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Medico-Legal Journal
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Brain stem death – an overview Article reuse guidelines:

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DOI: 10.1177/0025817218822008
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JSRG Saran1 and Jagadish R Padubidri2

Abstract
The concept of brain death has been a very intriguing topic and has taken many forms over the years. Brain stem death is
a complex state of inactivity defined by the loss of reflexes of the pathways that pass through the brain stem, the ‘shaft’ of
the brain which links the spinal cord to the cerebral cortex and the cerebellum where there is apnoea, loss of eye
movement and pain sensation. There are many criteria, based on which a person can be said to be brain dead. The best
recognised of these are the Harvard, Minnesota and Philadelphia criteria. India follows the UK notion of brain stem
death, and the Transplantation of Human Organs Act was passed in 1994 by the Indian parliament, which legalised brain-
stem death, and in 1995 ordered the brain death certification procedure, which is certified by a ‘Board of Medical
Experts’. Also, there are some legal and ethical implications that have to be considered in cases of disagreement in
diagnosis among the panel of doctors, time of death in cases when patients’ relatives disagree or request more time for
organ donation or to disconnect the life support system. In routine clinical practice, the issues pertaining to brain stem
death should be dealt with by experienced physicians, counselling the family members or relatives and educating them
about organ donation.

Keywords
Brain stem death, Harvard criteria, evolution of brain stem death, ethical and legal implications

Introduction cord below; hence, it is a very important structure in

The declaration of a person to be brain dead has always
been a topic of debate and has been an unresolved
problem for a long time, even now. There always
arises a common question, ‘Is a brain dead person clas-
sified as living or dead?’ Also the different criteria used
to diagnose a person as brain dead has evolved over
many years, some follow brain stem death and others,
brain death concepts. Now there are a panel of doctors
who should individually assess, collectively come to an
agreement and declare a person brain dead. Of course,
there are many legal and ethical implications that have
to be considered, both among the doctors or the
patient’s family. Therefore, the public should be made
aware of issues relating to brain stem death, and hence
educated and encouraged to proceed towards organ
donation.
Brain stem death and its causes
relaying information and inputs from the periphery to
the brain. It is formed by the midbrain superiorly, pons
Varolii and medulla oblongata inferiorly which
continue with the spinal cord. Its main functions are
regulating the rate of respiration through the respira-
tory centre, to control of eye movements, reflexes and
level of consciousness, perception of pain and the regu-
lation of the cardiovascular system. Therefore, if the
brain stem is dead, then all the functions are lost.
Thus, brain stem death can be defined as a complex
state of inactivity, portrayed by the loss of reflexes of
the pathways that pass through the brain stem, which
eventually results in apnoea, loss of eye movements and
1
Kasturba Medical College (affiliated to Manipal Academy of Higher
Education, Manipal, Karnataka, India), Mangalore, India
2
Department of Forensic Medicine, Kasturba Medical College (affiliated
to Manipal Academy of Higher Education, Manipal, Karnataka, India),
Mangalore, India

Before we talk about brain stem death, we should know Corresponding author:
about the brain stem and its functions. The brain stem Jagadish R Padubidri, Kasturba Medical College Mangalore, Manipal
is a stalk-like structure, which acts as a bridge between Academy of Higher Education, Manipal, India.
the cerebral cortex and cerebellum above and the spinal Email: ppjrao@gmail.com
2 Medico-Legal Journal 0(0)

leads to unconsciousness. There are numerous causes French (‘le coma de´passe´).1 After almost 70 years, on 5
that can lead to brain stem death of which the common August 1968, Harvard Medical School appointed a spe-
causes are trauma to the head, presence of a tumour in cial committee which defined brain death as apnoeic
the brain, bleeding in the brain and blockage of blood coma and absence of elicitable brain stem reflexes for
supply to the brain causing stroke. a period of 24 h, as confirmed by an electroencephalo-
gram (Harvard criteria).1 After a little over a decade,
the US President’s Commission published a criterion
Criteria for the diagnosis of brain stem on whole brain death as ‘The permanent cessation of
death functioning of the entire brain’. Later, in 1995, the
There are many criteria based on which a person can be American Academy of Neurology (AAN) emphasised
said to be brain dead of which the Harvard, Minnesota variables on irreversible state of unconsciousness
and Philadelphia1 criteria are the most widely accepted. (where the cause is known), loss of brain stem reflexes
The Harvard criteria are most commonly followed. and irreversible apnoea followed by additional tests to
Their particulars are listed in Tables 1 to 3, respectively. be used when there are astounding factors. Later, in
2010, AAN issued an evidence-based guideline and con-
cluded no recuperation of neurological activity after the
Evolution of the concept to diagnose brain diagnosis of brain death had been made.1
stem death
Personnel authorised to diagnose brain
The development of the concept of brain stem death
was first mentioned in Victor Halsey’s description of
respiratory arrest in a patient with pathological intra- stem death and approach to diagnosis
cranial tension in 1894, which was also mentioned in India follows the UK notion of brain-stem death, and
Mollaret and Goulon’s description of apnoeic coma in the Transplantation of Human Organs Act (THOA)
was promulgated in 1994 by the Indian parliament,
which legalised brain stem death, and in 1995, brought
Table 1. Harvard criteria.
about the brain-death certification procedure.2–4 In
Unreceptivity and These findings have to be India, and based on THOA 1994 (subsection 6 of sec-
unresponsiveness declared by two independent tion 3), brain stem death is certified by a ‘Board of
No movements teams, with two declarations Medical Experts’ comprising four members, namely
Apnoea with a 6-h interval in
the Medical Superintendent (MS), who is responsible
Absence of elicitable between them
for the hospital in which the brain stem death occurred,
reflexes
a specialist nominated by the MS who is also respon-
Isoelectric
sible for the hospital from a panel of names approved
electroencephalogram
by the suitable authority, a neurology specialist (phys-
ician or surgeon) nominated by the MS who is respon-
sible for the hospital among the approved names by the
Table 2. Minnesota criteria. suitable authority and the doctor who was in charge of
the patient.4 There are some tests done to document the
Known but irreplaceable All the findings should
absence of brain stem function, which are listed in
intracranial tension stay unchanged for a
period of 12 h Table 4. All four doctors should sign each test done
No spontaneous movements
separately. Also, the reversible causes of coma should
Apnoea
Absence of brain stem reflexes be excluded by all possible means, which include
absence of any intoxication (alcohol), use of drugs
that cause depression and drugs blocking the

Table 3. Philadelphia criteria. Table 4. Tests done to document loss of brain stem function.
Absence of responsiveness to internal and external environment 1. Pupillary or light reflex (both sides)
No spontaneous breathing for more than 3 min 2. Doll’s head eye movement or vestibulo-ocular reflex
Absence muscular movements with generalised flaccidity 3. Corneal or blinking reflex (both sides)
Absence of reflexes and responses 4. Gag or pharyngeal reflex
Declining arterial pressure without the use of drugs or by other 5. Cough (tracheal)
measures 6. Eye movements on caloric testing bilaterally
Isoelectric electroencephalogram recorded spontaneously and 7. Absence of motor response in all cranial nerve distributions
during tactile and auditory stimulation 8. Apnoea test
Saran and Padubidri
neuromuscular receptors. Primary hypothermia, hypo-
volemic shock and metabolic and endocrine disorders
should also be sought for and excluded.
Legal and ethical implications
Sometimes, due to difference in opinion, there can be
disagreements as to diagnosing the patient with brain
stem death among the panel of doctors, when further
confirmatory tests are carried out.5 Also, there is a con-
fusion sometimes as to the declaration of the time of
death of the patient, i.e. when the brain dies or when
the life support system is removed and the heart stops.
Due to this, the patient’s representatives may try to
prolong the usage of life supporting system on a
brain dead patient and may be completely against
organ donation. This query is answered by the United
Kingdom criteria, the one that is followed in India,
which states that the medical officer who is part of
the panel of doctors will speak to the patient’s repre-
sentatives and will announce the demise. Therefore, the
time of death is documented as the moment when the
final evaluation to satisfy the criteria for brain stem
death is complete.5 Also, if the deceased is pregnant
at the time of diagnosis of brain stem death, it is also
a very complex situation, as it has to be handled sensi-
tively and with care as to make sure no harm is done to
the foetus with complete monitoring until its delivery.
Different religions have many diverse beliefs and do not
accept brain stem death as the ultimate end. According
to a few minority Muslim people, death is acknowl-
edged only by cardio-pulmonary criteria.6
Conclusion
The approach to handling the issues of brain stem
death in clinical practice should be handled by an
3
experienced group of doctors for diagnosing the cases.
Also, the family and relatives of the patient should con-
stantly be counselled on multiple occasions about brain
stem death and about organ donation, as it can help
save a living patient who is suffering from an organ
dysfunction which has to be transplanted in order for
his or her survival.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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