1. Medical Aspects of Death

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

3. 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

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

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

6. Brain Death

7. 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

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

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

10. 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

11. 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

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

18. Persistent Vegetative State

19. 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Medical treatment can be withdrawn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

20. Death Certificate

21. Example of Death Certificate

22. 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!

23. Death Certificate
Cause of Death
Manner of Death

24. 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)

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

26. Death Certificate Manner of Death: Natural Homicide Suicide Accidental
undetermined

27. 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

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

29. 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?

30. 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?

31. 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