The diagnosis of brain death remains firmly rooted at the bedside in the clinical findings. An expanding list of electrophysiological and imaging techniques contending for the role of confirmatory tests in no way supplants the position of the clinical neurological examination. On the rare occasions when uncertainty exists about parts of the clinical examination, a confirmatory test may be used to demonstrate cessation of cerebral blood flow for example, by cerebral angiography. The current ICSI guidelines have added to the original fifteen criteria, the requirement for a minimum systolic blood pressure of 90 mmHg before testing brain stem reflexes. However, the Memorandum’s checklist of 15 criteria outlining the systematic stepwise clinical examination in the diagnosis of brain death has undergone only a minor evolution. Since the Irish Working Party’s publication in 1988, technological developments have continuously modified critical care medicine and neurology practices. These findings are irreversible in an adult patient. Bedside clinical examination in a patient with coma of known aetiology, and without confounders that demonstrates absence of brainstem reflexes and apnoea, establishes the diagnosis of brain death. In a 2010 national audit of all deaths in Irish intensive care units, 7.6% of patients reached a diagnosis of brain death.

This avoids further complicated but useless treatment and preserves a patient’s right to dignity in death. The main purpose of establishing the diagnosis of brain death is to determine finality.

Memoranda neurology