Checklist for Determination and Declaration of Brain Death
Section 1: Minimum Diagnostic Criteria for the Diagnosis of Brain Death
Affix patient label here.
A.
Neurologic unresponsiveness due to the following etiology:
______________________________________________
B. The following confounding factors are absent:
ABSENT
 Temp < 33 C
 Severe hypotension (SBP < 90)
 Drug intoxication or effects (i.e. barbiturates, opiates, neuromuscular blocking agents etc.)
 High cervical spinal cord injuries
 Severe electrolyte, acid-base and or endocrine disturbances
Section 2: Clinical exam
Bilateral motor responses (excluding spinal reflexes):
Cough reflex:
Gag reflex:
Bilateral corneal responses:
Bilateral vestibulo-ocular responses (cold calorics):
Bilateral oculocephalic responses (doll’s eyes):
Bilateral pupillary response to light:
*Newborns only: suck reflex absent
ABSENT
NOT ASSESSED
Section 3: Apnea Testing
Pre-apnea test ABG:
DATE_____/TIME_____ pH_____ PaCO2__________ mmHg
Post-apnea test ABG:
DATE_____/TIME_____ pH_____ PaCO2_______mmHg
PaCO2 ≥ 20 mmHg above the pre-apnea test level and is > 60
YES
NO
Section 4: Confirmatory Testing
A.
Confirmatory tests should be performed when any of the clinical testing cannot be reliably completed or
confounding factors are present.
B. Brain death has been confirmed by the following:
a. For purpose of organ donation:
b. Other:
 Cerebral radiocontrast angiography
 Transcranial doppler ultrasonography
 Radionuclide brain scan
 Electroencephalography
Section 5: Brain Death Declaration
In my opinion, the above criteria necessary to diagnose brain death have been met. The patient is declared brain
dead at _______________ on________________
(Time)
(Date)
Physician signature:____________________________
2nd physician signature if required by policy:
____________________________
____________________________
(Print name)
____________________________
(Print name)