StatePublished - Sep 15 2020

ASJC Scopus subject areas

  • General Medicine


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