End of life IssuesNeurology


Three years ago I published a blog post on brain death. It was an in-depth analysis of the criteria and mechanism by which terminally ill patients were pronounced dead. What we learned is there are two methods used to determine if a patient has truly died. They are Brain Death and Biological Death. 

Before reading this article I would encourage you to go back and read the article titled “What Does it Mean to be Brain Dead.” This helps you understand the two methods by which people are declared dead and highlights the controversies surrounding the two methods. Confusion has led to controversy and multiple lawsuits. We die either because we have irreversible cessation of circulatory and respiratory functions (biological death) or irreversible cessation of all functions of the entire brain including the brain stem (brain death). 

The huge controversy that arises from these methods is that quite often after Brain Death has been declared, patients retain most of the capacities of living people—they can still absorb nutrition, excrete waste, heal wounds, grow, even gestate—leading many families to reject that diagnosis and insist on continuing biologically life-sustaining health measures. When a patient is really dead, they decay and putrefy, and develop rigor mortis. 

Another concern with brain death is the requirement that all functions “of the entire brain” should be irreversibly absent. The hypothalamus, deep in the cerebral hemispheres, is an area of the brain where function cannot be adequately assessed so function is not tested. But some brain functions attributable to the hypothalamus are still recognized in patients diagnosed with brain death leading to many legal challenges to the concept.

Thus a re-definition of brain death is forthcoming. The U.S. Uniform Law Commission (ULC) is working to resolve the situation before it gets more confusing.

Reference: VIEWPOINT: Truog,RD. The uncertain Future of the Determination of Brain Death. JAMA 2023 March 28;329(12):971-972.

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