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Today, where a definition of the moment of death is required, doctors and coroners usually turn to "brain death" or "biological death": people are considered dead when the electrical activity in their brain ceases (cf. persistent vegetative state). It is presumed that a stoppage of electrical activity indicates the end of consciousness. However, suspension of consciousness must be permanent, and not transient, as occurs during sleep, and especially coma. In the case of sleep, EEGs can easily tell the difference.
Brain activity is a necessary condition to legal personhood. "It appears that once brain death has been determined … no criminal or civil liability will result from disconnecting the life-support devices." Dority v. Superior Court of San Bernardino County, 193 Cal.Rptr. 288, 291 (1983)
However, those maintaining that only the neo-cortex of the brain is necessary for consciousness sometimes argue that only electrical activity there should be considered when defining death. Eventually it is likely that the criterion for death will be the permanent and irreversible loss of cognitive function, as evidenced by the death of the cerebral cortex. All hope of recovering human thought and personality is then gone. However, at present, in most places the more conservative definition of death — cessation of electrical activity in the whole brain, as opposed to just in the neo-cortex — has been adopted (for example the Uniform Determination Of Death Act in the United States). In 2005, the case of Terri Schiavo brought the question of brain death and artificial sustainment to the front of American politics. Generally, in such contested cases the cause of death is anoxia. Oxygen deprivation for about seven minutes is sufficient to kill the cerebral cortex.
Even in these cases, the determination of death can be difficult. EEGs can detect spurious electrical impulses when none exists, while there have been cases in which electrical activity in a living brain has been too low for EEGs to detect. Because of this, hospitals often have elaborate protocols for determining death involving EEGs at widely separated intervals.
There are many anecdotal references to people being declared dead by physicians and then coming back to life, sometimes days later in their own coffin, or when embalming procedures are just about to begin. Stories of people actually being buried alive (which must assume no embalming) led one inventor in the early 20th century to design an alarm system, with a bell and a cord that could be pulled from inside the coffin.
Because of the difficulties in determining death, under most emergency protocols, a first responder is not authorized to pronounce a patient dead; some EMT training manuals, for example, specifically state that a person is not to be assumed dead unless there are clear and obvious indications that death has occurred, such as mortal decapitation, rigor mortis (rigidity of the body), livor mortis (blood pooling in the part of the body at lowest elevation), decomposition, or incineration, or other bodily damage clearly inconsistent with life. If there is any possibility of life and in the absence of a do not resuscitate (DNR) order, emergency workers are instructed to begin rescue and not end it until a patient has been brought to a hospital to be examined by a physician. This frequently leads to situation of a patient being pronounced dead on arrival (DOA).
In cases of electrocution, CPR for an hour or longer can allow stunned nerves to recover, allowing an apparently-dead person to survive. People found unconscious under icy water may survive if their faces are kept continuously cold until they arrive at an emergency room. This "diving response", in which metabolic activity and oxygen requirements are minimal, is something we share with cetaceans.
Brain death is defined as a complete and irreversible cessation of brain activity. Absence of apparent brain function is not enough. Evidence of irreversibility is also required. Brain-death is often confused with the state of vegetation.
Traditionally, death has been defined as the cessation of all body functions, including respiration and heartbeat. Since it became possible to revive some people after a period without respiration, heartbeat, or other visible signs of life, as well as to maintain respiration and blood flow artificially using life support treatments, an alternative definition for death was needed. In recent decades, the concept of "brain death" has emerged. By brain-death criteria, a person can be pronounced legally dead even if the heart continues to beat due to life support measures.
A brain-dead individual has no electrical activity and no clinical evidence of brain function on neurologic examination (no response to pain, no cranial nerve reflexes (pupillary response (fixed pupils), oculocephalic reflex, corneal reflexes), and no spontaneous respirations). It is important to distinguish between brain death and states that mimic brain death (eg. barbiturate intoxication, alcohol intoxication, sedative overdose, hypothermia, hypoglycemia, coma or chronic vegetative states). Some comatose patients can recover, and some patients with severe irreversible neurologic dysfunction will nonetheless retain some lower brain functions such as spontaneous respiration, loss of both cortex and brainstem function. Thus anencephaly, in which there is no higher brain present, is generally not considered brain death, although it is certainly an irreversible condition in which it may be appropriate to withdraw life support.
Note that brain electrical activity can stop completely, or apparently completely (a "flat EEG") for some time in deep anaesthesia or during cardiac arrest before being restored. Brain death refers only to the permanent cessation of electrical activity. Numerous people who have experienced such "flat line" experiences have reported near-death experiences, the nature of which is controversial.
It is presumed that a permanent cessation of electrical activity indicates the end of consciousness. Those who view the neo-cortex of the brain as solely responsible for consciousness, however, argue that only electrical activity there should be considered when defining death. In many cases, especially when elevated intracranial pressure prevents blood flow into the brain, the entire brain is nonfunctional; however, some injuries may affect only the neo-cortex.
The diagnosis of brain death needs to be made quite rigorously to be certain the condition is truly irreversible. Legal criteria vary from place to place, but generally require neurologic exams by two independent physicians showing complete absence of brain function, and may include two isoelectric (flat-line) EEGs 24 hours apart. The proposed Uniform Determination Of Death Act in the United States is an attempt to standardize criteria. The patient should have a normal temperature and be free of drugs that can suppress brain activity if the diagnosis is to be made on EEG criteria. Alternatively, a radionuclide cerebral blood flow scan that shows complete absence of intracranial blood flow can be used to confirm the diagnosis without performing EEGs.
Most organ donation for organ transplantation is done in the setting of brain death. In some nations (for instance, Belgium, Poland and Portugal) everyone is automatically an organ donor, unless you get a special attest stating that you are not an organ donor. In others, consent from family members or next-of-kin is required. The non-living donor is kept on ventilator support until the organs have been surgically removed. If a brain-dead individual is not an organ donor, ventilator and drug support is discontinued and cardiac death is allowed to occur.
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