Certification of death

Dr Priyal JainPG Forensic Medicine

Definition

Total stoppage of circulation of the blood & consequent thereupon cessation of the animal and vital functions.

Somatic death : complete loss of sensivity and the ability to move and there is complete cessation of the functions of the heart, the brain and the lungs.

Molecular death : death of the tissue and the cells individually.

Legal definition

Death. means the permanent disappearance of all evidence of life at any time after live-birth has taken place.

(The Registration of Births and Deaths Act, 1969 )

Legal definition

“Deceased person” means a person in whom permanent disappearance of all evidence of life occurs, by reason of brain-stem death or in a cardio-pulmonary sense, at any time after live birth has taken place.

Brain-stem death” means the stage at which all functions of the brain stem have permanently and irreversibly ceased.

(the transplantation of human organs act, 1994)

Gordon`s classification of deaths

Medico-legal deaths : - the cessation of the vital functions depends upon tissue anoxia which is brought about in the following four different ways

1. Defective oxygenation of the blood in the lung. (anoxic anoxia)

2. Reduced O2 carrying capacity of blood.

3. Depression of oxidative process in tissue.

4. Inefficient circulation through the tissue.

Gordon`s classification of deaths

Post mortem findings should be divided in two groups

1. The basic pathological change of circulatory failure.

2. The special pathological changes depending upon the particular type of death.

Circulation stoppage tests

1. Magnus test

2. Diaphanous test

3. Icard test

4. Application & withdrawal of pressure

5. Application of heat

6. Cutting a small artery

7. ECG tracing

Respiration stoppage test

Mirror in front of open mouth and nostrils.

Feather or cotton fibers in front of open mouth and nostrils.

Death certificate

Part I :- records (a) immediate cause and (b) the morbid condition, if any, giving rise to the immediate cause

Part II :- records any other significant condition ( if important ) contributing to death but not related to the immediate cause of death.

Duty of the doctor

Who attended the person in last 7 days.Fill the prescribe format form 4. No refusal / no delay.No fee.Forward to the registering authority.Symptomatology or modes of death should

not be recorded as cause of death without mentioning the underlying pathological cause.

Duty of the doctor

In any of the domiciliary deaths not attended by a medical person before death, a statement from the relatives of the deceased should be obtained in writing to that effect, clearly mentioning the morbidity condition with sign and symptoms prevailed preceding death, with duration of such illness so that the most possible cause of death could be entered.

When not to issue

1. The injured is brought dead

2. A crime has already been registering by the police.

3. The police has already been informed about the case.

4. The cause of death is unknown.

Special circumstances

For organ donation cases.For withholding life support in terminally ill

person in ICU settings.

Test to certify brain-stem death

1. Pupillary reflex

2. Extra-ocular movements

3. Corneal reflex

4. Gag reflex

5. Cough reflex

6. EEG

Who will certify

Board of medical experts consist of four doctors.

Examine the person on two occasion.

Withholding life support(legality)

1. Does the right to refuse treatment extend to refusal of life supporting systems?

2. Does it extend to the extent that the individual can insist on the removal of life supporting systems?

3. Does the exercise of these rights, at any point cease to be the exercise to lawful (if not fundamental) rights and enter the forbidden zone of suicide?

Withholding life support(legality)

4. If an individual, to begin with, has these rights, then, does he lose them when he becomes incompetent for decision-making as in a state of unconsciousness?

5. In cases of unconscious patients or patients who cannot interact or communicate their decisions who is entitled to exercise these rights for and on behalf of these patients?

Withholding life support(legality)

Indian Law has no clearly stated position on any of these issues. The opinion of professional bodies must therefore precede the evolution of legal provisions in matters concerning life-supporting interventions, as no relevant case laws exist in the country.

Supreme court of india

In the casse of L.B.Joshi v/s T.B.Ghodbole SCI held that “ the law requires the practitioner must bring to his task a reasonable degree of skill and knowledge and he must exercise a reasonable degree of care, neither the very highest nor the very low degree of care and his competence is judged in the light of the particular circumstances of each case.

The test of the reasonableness of the decision of the doctor would essentially depend upon the norms set out and announced by the professional bodies.

Guidelines for limiting life-prolonging interventions and providing palliative care (ISCCM)

1. The physician has a moral obligation to inform the capable patient/family, with honesty and clarity, the poor prognostic status of the patient when further aggressive support appears non-beneficial. The physician is expected to initiate discussions on the treatment options available including the option of no specific treatment.

2. When the fully informed capable patient/family desires to consider comfort care, the physician should explicitly communicate the available modalities of limiting life prolonging interventions

Guidelines for limiting life-prolonging interventions and providing palliative care (ISCCM)3. The physician must discuss the implications of forgoing

aggressive interventions through formal counseling sessions with the capable patient/family, and work towards a shared decision-making process. Thus, he accepts patient’s autonomy in making an informed choice of therapy, while he fulfills his obligation of providing beneficent care.

4. Pending consensus decisions or in the event of conflicts between the physician’s approach and the family’s wishes, all existingsupportive interventions should continue. The physician however, is not morally obliged to institute new therapies against his better clinical judgment.

Guidelines for limiting life-prolonging interventions and providing palliative care (ISCCM)

5. The proceedings of the counseling sessions, the decision-making process, and the final decision should be clearly documented in the case records, to ensure transparency and to avoid future misunderstandings.

6. The overall responsibility for the decision rests with the attending physician /intensivist of the patient, who must ensure that all members of the caregiver team including the medical and nursing staff represent the same approach to the care of the patient.

Guidelines for limiting life-prolonging interventions and providing palliative care (ISCCM)

7. If the capable patient/family consistently desires that life support be withdrawn, in situations in which the physician considers aggressive treatment non-beneficial, the treating team is ethically bound to consider withdrawal within the limits of existing laws.

8. In the event of withdrawal or withholding of support, it is the physician’s obligation to provide compassionate and effective palliative care to the patient as well as attend to the emotional needs of the family.