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Before the advent of modern technology, death was considered to have occurred when the heartbeat and breathing ceased, and the soul abandoned the body. The absence of fog on a glass or a mirror placed under the nostrils and the patient’s failure to get up after being called three times by name were popular methods to document death.

At the beginning of 1959,Wertheimer et al. wrote about the “death of the nervous system.“ Later that year, Mollaret and Goulon coined the term , to describe an irreversible state of both coma and apnea. Those were the first attempts to characterize the clinical and pathophysiological condition of mechanically ventilated patients who had suffered the loss of brain functions but whose heartbeat was preserved.

Any full account of death should include three distinct elements: the definition of death, the criterion (anatomical substratum) of brain death, and the tests to prove that the criterion has been satisfied. Undoubtedly, the term ‘criterion’ for referring to the anatomical substratum introduces confusion in this discussion, because protocols of tests (clinical and instrumental) for brain diagnosis are called ‘diagnostic criteria’ or ‘sets of diagnostic criteria’. Therefore, I will use the term ‘anatomical substratum’ instead of criterion.

Most authors affirm that the diagnosis of brain death (BD) is just a clinical assessment, and after the Harvard Committee Report was published, most countries and states designed their BD diagnostic criteria. Brain death diagnosis should be carried out following a certain set of principles, excluding confusing factors, establishing the cause of the coma, determining irreversibility, and precisely testing brainstem reflexes at all levels of the brainstem.

It is widely accepted that BD is a clinical diagnosis, and that confirmatory tests are not mandatory in most situations. According toWijdicks, “a confirmatory test is needed for patients in whom specific components of clinical testing cannot be reliably evaluated.” An ideal confirmatory study for BD should be safe, extremely accurate and reliable, available, quick and inexpensive.

Although a brain death (BD) diagnosis in children encloses the same concept and similar diagnostic procedure as in adults, it is a more difficult task for physicians and nurses because of several ethical and psycho-emotional issues. Parents and the general population are more reluctant to accept death in children, and find it difficult to understand an explanation that a child with preserved heartbeats but no brain activity is dead.

The Terry Schiavo case has raised new controversies about the diagnosis and management of the persistent vegetative state (PVS) and the minimally conscious state (MCS). This controversy dominated the national news in the United States for some time and the case was taken to the courts, the Florida legislature, the Florida governor, the Congress, and all the way to the President of the United States. The Schiavo case and other famous patients, including Karen Ann Quinlan and Nancy Cruzan in the United States and Tony Bland in the United Kingdom, have made it necessary for neurologists and neuroscientists to propose reliable diagnostic guidelines for testing brain function in altered states of consciousness.

Although there has been a worldwide debate, the idea that a human being with irreversible loss of brain function is dead has been progressively accepted beginning in the early 1960s. The development of the intensive care unit (ICU) facilitated maintaining under mechanical ventilation (and by this means maintaining circulation) patients with complete destruction of their brains.

During the last several decades physicians and the public have needed urgent changes in the legal codes for accepting brain death (BD) as death, in order to obtain organs from heart-beating donors. As transplantation has become increasingly more effective, the demand for organs has outpaced the supply. Patients in need of organ transplants are dying needlessly because of the paucity of organs. The needs of tissues and organs for treatment through transplantation and the demand for organs quickly outpaced the supply; consequently, it became evident that standards and priorities needed to be established in order to allocate the increasingly scarce number of organs for transplantation. The transplant community continues to grapple with the organ-sharing shortage, to find new and inventive ways to increase the donor pool, and to allocate organs in a fair and equitable way based on sound scientific decision making, while enhancing the science of transplantation. The “dead donor rule” requires that donors must first be declared dead.