1. Death medicolegal aspects Dr Rakhin.K.B

2. Death is a process rather than an eventExceptions 3. Def The cessation of life3 vital system nervous, circulatory, respiratoryAtria mortis death portal of entry4 -6 minutes - serious permanentimpairment to brain6-10 minutes total loss of function 4. Irreversible damage to brain stem (somatic death) Organ transplantation Loss of spontaneous breathingability, cardiac arrest (cellular deathprogresses) 5. IEA 108 presumption of survivorship.Burden of proving that person is alive whohas not been heard of for seven years. - Provided that when the question is whether aman is alive or dead, and it is proved that hehas not been heard of for seven years bythose who would naturally have heard of himif he had been alive, the burden of provingthat he is alive is shifted to the person whoaffirms it. 6. IEA 107 presumption of death. Burden of proving death of personknown to have been alive within thirtyyears. - When the question is whether aman is alive or dead, and it is shown that hewas alive within thirty years, the burden ofproving that he is dead is on the personwho affirms it. 7. Historical PerspectivePrior to the advent ofmechanical respiration, deathwas defined as the cessation ofcirculation and breathing 8. Historical Perspective1959 Coma depasse Mollaret and Goulon1968 Irreversible Coma/Brain Death HarvardMedical School Ad Hoc Committee1981 Uniform Determination of Death Act -Presidents Commission for the Study ofEthical Problems in Medicine (US)1994 American Academy of Neurology Guidelinesfor the determination of Brain Death1994 Transplantation of Human Organs Act (India) 9. Brain Death Current ConsensusAbsent Cerebral FunctionAbsent Brainstem FunctionApnea 10. Normal Brain Anatomy 11. Normal Brain Anatomy Cerebral CortexReticularActivatingBrain StemSystem 12. Cerebral CortexCognitionVoluntary MovementSensation 13. Brain Stem 14. Brain Stem Midbrain Cranial Nerve III pupillary function eye movement 15. Brain StemPons Cranial Nerves IV, V, VI conjugate eye movement corneal reflex 16. Brain StemMedulla Cranial Nerves IX, X Pharyngeal (Gag) Reflex Tracheal (Cough) Reflex Respiration 17. Reticular Activating SystemReceives multiple sensory inputsMediates wakefulness 18. Causes of Brain DeathNormal Cerebral Anoxia 19. Causes of Brain DeathNormal Cerebral Hemorrhage 20. Causes of Brain DeathNormal Subarachnoid Hemorrhage 21. Causes of Brain DeathNormalTrauma 22. Causes of Brain DeathNormalMeningitis 23. Mechanism of Cerebral DeathNeuronal Injury Neuronal Swelling ICP>MAP is incompatible with lifeDecreased Intracranial Increased Intracranial Blood Flow Pressure 24. Conditions Distinct From Brain DeathPersistent Vegetative StateLocked-in SyndromeMinimally Responsive State 25. Persistent Vegetative StateNormal Sleep-Wake CyclesNo Response to Environmental StimuliDiffuse Brain Injury with Preservation of Brain Stem Function 26. Locked-in SyndromeVentral Pontine Infarct Complete Paralysis Preserved Consciousness Preserved Eye Movement 27. Minimally Responsive StateStatic EncephalopathyDiffuse or Multi-Focal Brain InjuryPreserved Brain Stem FunctionVariable Interaction with Environmental Stimuli 28. Brain Death Neurological ExaminationClinical Prerequisites: Known Irreversible Cause Exclusion of Potentially Reversible ConditionsDrug Intoxication or PoisoningElectrolyte or Acid-Base ImbalanceEndocrine Disturbances Core Body temperature > 32 C Team of doctors at least twice, with a reasonable gap of time in between ( 6 hours or so) 29. Brain Death Neurological Examination Coma Absent Brain Stem Reflexes Apnea 30. ComaNo Response to Noxious Stimuli Nail Bed Pressure Sternal Rub Supra-Orbital Ridge Pressure 31. Absence of Brain Stem Reflexes Pupillary Reflex Eye Movements Facial Sensation and Motor Response Pharyngeal (Gag) Reflex Tracheal (Cough) Reflex 32. Pupillary ReflexPupils dilated with no constriction to bright light 33. Eye MovementsOcculo-Cephalic ResponseDolls Eyes Maneuver 34. Eye MovementsOculo-Vestibular ResponseCold Caloric Testing 35. Facial Sensation and Motor Response Corneal Reflex Jaw Reflex Grimace to Supraorbital or Temporo-Mandibular Pressure 36. Apnea TestingPrerequisitesCore Body Temperature > 32 CSystolic Blood Pressure 90 mm HgNormal ElectrolytesNormal PCO2 37. Apnea Testing1. Pre-Oxygenation 100% Oxygen via Tracheal Cannula PO2 = 200 mm Hg2. Monitor PCO2 and PO2 with pulse oximetry3. Disconnect Ventilator4. Observe for Respiratory Movement until PCO2 = 60 mm Hg5. Discontinue Testing if BP < 90, PO2 saturation decreases, or cardiac dysrhythmia observed 38. Confounding Clinical Conditions Facial Trauma Pupillary Abnormalities CNS Sedatives or Neuromuscular Blockers Hepatic Failure Pulmonary Disease 39. Observations Compatible with Brain Death Sweating, Blushing Deep Tendon Reflexes Spontaneous Spinal Reflexes- Triple Flexion Babinski Sign 40. Confirmatory TestingRecommended when the proximate cause of coma is not known or when confounding clinical conditions limit the clinical examination 41. Confirmatory TestingEEG Normal Electrocerebral Silence 42. Confirmatory TestingCerebral Angiography Normal No Intracranial Flow 43. Confirmatory TestingTechnetium-99 Isotope Brain Scan 44. Confirmatory TestingMR- Angiography 45. Confirmatory Testing Transcranial Ultrasonography 46. Confirmatory TestingSomatosensory Evoked Potentials 47. Transplantation of Human Organs ActTHOA 19948 July 19947 Chapters, 25 Sections and variable no. of subsections 48. Transplantation of Human Organs ActTHOA 1994Some definitionsDeceased person A person in whom permanent disappearance of all evidence of life occurs, by reason of brain stem death or in a cardiopulmonary sense, at any time after live birth has taken placeBrain stem death Stage at which all functions of the brain stem have permanently and irreversibly ceased 49. Transplantation of Human Organs ActTHOA 1994Donor Any person not less than 18 years of age, who voluntarily authorizes the removal of any of his human organs for therapeutic purposes under subsection(1) or (2) of section(3)Human Organ Any part of a human body consisting of a structured arrangement of tissues which if wholly removed, cannot be replicated by the body. 50. Transplantation of Human Organs Act THOA 1994The brain stem death need to be certified by a team of doctors consisting of the following 1) The RMP in charge of the hospital in which the brain stem deathhas occurred. 2) An independent RMP, being a specialist to be nominated byRMP in clause(1), from the panel of names approved by theappropriate authority. 3) A neurologist or a neurosurgeon to be nominated by the RMPspecified in clause(1) from the panel of names approved by theappropriate authority. 4) The RMP treating the person whose brain stem death hasoccurred. 51. Transplantation of Human Organs(Amendment) Act, 2009 Human organs and tissues Expansion of the term near relative Tissue Transplant coordinator Technician for enucleation of cornea Non availability of neurosurgeon Donor/recipient - near relative - foreign national Minors Swap donations Fine/ imprisonment 52. Concern for man and his fate must always form the chiefinterest of all technical endeavors. Never forget this in themidst of your diagrams and equations.Albert Einstein