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 35° C
 Severe hypotension (SBP less than 90mmHg as appropriate for patient’s age)
 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 greater than 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, based on my personal assessment, 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)
References: Neurology 2010; 74: 1911-1918
Wijdicks, EFM. The diagnosis of brain death. NEJM 2001; 344(16): 1215-1221
Oregon Revised Statute 432.300, Determination of Death