E.5.6 discuss the concept of brain death and the use of the pupil reflex in testing for this.

Until the late twentieth century, death was defined in terms of loss of heart and lung functions, both of which are easily observable criteria. However, with modern technology these functions can be maintained even when the brain is dead, although the patient's recovery is hopeless. By definition, "brain death" is "when the entire brain, including the brain stem, has irreversibly lost all function." The legal time of death is "that time when a physician(s) has determined that the brain and the brain stem have irreversibly lost all neurological function." Brain death is caused by any disease or injury that creates swelling in the brain. Some common causes of brain death in children include shaken baby syndrome, brain tumor, traumatic head injury, and stroke. Due to the continual medical advancements, there will be more and more patients who are able to be maintained by ventilation support systems -- their body temperature, blood pressure, pulse, nutrition and fluid requirements are being artificially maintained, but they have a non-viable (dead) brain. These patients are brain dead without any hope of recovery or survival. There is a difference between brain stem death and a persistent vegetative state (PVS), which can occur after extensive damage to the brain. Someone in a PVS is conscious but has no awareness of their surroundings and is incapable of feeling mental distress or physical pain. However, unlike a person with brain death, there is a slim chance that a person with PVS can recover because the core functions of the brain stem are often unaffected. Unfortunately, there is no chance of a person recovering once their brain stem has died. This is because all of the core functions of the body have stopped working and can never be restarted. Although a ventilator can keep the heart beating, the person is effectively dead. The pupils are unreactive (fixed). The patient's eyes are opened and a very bright light is shined into the pupil. The light will activate the optic nerve and send a message to the brain. In the normal brain, the brain will send an impulse back to the eye to constrict the pupil. In the non-viable brain, no impulse will be generated. This is performed in both eyes.x The patient has no oculocephalic reflex. The patient's eyes are opened and the head turned from side to side. The active brain will allow a roving motion of the eyes; the non-functional brain will not. The eyes remain fixed. The patient has no corneal reflexes. A cotton swab is dragged across the cornea while the eye is held open. The intact brain will want the eye to blink. The dead brain will not. This is performed in both eyes.