Brain stem death has remained a topic of contention among physicians and laypersons for many years. The evolution of the current definition of brain stem death has been the end result of decades of scientific study and deliberation. Although the concept has been known historically, a scientific probe into the matter had been made possible only during the late 20^th century. This led to a healthy discussion regarding the obscure nature of brain stem death among experts on different continents, leading to the current definition provided by the American Association of Neurology in 2010. This review article aims at shedding light on the institution of brain stem death and the evolution of the definition, as we know it today. Brain stem death has remained a topic of contention among physicians and laypersons for many years. The evolution of the current definition of brain stem death has been the end result of decades of scientific study and deliberation. Although the concept has been known historically, a scientific probe into the matter had been made possible only during the late 20^th century. This led to a healthy discussion regarding the obscure nature of brain stem death among experts on different continents, leading to the current definition provided by the American Association of Neurology in 2010. This has proved to be a boon for the organ transplantation program; providing the system with a new, ethical donor pool and making available healthy organs that could change the lives of people living with organ failure. All this progress is relatively new and comes hand in hand with controversies. This review article aims at shedding light on the institution of brain death and the evolution of the definition, as we know it today.

Brain stem death (BD) is a pathological process which has a profound effect on hemodynamic balance, hormone levels and functioning of other organ systems. It also triggers a systemic inflammatory response. Knowledge about the changes that occur during brain stem death is necessary for subsequent management. This article discusses the pathophysiological changes in the body after brain stem death.

This article will focus on a step by step description of the process of brain stem death testing as per Indian Society of Critical Care Medicine (ISCCM) guidelines. This will be followed by a narrative on how the testing criteria differ among the various international guidelines. The importance of identifying a potential brain stem dead patient and confirming the same, zeroes down to two reasons. First and foremost, confirmation of death is needed for both the treating team of doctors and relatives to make informed decisions regarding ongoing care, including futility. The second is that it opens the opportunity to discuss the possibility of organ donation with the relatives. The criteria to diagnose brain stem death follows a stringent protocol and is laid in a fool proof manner so that the chances of making an error is infinistically minimal.

The diagnosis of brain stem death is quintessential in modern medical practice. It not only identifies the patients who will not benefit from continuing treatment but also opens the possibility of the patient becoming an organ donor. The increasing demand for organs has resulted in an evidence-based and scientific approach to optimizing these patients to ensure smooth conduct of brain stem death testing and ensuring the viability of organs. These guidelines describe the decision-making process for identifying the potential donors, medico-legal concerns regarding consent, exclusion criteria for eligibility, and suggested age limits of the donor as a consideration for the viability of different organs. The system-wise approach of assessing these patients, optimizing those using pharmacological and nonpharmacological interventions, and the targets for resuscitation are described in detail.

Pediatric brain stem death needs to be recognized both for futility in resuscitative efforts and in scope for organ donation. Pediatric donation can be performed from 37 weeks gestational age to 18 years. The diagnosis of brain stem death is completed by two clinical examinations separated by an interval of 24 h in term newborns and neonates and 12-h interval infants and children. Apnea testing is the main diagnostic test supported by tests of cranial nerve functions. Ancillary tests have not been approved for the diagnosis of brain stem death in India. Donor management is critical and needs invasive lines and attention to the maintenance of hemodynamics, fluid management, temperature, and hormonal resuscitation.Shifting the goals of care to organ maintenance can be challenging for the medical team. Counseling for donation needs to be sympathetic and honest while letting the parents understand that return back to life is impossible. Religious, cultural, and social customs of the family need to be respected and supported and the medical social worker is the key person in the establishment of a rapport with the grieving family. Creation of awareness among public and health-care professionals beside the involvement of governmental organizations both to endorse the process and support costs toward the program at least in its developmental phase is needed for this program in India.

At present, the determination of brain stem death for the declaration of death in India is a clinical practice followed only in the context of organ donation. It has still not evolved into a standard clinical practice in the intensive care units for determination of death. The probable explanation for this could be that, in India, the declaration of death by determination of brain stem death is mentioned only in the Transplantation of Human Organs and Tissues Act, 1994. Even after 25 years of application of this legislation and the definition of brain stem death in place, no uniform guidelines on the procedure to be followed in the determination of brain stem death have been issued either by the statute or by a national or state authority. The article tries to analyze the lacunae existing in the legal framework in relation to the certification of brain stem death in India.

Evolution of brain stem death certification has been linked to potential for organ donation. This has caused considerable legal and ethical controversies which are outlined. These include differences in the mode of death, challenge to irreversibilty of death; absence of laws to deal with withdrawal of support unless for organ donation, and clinical documentation of cardiac rather than brain stem death. Other legal, economic and ethical issues are discussed.

Religion plays a major role in the life of most people from the Indian subcontinent. Although religions originated many centuries years ago, the concepts of brain stem death and organ donation are less than a 100 years old. While acknowledging that religions have various denominations and may have varying opinions within them, this article attempts to provide a balanced view of how the major religions in India view these concepts of modern medicine.

Deceased organ donation (OD) involves a complex interplay of government policy, involvement of hospitals and health-care professionals (HCPs), and public support. When the Transplantation of Human Organs Act was passed in 1994 in India, acceptance of brain stem death and understanding about the deceased donation process was poor, both among the public and HCPs. While government support along with training of HCPs, public–private–nongovernmental organization partnerships, and public advocacy has enabled the deceased OD rate to move up from 0.16 per million population (pmp) in 2012 to 0.65 pmp in 2017, there is still much that needs to be done. A review of the literature undertaken to assess the knowledge, attitude, and practice of the public and HCPs toward brain stem death and OD in India revealed the need for interventions at multiple levels.

Organ donation after brain stem death is quite common in the west. In India, the procedure is still gaining acceptance. The surgical steps for multi-organ retrieval have evolved in different centers with significant variations, and the scientific evidence levels for each technique are low. Organ retrieval requires a fairly rapid surgical technique to avoid ischemic injury to the target organs yet avoid iatrogenic injuries. This article offers and outline of the multi-organ donation procedure. It details the abdominal organ retrieval techniques and touches on thoracic organs and composite tissue grafts as well. It also briefly touches upon machine perfusion of organs.