Medical Aspects of Death

Death Cessation of life Is it event or process When does death actually occur? “Cellular Death” “Somatic Death”

Cellular Death Cessation of Respiration Followed by autolysis Skin, bone: remain active for hours WBC: can move 12 hours after cardiac arrest Neurons: 3-7 minutes

Somatic Death Individual will never communicate with the environment Irreversible “True” Death

Resuscitation Results of resuscitation Recovery of consciousness and breathing Not conscious , but can breathe Not conscious, and Cannot breathe without mechanical ventilator

Brain Death

Code of Practice concerning Brain Death in UK (1970) Deep coma (excluding treatable causes) Need of mechanical ventilator Firm diagnosis of pathology and brain damage Tests for brain stem death must be positive

Code of Practice concerning Brain Death in UK (1970) Absent cerebral function Absent brain stem function Apnea

Code of Practice concerning Brain Death in UK (1970) Cerebral Cortex: Cognition Voluntary movement Sensation

Code of Practice concerning Brain Death in UK (1970) Mid brain Cranial nerve III Pupillary function Eye movement Pons Cranial nerve IV, V, VI Conjugate eye movement Corneal reflex Medulla Cranial nerve IX, X Gag reflex Cough reflex Respiration

Clinical Tests Brain stem reflexes are absent with fixed dilated unreactive pupils No motor response to painful stimuli to any cranial nerves No gag reflex No respiratory movement Test performed in >35 degrees temperature

Causes of Brain Death Cerebral anoxia Cerebral hemorrhage Subarachnoid hemorrhage Trauma Meningitis

Persistent Vegetative State

Persistent Vegetative State Long term survival of unconscious but spontaneously respiring patient There is some brain stem activity No higher cerebral function Medical treatment can be withdrawn ?? Withdraw nutrition and hydration

Death Certificate

Example of Death Certificate

Questions need answers Who is the deceased? When & Where did death occur? How did he/she died? Cause and Manner of Death? If we can answer the questions we can sign the Death certificate!

Death Certificate Cause of Death Manner of Death

Death Certificate Cause of Death Part I: Conditions that led directly to death A B due to: C due to Part II: Other conditions (may contribute to death)

Death Certificate Is this Correct?! Death certificate written: Cause of death: Cardio-respiratory arrest Old age Heart failure

Death Certificate Manner of Death: Natural Homicide Suicide Accidental undetermined

Medico legal investigation If death is natural and the doctor can sign death certificate, no investigation needed. If death certificate cannot be singed, we usually need medico legal investigation

Why cannot sign death certificate Unnatural death Homicide Suicide Suspicious Traumatic Violence Neglect Poisoning Unexpected unexplained accidental

Exercise: 56 year old man is diagnosed to have pancreatic cancer. He is admitted to hospital for surgical resection. While in the hospital the patient develops DVT in the deep vein of legs. The next day, the condition is complicated by pulmonary thromboembolism. He dies few hours later. How do you write the Cause of Death?

Exercise: Following a car accident a young male patient, 24 years old develops head injury. He is found to have subarachnoid hemorrhage. He develops pneumonia and dies few days late. He is also HIV positive. How do you write the cause of Death?

Home work Define death, and somatic death Discuss the meaning of “cause of death” in forensic setting List, define and understand the implications of different “manners of death” List the criteria of brain death, persistent vegetative state Discuss the implications and the treatment options in cases of brain death and persistent vegetative state