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• Medical treatment can be withdrawn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
– Cause of death:
• Old age
– Cause of death:
• 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