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
 Temperature less than 36° C
 Severe hypotension (SBP less than 100mmHg as appropriate for patient’s age)
 Drug intoxication or effects (i.e. barbiturates, opiates, neuromuscular blocking agents etc.)
 Severe electrolyte, acid-base and or endocrine disturbances
Section 2: Clinical exam
Bilateral pupillary response to light:
Bilateral corneal responses:
Gag reflex:
Cough reflex:
Bilateral vestibulo-ocular responses (cold calorics):
Bilateral oculocephalic responses (doll’s eyes):
Bilateral motor responses (excluding spinal reflexes):
*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 or ≥ 60 mmHg
YES
NO
Section 4: Ancillary Testing
Only one ancillary test needs to be performed; to be ordered only if clinical examination cannot be fully
performed due to patient factors, or if apnea testing inconclusive or aborted.
□ Radionuclide cerebral blood flow
□ Transcranial Doppler
study
□ EEG
□ Cerebral angiography
□ CT angiogram
Section 5: Brain Death Declaration
I certify that the above tests have been performed.
The patient is declared brain dead at _______________ on________________
(Time)
(Date)
Physician signature:____________________________
References: Neurology 2010; 74: 1911-1918
Oregon Revised Statute 432.300, Determination of Death
____________________________
(Print name)
Revised 11-20-2013