Confounding factors in diagnosing brain death: a case report.
BACKGROUND
Brain death is strictly defined medically and legally. This diagnosis depends on three cardinal neurological features: coma, absent brainstem reflexes, and apnea. The diagnosis can only be made, however, in the absence of intoxication, hypothermia, or certain medical illnesses.


METHODS
A patient with severe hypoxic-ischemic brain injury met the three cardinal neurological features of brain death but concurrent profound hypothyroidism precluded the diagnosis. Our clinical and ethical decisions were further challenged by another facet of this complex case. Although her brain damage indicated a hopeless prognosis, we could not discontinue care based on futility because the only known surrogate was mentally retarded and unable to participate in medical planning.


CONCLUSIONS
The presence of certain medical conditions prohibits a diagnosis of brain death, which is a medicolegal diagnosis of death, not a prediction or forecast of future outcome. While prognostication is important in deciding to withdraw care, it is not a component in diagnosing brain death.
Burns
Jeffrey M
JM
Department of Neurology, University of Virginia Health Sciences Center, Box 800394, Charlottesville, VA 22908, USA. jburns@virginia.edu
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Ivan S
IS
D001921:Brain / Q000098:blood supply / Q000000981:diagnostic imaging; D001926:Brain Death / Q000175:diagnosis*; D016887:Cardiopulmonary Resuscitation; D015897:Comorbidity; D015986:Confounding Factors, Epidemiologic; D003937:Diagnosis, Differential; D004992:Ethics, Medical; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007035:Hypothermia / Q000209:etiology; D007037:Hypothyroidism / Q000150:complications / Q000175:diagnosis*; D020925:Hypoxia-Ischemia, Brain / Q000150:complications / Q000175:diagnosis; D018447:Medical Futility / Q000941:ethics; D008875:Middle Aged; D019338:Polypharmacy; D011877:Radionuclide Imaging; D013667:Technetium; D014057:Tomography, X-Ray Computed
D013667:Technetium