Certification of Adult Death by Neurologic Criteria
Examination
Represents guidelines from the American Academy of Neurology
Date: _______Time: _____
1. Date and Time of Exam
2. Etiology of Coma confirmed by:
CT
MRI
Other
Please circle all that apply
3. Complicating Conditions
Vital Signs: If hemodynamically unstable, consider
(A)
Ancillary Tests listed below
Record SaO2 or PaO2
(B)
Consider CPAP Apnea Test if hypoxic (SaO2 must be greater than or equal to 90%)
(C)
Record body temperature (must be greater than or equal to 35 C or 95 F)
(D)
Neuromuscular paralyzing present? (Check train-of-four)
(E)
Evidence of drug or metabolic Intoxication? (if in doubt, consider ancillary tests listed below.)
4. Evaluation of Coma
(A)
Response to deep painful stimuli
(B)
Deep muscular movements (except spinal reflexes)
5. Evaluation of Brain Stem Function Documented
(A)
Pupillary response to light
(B)
Corneal/blink reflexes
(C)
Oculocephalic (Doll’s eyes) reflexes
(D)
Oculovestibular (cold caloric) reflexes
(E)
Gag reflex
(F)
Cough reflex
6. Apnea Test
(A)
Evidence of respiratory effort
PCO2 results:
(B)

pCO2 prior to apnea test (recommended is 40-50 mmHg)

Ending pCO2 (should be greater than 60 mm Hg)
7. Ancillary Tests (if clinical examination is unreliable or inconclusive)
 Cerebral angiography/Perfusion Study
 Nuclear Med. Cerebral Perfusion Study
 CT angiography
 EEG
 Transcranial Dopplers
Physical Exam
BP: _______ P: _______
SaO2:
Temp:
❏ Yes
❏Yes
❏ No
❏ No
❏ Absent
❏ Absent
❏ Present
❏ Present
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
Absent
Absent
Absent
Absent
Absent
Absent
❏ Absent
Results
Results
Results
Results
Results
Time of Death:__________
Pysician Signature: ______________________________
Date _________
❏ Present
Baseline pCO2 = ________
Final pCO2 = __________
Comments: ______________________________________________________________________________
Date of Death:_______________
Present
Present
Present
Present
Present
Present
Time: _________