The questionnaire was mailed to a random sample of 500 board-certified neurologists in the United States; after the second mailing, 218 (44%) had been returned. Of the 218 returned, 26 (12%) did not have data that could be analyzed: 24 were returned to sender, and 2 were returned blank. Therefore, there were 192 of 477 (40.3%) eligible surveys returned with data for analysis.
The first question asked, "Which of several choices is an acceptable stand-alone conceptual reason to explain why BD is equivalent to death." Fifty-two (27%; 95% CI, 21-34%) chose the irreversible loss of the integration of body functions by the brain, 22 (12%; 8-17%) a cessation of the vital work of the organism, and almost half (48%; 41-55%) used a higher brain concept (Table ).
Responses to the question on conceptual reasons to explain why brain death is equivalent to death
The next two questions asked about which objective test results, or pathology results (in a patient maintained as BD for 48 hours), would not be compatible with BD. A majority of respondents were unaware of the findings their patients may have when diagnosed with BD (Table ).
The objective findings that respondents considered would not be compatible with brain death
The next three questions asked about the timing of BD in different patient situations. When faced with a patient who has EEG activity yet fulfills BD criteria, 26 (14%; 9-19%) consider the patient dead at the first BD examination, 72 (38%; 31-45%) at the second examination, and 90 (47%; 40-54%) only when the EEG became isoelectric 12 hours later. When faced with a pregnant patient with BD supported for 11 weeks until delivery, most agreed the patient was dead by the first (36, 19%; 14-25%) or second (119, 62%; 55-69%) examination. However, in this brain-dead pregnant patient, 36 (19%; 14-25%) answered that she was not actually dead until sometime later: 11 (6%; 3-10%) after delivery of the neonate, 19 (10%; 6-15%) after organs are recovered and the ventilator is stopped, and 6 (3%; 1-7%) at none of these times. When faced with a brain-dead patient who has no cerebral blood flow but a family who insists on continued life support for the next months, and asked "was this patient dead for the last 8 months," 31 (16%; 12-22%) responded "no." When asked if this patient was performing vital work during those months, 164 (85%; 80-90%) responded no, and 30 (15%; 11-21%) responded yes [receptive to stimuli, 9 (5%; 2-9%); acting upon the world, 5 (3%; 1-6%), and carrying out basic (non-conscious) felt needs, 16 (8%; 5-13%)].
The next two questions asked again about the underlying conceptual basis of BD: "In your own words, what is it about loss of brain function including the brainstem that makes this patient dead?" and "Prior to this survey, had you thought about why, at a conceptual level, brain death is equivalent to death of the patient?" Only 21 (11%; 7-16%) of respondents had not previously thought about why BD is equivalent to death. In their own words, only 15 (8%; 5-13%) used a loss of integration concept (Table ).
Response to the question about what, in the respondent's own words, makes a patient dead
The next question asked which choice "best describes why you are comfortable diagnosing death based on the criteria of brain death?" Most (133, 69%; 62-75%) responded that "the conceptual basis of brain death makes it equivalent to death of the patient." Many responded that the reason is because it is a standard: an accepted medical standard (46, 24%; 18-30%), an accepted legal standard (24, 13%; 8-18%), and/or "the diagnosis of brain death was taught to me during my training" (14, 7%; 4-12%). Five (3%; 1-6%) were not comfortable diagnosing death based on BD.
The final question asked: "Are brain death and cardiac death the same state (i.e., are both death of the patient)?" More than half (104, 54%; 47-61%) chose "no," 86 (45%; 38-52%) chose "yes," and 2 (1%; 0-4%) left the answer blank.
Further analysis was done for those 133 (69%) who responded that they were comfortable diagnosing BD, because "the conceptual basis of brain death makes it equivalent to death of the patient." Their responses to the question asking to state the concept of BD in their own words is shown in Table . Only 13 (10%; 6-16%) used a loss of integration concept, and 59 (44%; 36-53%) did not articulate a concept (i.e., used a restatement of the criterion or left no response). On the first question, only 39 (29%; 22-38%) considered "irreversible loss of the integration of body functions by the brain" as an acceptable conceptual reason to explain BD being equivalent to death and 67 (50%; 42-59%) chose a higher brain conceptual reason.