Clinical or Bedside: Hapter Three

CHAPTER THREE | 31
Another requirement for the diagnosis of total brain failure con-

cerns the patient’s history. The cause of the patient’s brain injury
cannot be hypothermia, poisoning, drug intoxication, or any such
cause that brings about metabolic changes that can mimic the ef-
fects of total brain failure. The reason that a total brain failure
diagnosis is ruled out in these cases is plain: A condition like this is
often transient— it may clear up when the cause of the metabolic
change passes out of the patient’s system or is otherwise removed.*
If the patient being diagnosed is determined to be in a deep, unre-

sponsive coma and none of the excluding causes just mentioned is
present, then a battery of further tests must be conducted. These
tests can be divided into two complementary groups: clinical or bedside
tests and laboratory or imaging tests. The bedside tests are performed
by trained clinicians, usually neurologists, and do not involve any
high-tech instruments. The laboratory tests do involve such equip-
ment and are intended to provide a more complete picture of what
the clinician observes during the clinical examination.
With the clinical bedside tests for total brain failure, the clinician
examines the comatose patient for any signs of brainstem function
(See Figure 4). The functional status of this part of the brain is im-
portant for several reasons. First, the functions that depend on the
brainstem are central to the basic work of the organism as a whole.
This has already been noted with respect to the brainstem’s (par-
ticularly, the medulla’s) involvement in breathing. Brainstem
function is also critical to an organism’s conscious life. O ne part of
the brainstem, known as the “reticular activating system,” is essen-
tial for maintaining a state of wakefulness, which is a prerequisite
for any of the activities associated with consciousness.
In addition to its significance for the patient’s functional capacities,

the condition of the brainstem also has a general diagnostic signifi-
* For a clinical case study of a patient who showed all the signs of total brain
failure after a snake bite but then recovered after receiving an antidote, see R.
Agarwal, N. Singh, and D . G upta, “Is the Patient Brain-D ead?” E merg M ed J 23,
no. 1 (2006): e5.
32 | CO NTRO VERSIES IN THE D ETERMINATIO N O F D EATH
cance in most cases, for the brainstem is the most resilient part of
the brain as a whole. As will be elaborated in Part III, if a brain in-
jury has progressed to the point at which the brainstem retains no
function, it has probably ravaged the more fragile parts of the brain
as well. Thus, the bedside tests for brainstem function are tests for
the extent of destruction both to the brainstem and to the parts of
the brain “above the brainstem”— the so-called “higher centers.” *
How, then, do the clinical tests determine the status of the brain-
stem? O ne marker of brainstem function has already been explored
in depth: the signal that is sent from the respiratory centers to the
muscles of respiration. Thus, the patient’s drive to breathe must be
tested with an apnea test. “Apnea” is the technical term for an in-
ability to breathe. Although all patients who receive ventilator
support need the machine’s help to breathe, most are not so injured
that they have no drive to breathe whatsoever. The purpose of the
apnea test for total brain failure is to establish that the patient has no
drive to bring air into the body even when the sensors in the brain-
stem are receiving an unambiguous signal that breathing is required.
Recall from the previous discussion that these sensors serve to trig-
ger movement of the muscles of respiration when high levels of
carbon dioxide in the blood are detected. In the apnea test, then,
the ventilator is removed and the level of carbon dioxide in the pa-
tient’s bloodstream is permitted to increase beyond the point that
* The exception to the rule discussed in the text is a case where a primary lesion
of the brainstem leads to the diagnostic signs that usually indicate total brain fail-
ure. In such a case, the condition of the brainstem is not itself a reliable indicator
of the condition of the higher centers of the brain. Among those who accept the
neurological standard for determining death, there is controversy about the vital
status of the patient about whom all that is k nown is the condition of the brain-
stem. See S. Laureys, “Science and Society: D eath, Unconsciousness and the
Brain,” N at R ev N eurosci 6, no. 11 (2005): 901-02; J. L. Bernat, “O n Irreversibility
as a Prerequisite for Brain D eath D etermination,” A dv E x p M ed Biol 550 (2004):
166; and C. Pallis and D . H. Harley, A BC of Brainstem D eath, Second ed. (London:
BMJ Publishing G roup, 1996): 11-12. For the purposes of this report, such pa-
tients are excluded from the group considered to have “total brain failure.”
CHAPTER THREE | 33
would normally trigger inhalation.* If the examining clinicians see

any signs that the chest is moving, the brainstem clearly has some
vitality left and thus the patient cannot be diagnosed with total brain
failure.
Another set of indicators of brainstem function are the automatic

responses or “brainstem reflexes.” Elicited by appropriate stimuli,
these include the gag reflex, the cough reflex, and the reflex to
move the eyes in certain ways under certain conditions (e.g., when
the head is moved, which normally causes the oculocephalic reflex
or doll’s eyes phenomenon, or when cold water is injected into the
ear canal). The examining clinicians will provide the appropriate
stimuli to detect the presence or absence of these reflexes. If any
are present, a diagnosis of total brain failure is ruled out.
In summary, a diagnosis of total brain failure can be made only

when each of the following four conditions has been met:
1. The patient has a documented history of injury that

does not suggest a potentially transient cause of symp-
toms, such as hypothermia or drug intoxication.
2. The patient is verified to be in a completely unrespon-

sive coma.
3. The patient demonstrates no brainstem reflexes.
* The patient is prepared for this test by receiving, in advance, an elevated level of
circulating oxygen that will prevent any further damage to tissues while the test is
being carried out. Some inconsistencies in the way the apnea test is carried out in
different places— including whether it is required at all in some countries— have
been documented. For more information, see E. F. Wijdicks, “Brain D eath
Worldwide: Accepted Fact but No G lobal Consensus in D iagnostic Criteria,”
N eurology 58, no. 1 (2002): 20-5; R. Vardis and M. M. Pollack, “Increased Apnea
Threshold in a Pediatric Patient with Suspected Brain D eath,” C rit C are M ed 26,
no. 11 (1998): 1917-9; and R. J. Brilli and D . Bigos, “Apnea Threshold and Pedi-
atric Brain D eath,” C rit C are M ed 28, no. 4 (2000): 1257.

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CHAPTER THREE | 31

Another requirement for the diagnosis of total brain failure con-

If the patient being diagnosed is determined to be in a deep, unre-

In addition to its significance for the patient’s functional capacities,

would normally trigger inhalation.* If the examining clinicians see

Another set of indicators of brainstem function are the automatic

In summary, a diagnosis of total brain failure can be made only

1. The patient has a documented history of injury that

2. The patient is verified to be in a completely unrespon-

3. The patient demonstrates no brainstem reflexes.

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