INVITED REVIEW ARTICLE
An Update on Brain Death Criteria
A Simple Algorithm With Complex Questions
Patricia D. Scripko, MD, MA* and David M. Greer, MD, MA, FCCPw
Abstract: Brain death criteria have been based on 3 cardinal features
throughout history: coma, brainstem areflexia, and apnea, and thus
have undergone little change. In 1995, the American Academy of
Neurology (AAN) detailed these criteria in a step-by-step fashion that
included meeting prerequisites, performing the clinical examination,
performing ancillary testing, and documentation. Fifteen years later,
many questions still remain regarding the diagnosis of brain death. The
Quality Standards Subcommittee of the AAN sought to answer 5 of
these outstanding questions. Ultimately, their data supported the utility
of the 1995 criteria and warned against the use of new technologies
before proper validation. This review briefly tells the story of brain
death criteria, making mention of the steps outlined by the AAN in
1995 and discussing the recent evidence released by the Quality
Standards Subcommittee in the new 2010 Practice Parameter Update.
Key Words: brain death, coma, apnea, ancillary testing, prognosis,
practice parameters
(The Neurologist 2011;17:237240)
D espite a general consensus on the 3 cardinal features of
brain death, there are nevertheless variations in the
specific criteria used to diagnose brain death at local and global
levels. Here, we review the criteria for brain death in the
context of the recent evidence-based updates provided by the
American Academy of Neurology (AAN).1 These updates are
notable for their attention to the absence of any reported case
that challenges the validity of the 1995 AAN criteria,2 despite
ongoing uncertainty in such areas as the proper observation
time, the proper methods of apnea testing and the validity of
apnea testing, in addition to the presence of states that mimic
brain death, or conversely, those that mimic life in a brain dead
patient. Thus, although there remain unknowns and contro-
versies regarding certain specifics of its diagnosis, brain death
is a simple clinical diagnosis, as shown by the interim 14-year
validity of the AAN Practice Parameters.
THE ORIGIN OF BRAIN DEATH CRITERIA
Death is contextual; it is defined by the abilities of man
and technology to preserve or restore life and to identify it.
This is evident throughout history. When all man had was his 5
senses, visual, auditory, and tactile evidence of respiration was
From the *Department of Neurology, Massachusetts General Hospital/
Brigham and Womens Hospital, Boston, MA; and wDepartment of
Neurology, Yale Medical School, New Haven, CT.
The authors declare no conflict of interest.
Reprints: David M. Greer, MD, MA, FCCP, Department of Neurology,
Yale Medical School, LLCI 708, 15 York Street, New Haven, CT
06520-8018. E-mail: david.greer@yale.edu.
Copyright r 2011 by Lippincott Williams & Wilkins
ISSN: 1074-7931/11/1705-0237
DOI: 10.1097/NRL.0b013e318224edfa
The Neurologist  Volume 17, Number 5, September 2011
the definitive criteria for life. Then, after the acceptance of the
stethoscope, the sounds of a beating heart became the
paramount sign. Death by neurological criteria, or brain death,
then came about in the 1950s when ventilators and resuscitation
efforts in the intensive care unit (ICU) became widespread.
These efforts could restart and maintain cardiorespiratory
function for some time despite an irreversible complete
destruction of the brain that would have otherwise terminated
cardiorespiratory function. Thus, the term brain death is an
unfortunate one, leading to confusion that it might be something
different than death. There are often misuses of the term
brain dead and thus, a subsequent misunderstanding by those
exposed to the medias story. For instance, in a recent publicized
case of a brain dead pregnant mother, she was referred to as
alive, dying the moment the ventilator was withdrawn, rather
than dead once she met neurological criteria.3
VARIATION IN DIAGNOSTIC CRITERIA
With the brain being the most complex and least
accessible organ, doubt over the definition of and criteria for
brain death resulted in controversy and scrutiny. This, along
with insufficient education and poor adherence to current
guidelines for establishing brain death, likely led to widespread
variations in diagnostic criteria both throughout the world4 and
even between leading neurological institutions in the United
States.5
There have been innumerable influential laws and
position statements over the past several decades that have
aimed at conformity. These began with the establishment of
the Harvard Criteria in 1968,6 and have included the Uniform
Determination of Death Act of 1981,7 legal positions, such as
that endorsed by the American Bar Association in 1975,8 and
other medical positions, specifically those of the United
Kingdom Royal College, which brought about the concept of
brainstem death equating to brain death9,10 and those of the
AAN, which, as mentioned earlier, were recently updated
based on scientific evidence.1,2
The AAN Quality Standards Subcommittee sought to
answer 5 ongoing questions regarding brain death diagnosis.1
These questions, the relevant studies they analyzed, and their
conclusions are listed in Table 1. They reviewed the literature
systematically from January of 1996 to May of 2009, the time
period since the 1995 guidelines were released. In summary,
there was Level U evidence that there are no published reports
of patients fulfilling the 1995 AAN brain death criteria who
regain neurologic function, and that there is insufficient
evidence to determine the minimum number of hours a patient
must be observed before declaring brain death, as well as the
safety of one means of testing apnea over another, and the
accuracy of newer ancillary tests in the confirmation of brain
death. Furthermore, there was level C evidence that complex
motor movements can occur after brain death. Their findings
www.theneurologist.org | 237
Scripko and Greer The Neurologist  Volume 17, Number 5, September 2011

TABLE 1. Summary of the American Academy of Neurology Quality Standards Subcommittees Findings1
Question Studies Reviewed Conclusion
1. Are there patients diagnosed with Nine class IV studies reporting brain-death There is level U evidence that there are no
brain death who recover neurologic mimics,1119 including Guillain-Barre, published reports of patients fulfilling the 1995
function? organophosphate, lidocaine, baclofen and AAN brain death criteria who regain neurologic
vecuronium intoxication, and high spinal cord function
injury
2. What is an adequate observation None found There is level U evidence that there is insufficient
period to ensure that cessation of evidence to determine the minimum number of
neurologic function is permanent? hours a patient must be observed before declaring
brain death
3. Are complex motor movements that Nine class III studies,2330,32,33 one class IV,31 There is level C evidence that complex motor
falsely suggest retained brain function noting bilateral finger tremor, ocular movements can occur after brain death
sometimes observed in brain death? microtremor, facial myokymia, repetitive leg
movements, cyclical pupillary constriction and
dilatation, plantar reflexes, an undulating toe
reflex, and ventilator-initiated breaths that appear
to be initiated by the patient
4. What is the comparative safety of Four class IV studies3437 investigating use of a There is level U evidence that there is insufficient
techniques for determining apnea? T-piece with CPAP, transcutaneous CO2 evidence to determine the safety of one means of
monitoring and a preoxygenation with an apneic testing apnea over another
oxygenation-diffusion technique
5. Are there new ancillary tests that CTA: Five class IV studies4751 and one class III There is level U evidence that there is insufficient
accurately identify patients with brain study52 reporting high false negative rates evidence to determine the accuracy of newer
death? MRA: Three class IV case series4446 reporting ancillary tests in the confirmation of brain death
high sensitivity of MRA and one class II case-
control study43 corroborating these data
SSEP: Two class III cohort studies53,54 reporting
high sensitivity and specificity for N14
nasopharyngeal SSEPs
Bispectral index: One class III study55 comparing
bispectral to TCD, finding no difference in their
results
CPAP indicates continuous positive airway pressure; CTA, computed tomography angiography; MRA, magnetic resonance angiography; SSEP, somatosensory-
evoked potentials; TCD, transcranial Doppler.

serve as strong support for use of the 1995 guidelines in the
diagnosis of brain death, in addition to further research
regarding the still unanswered questions in brain death, such as
the proper observation period, the safest apnea test, and the
utility of newer technologies in the diagnosis. They also serve
as a word of caution regarding reliance on these newer
technologies before they are validated for use as ancillary tests
in the diagnosis of brain death.
The remainder of this article provides an overview of how
brain death is diagnosed based on the AAN 1995 criteria, with
specific mention of the evidence-based updates from the AAN
in 2010.
THE DIAGNOSIS OF BRAIN DEATH
The steps in diagnosing brain death can be broken down
into 4 areas as described by the AAN1: meeting prerequisites,
performing the clinical examination, using ancillary testing if
appropriate (ie, when the clinical examination cannot be
performed), and documentation and consideration for organ
donation. The need for completeness of these steps is evident
in the 9 Class IV studies reviewed by the AAN for their reports
of brain death mimicry.1119 None of these reports were
accompanied by a complete brain death examination in line
with the AAN 1995 Practice Parameters.
Prerequisites
The prerequisites for brain death include knowledge of
the proximate cause of brain death, in addition to confirma-
tion of its irreversibility and a lack of confounding variables.1,2
Confounders include metabolic disturbances, such as severe
electrolyte disturbances, hyperammonemia and acid-base
abnormalities, hypothermia, endocrine disturbances and drug
intoxication. Small changes to the 1995 Practice Parameter,
including raising the lowest acceptable temperature from
>321C to >361C), and the need for a systolic blood pressure
Z100 mm Hg were also added to the prerequisites. Case
reports of brain death mimicry by toxic agents1114,20 and
hypothermia21 continue to emphasize the importance of
meeting the prerequisites.
Over time, specific clinical findings that do not negate the
patients status as brain dead have been reported and reviewed.
These include the absence of diabetes insipidus,2,22 organ failure,
and the presence of sweating, tachycardia, simple and complex
reflexive and spontaneous movements,2,2333 and spontaneous or
reflexive complex motor movements that may be of spinal or
peripheral origin. These typically occur within the first 24 hours
after brain death ensues.23 Nine Class III studies and 1 Class IV
study reporting complex movements after brain death were
recently reviewed by the AAN, and confirmed that the presence
of these movements does not preclude a diagnosis of brain death.
These studies included reports of bilateral finger tremor,24
cyclical pupillary constriction and dilation,25 ocular microtre-
mor,26 repetitive leg movements,27 facial myokymias,23 eyelid
opening,28 an undulating toe reflex,29,30 and seemingly patient-
initiated breaths that were in reality ventilator-initiated, or
autocycling.31,32 Such movements are added to the AANs list
from 1995 including cremasteric, plantar and abdominal
reflexes,23,33 triple flexion of the lower extremities, deep tendon

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The Neurologist  Volume 17, Number 5, September 2011
reflexes, a respiratory-like reflex,34 the Lazarus sign,23 and
limb movements other than pathologic posturing.
Bedside Diagnosis
The clinical examination involves primarily tests of brain
stem function (ie, pupillary reflex, oculocephalic and oculoves-
tibular reflexes, corneal reflex, and gag reflex), in addition to
tests of responsiveness to ensure the patient is comatose.
Examination technique has remained unchanged, aside from
conducting the apnea test and the inclusion or exclusion of an
observation period. There were 4 Class IV studies on various
apnea testing techniques reviewed by the AAN.22,3537 These
included 1 study using a T-piece and continuous positive airway
pressure valve,35 2 studies recommending monitoring with
transcutaneous carbon dioxide partial pressure monitoring,36,37
and 1 study with the use of preoxygenation and an apneic
oxygenation-diffusion technique.22 As none of these studies
compared one technique against another, the AAN concluded
that there is insufficient evidence to declare superior safety of 1
technique. The updated guidelines provide a step-by-step means
of conducting the apnea test, as was done in 1995.
An observation period is not requisite under many states
laws. Some states, however, require observation and a repeat
examination. There are no data to support a particular duration
for which patients should be observed, and thus the AAN
continues to recommend the performance of only 1 examina-
tion, unless state law requires differently.
Ancillary Testing
Ancillary testing is optional in the United States, but
mandatory in many other countries.4 These tests include
electroencephalography (EEG), cerebral angiography, tran-
scranial Doppler ultrasound, and cerebral radionuclide scinti-
graphy using single photon emission computed tomography.
There are numerous limitations to these tests, and they are
recommended only if the clinical examination, including the
apnea test, is unable to be performed completely, reliably, or
safely, or if there is doubt owing to a questionable confounder
(ie, intoxication with an unknown substance after a prolonged
observation period) or a possible mimicker of life (ie, complex
motor movements). Newer ancillary tests have received recent
attention, but are not validated for the confirmation of brain
death. Here, we touch on the major limitations of the 4
traditional tests as well as the newer technologies.
The classic 4 tests are mostly limited by their sensitivity,
having necessarily low false positive rates. EEG lends insight to
cortical activity and is one of the simplest tests to perform.
Unfortunately, it is often difficult to interpret owing to its
susceptibility to artifact, and may be uninterpretable in up to 20%
of cases in which brain death is being assessed.38 Machines in
the ICU and electromyographic signals can both produce artifact
on the EEG, leading to false negatives. False positives can also
occur, such as in the setting of sedatives or hypothermia. Digital
subtraction angiography and single photon emission computed
tomography have similar high sensitivities.39 False negatives can
occur from blood reflow to a necrotic brain, in which cellular
necrosis is so great that the intracranial pressure decreases.40
Both of these tests are limited by their technical requisites,
including the need to transport the patient from the ICU for
completion of the study. Angiography is particularly limited by
its labor-intensive nature, time requirement, and use of
intravenous contrast. Finally, transcranial Doppler ultrasounds
are often used, but have an unclear sensitivity, reported to range
from 75% to 100%.4143 Physicians must be cautious to not
misinterpret a lack of signal as a positive test; no signal is
r 2011 Lippincott Williams & Wilkins
Update on Brain Death
obtained in 5% to 10% of patients, typically owing to a lack of
ability to insonate the intracranial arteries because of poor bone
windows.44
The AAN Quality Standards Subcommittee found that the
sensitivity and specificity of newer techniques to examine
cerebral blood flow, notably computed tomography angiogra-
phy and magnetic resonance angiography, are not yet known
owing to the small sample sizes of studies conducted thus far.
Also, they noted that the false positive rate is unknown, in
large part because all but 1 small study45 excluded patients
who were comatose but not brain dead.4654 Going forward, it
is important to note that, unlike conventional angiography,
computed tomography angiography and magnetic resonance
angiography are venous injections, and as such cannot be
performed under pressure to augment forward flow. This may
decrease the specificity but increase the sensitivity of the test.
The evidence for other testing modalities, such as
somatosensory-evoked potentials and bispectral index mon-
itoring, was also deemed insufficient by the AAN. The
evidence specifically for the lack of a P14 response on
nasopharyngeal SSEP, however, is promising. This evidence
came from 2 Class III studies that reported near perfect
sensitivities, specificities, and false positive rates, but did not
fully validate this test.55,56 Only 1, small Class III study for
bispectral index was evaluated, providing preliminary data on
the utility of this technology.57 One must remain skeptical
about this technology, as it samples a very small and limited
section of brain; it may be useful as a screening test, but not as
a validated ancillary test.
THE FUTURE OF BRAIN DEATH
Although brain death is a relatively simple clinical
diagnosis, there are hurdles ahead for brain death criteria. These
include an ongoing lack of conformity among countries, states,
and even between hospitals. There are also the obstacles of
cultural and religious opposition that has led to religious
exemption from determination of death by neurologic criter-
ia.58,59 Moving forward, increased awareness of current criteria
and an understanding in the lay community will be necessary to
ensure validity, standardization and acceptance of criteria.
Furthermore, significant research is necessary to ensure that
new technologies are properly validated, and that the perfor-
mance of clinical testing is done with an extremely high level of
accuracy.
REFERENCES
1. Wijdicks EFM, Varelas PN, Gronseth GS, et al. Evidence-based
guideline update: determining brain death in adults: report of the
quality standards subcommittee of the American academy of
neurology. Neurology. 2010;74:19111918.
2. The Quality Standards Subcommittee of the American Academy of
Neurology Practice Parameters for Determining Brain Death in
Adults. Neurology. 1995; 45:10121014.
3. McCrummer S. Brain-dead mother is taken off life support.
[Washington post website]. August 4, 2005. Available at: http://
www.washingtonpost.com/wp-dyn/content/article/2005/08/03/AR
2005080300224.html. (Accessed July 31, 2010).
4. Wijdicks EFM. Brain death worldwide: accepted fact but no global
consensus. Neurology. 2002;58:2025.
5. Greer DM, Varelas PN, Haque S, et al. Variability of brain death
determination guidelines in leading US neurologic institutions.
Neurology. 2008;70:284289.
6. Ad Hoc Committee of the Harvard Medical School. A definition of
irreversible coma. JAMA. 1968;205:337340.
www.theneurologist.org | 239
Scripko and Greer
7. Uniform Determination of Death Act, UNIFORM LAWS ANNOT
12A:589 Available at: http://www.law.upenn.edu/bll/archives/ulc/
fnact99/1980s/udda80.htm. (Accessed June 2009).
8. House of Delegates redefines death, urges redefinition of rape, and
undoes the Houston amendments. Am Bar Assoc J. 1975;
61:463464.
9. Conference of Medicial Royal Colleges and Their Facilities in the
United Kingdom. Diagnosis of brain death. Br Med J. 1976;
9n:11871188.
10. Conference of Medicial Royal Colleges and Their Facilities in the
United Kingdom. Diagnosis of brain death. Lancet. 1976;308:
10691070.
11. Richard IH, LaPointe M, Wax P, et al. Non-barbitrate, drug=in-
duced reversible loss of brainstem reflexes. Neurology.
1998;51:639640.
12. Ostermann ME, Young B, Sibbald WJ, et al. Coma mimicking
brain death following baclofen overdose. Intensive Care Med.
2000;26:11441146.
13. Peter JV, Prabhakar AT, Pichamuthu K. In-laws, insecticide and a
mimic of brain death. Lancet. 2008;371:622.
14. Kainuma M, Miyake T, Kanno T. Extremely prolonged vecurium
clearance in a brain death case. Anesthesiology. 2001;95:10231024.
15. Waters CE, French G, Burt M. Difficulty in brainstem death
testing in the presence of high spinal cord injury. Br J Anaesth.
2004;92:760764.
16. Stojkovic T, Verdin M, Hurtevent JF, et al. Guillain-Barre
syndrome resembling brainstem death in a patient with brain
injury. J Neurol. 2001;248:430432.
17. Rivas S, Douds GL, Ostdahl RH, et al. Fulminant Guillain-Barre
syndrome after closed head injury: a potentially reversible cause of
an ominous examination. J Neurosurg. 2008;108:595600.
18. Friedman Y, Lee L, Wherrett JR, et al. Simulation of brain death
from fulminant de-efferentation. Can J Neurol Sci. 2003;30:
397404.
19. Joshi MC, Axim A, Gupta GI, et al. Guillain-Barre syndrome with
absent brainstem reflexes: a report of two cases. Anaesth Intensive
Care. 2008;36:867869.
20. Yang KL, Dantzker DR. Reversible brain death: a manifestation of
amitriptyline overdose. Chest. 1991;99:10371038.
21. Danzl DF, Pozos RS. Accidental hypothermia. N Engl J Med.
1994;331:17561760.
22. Wijdicks EFM, Rabinstein AA, Manno EM, et al. Pronouncing
brain death: contemporary practice and safety of the apnea test.
Neurology. 2008;71:12401244.
23. Saposnik G, Bueri J, Maurino J, et al. Spontaneous and reflex
movements in brain death. Neurology. 2000;54:221223.
24. Araullo ML, Frank JI, Goldenberg FD, et al. Transient bilateral
finger tremor after brain death. Neurology. 2007;68:E22.
25. Shulgman D, Parulekar M, Elston JS, et al. Abnormal pupillary
activity in a brainstem-dead patient. Br J Anaesth. 2001;86:717720.
26. Bolger C, Bojanic S, Phillips J, et al. Ocular microtremor in brain
stem death. Neurosurgery. 1999;44:12011206.
27. Jung KY, Han SG, Lee KH, et al. Repetitive leg movements
mimicking periodic leg movement during sleep in a brain-dead
patient. Eur J Neurol. 2006;13:e3e4.
28. Santamaria J, Orteu N, Iranzo A, et al. Eye opening in brain death.
J Neurol. 1999;246:720722.
29. de Freitas GR, Andre C. Absence of the Babinski sign in brain
death. J Neurol 2005;252:106107.
30. Xubkov AY, Wijdicks EFM. Plantar flexion and flexion synergy in
brain death. Neurology. 2008;70:e74.
31. Willatts SM, Drummond G. Brain death and ventilator trigger
settings. Anaesthesia. 2000;55:676684.
32. Wijdicks EFM, Manno EM, Holets SR. Ventilator self-cycling
may falsely suggest patient effort during brain death determina-
tion. Neurology. 2005;65:774.
33. Ivan LP. Spinal reflexes in cerebral death. Neurology. 1973;23:
650652.
34. Ropper AH. Unusual spontaneous movements in brain-death
patients. Neurology. 1984;34:10891092.
35. Levesque S, Lessard MR, Nicole PC, et al. Efficacy of a T-piece
system and a continuous positive airway pressure system for apnea
240 | www.theneurologist.org
The Neurologist  Volume 17, Number 5, September 2011
testing in the diagnosis of brain death. Crit Care Med. 2006;34:
22132216.
36. Lang CJG, Heckmann JG, Erbguth F, et al. Transcutaneous and
intra-arterial blood gas monitoring: a comparison during apnoea
testing for the determination of brain death. Eur J Emerg Med.
2002;9:5156.
37. Vivien B, Marmion F, Roche S, et al. An evaluation of trans-
cutaneous carbon dioxide partial pressure monitoring during apnea
testing in brain-dead patients. Anesthesiology. 2006;104:701707.
38. Buchner H, Schuchardt V. Reliability of the electroencephalo-
graming the diagnosis of brain death. Eur Neuro. 1990;30:
138141.
39. Munari M, Zucchetta P, Carollo C, et al. Confirmatory tests in the
diagnosis of brain death: comparison between SPECT and contrast
angiography. Crit Care Med. 2005;33:20682073.
40. Marrache F, Megarbane B, Prinay S, et al. Difficulties in assessing
brain death in a case of benzodiazepine poisoning with persistent
cerebral blood flow. Hum Exp Toxicol. 2004;23:503505.
41. Report of the American Academy of Neurology, Therapeutics and
Technology Assessment Subcommittee. Assessment: transcranial
Doppler. Neurology. 1990;40:680681.
42. de Freitas GR, Andre C. Sensitivity of transcranial Doppler for
confirming brain death: a prospective study of 270 cases. Acta
Neurol Scand. 2006;113:426432.
43. Ducrocq X, Braun M, Debouverie M, et al. Brain death and
transcranial Doppler: experience in 130 cases of brain dead
patients. J Neurol Sci. 1998;160: 4146.
44. de Freitas GR, Andre C, Bezerra M, et al. Persistence of isolated
flow in the internal carotid artery in brain death. J Neurol Sci.
2003;210:3134.
45. Shii K, Onuma T, Kinoshita T, et al. Brain death: MR and MR
angiography. AJNR Am J Neuroradiol. 1996;17:731735.
46. Karantanas AH, Hadjigeorgiou GM, Paterakis K, et al. Contrib-
ution of MRI and MR angiography in early diagnosis of brain
death. Eur Radiol. 2002;12:27102716.
47. Matsumura A, Meguro K, Tsurushima H, et al. Magnetic
resonance imaging of brain death. Neurol Med Chir. 1996;36:
166171.
48. Lovblad KO, Bassetti C. Diffusion-weighted magnetic resonance
imaging in brain death. Stroke. 2000;31:539542.
49. Quesnel C, GUlgencio J-P, Adrie C, et al. Limitations of computed
tomography in the diagnosis of brain death. Intensive Care Med.
2007;33:21292135.
50. Combes JC, Chomel A, Ricolfi F, et al. Reliability of computed
tomographic angiography in the diagnosis of brain death.
Transplant Proc. 2007;39:1620.
51. Frampas E, Videcoq M, de Kerviler E, et al. CT angiography
for brain death diagnosis. Am J Neuroradiol. 2009;30:
15661570.
52. Escudero D, Otero J, Marques L, et al. Diagnosing brain death by
CT perfusion and multislice CT angiography. Neurocrit Care.
2009;11:261271.
53. Greer DM, Strozyk D, Schwamm LH. False positive
CT angiography in brain death. Neurocrit Care. 2009;11:
272275.
54. Dupas B, Gayet-Delacroix M, Villers D, et al. Diagnosis of brain
death using two-phase spiral CT. Am J Neuroradiol. 1998;19:
641647.
55. Wagner W. Scalp, earlobe and nasopharyngeal recordings of the
median nerve somatosensory evoked P14 potential in coma and
brain death. Brain. 1996;119:15071522.
56. Roncucci P, Lepori P, Mok MS, et al. Nasopharyngeal electrode
recording of somatosensory evoked potentials as an indicator in
brain death. Anaesth Intensive Care. 1999;27:2025.
57. Misis M, Raxach JG, Molto HP, et al. Bispectral index monitoring
for early detection of brain death. Transplant Proc. 2008;40:
12791281.
58. NY COMP CODES, RULES & REGS, Title 10, section 400.16(d),
(e)(3) (1992).
59. Olick RS. Brain death, religious freedom, and public policy: New
Jerseys landmark legislative initiative. Kennedy Inst of Ethics J.
1991;1:275288.
r 2011 Lippincott Williams & Wilkins