CONCEPT OF DEATH



Death is the end of dying. 

It is a process rather than an event, except in situations where death occur instantaneously like bomb blast, crushing of head in Road side accidents.

DEFINITION
1. 

Complete and permanent cessation.
Irreversible loss of properties of living matter. 

Section 2b of the Registration of Births and Deaths Act defines death as ³Permanent disappearance of all evidence of life at any time after live birth has taken place´ 

United State (Black¶s) Dictionary of Law defines death as: ³The cassation of life, the ceasing to exist´

Defined by Physician as ³Total stoppage of circulation and cessation of vital functions, thereupon such as respiration and pulsation´ 

Shapiro (1969) defines death as ³The irreversible lose of the properties of living matter´ 

1) 2) 3) 4)

Calne (1970) states that ³ When destruction of the brain has been established, the individual has died no matter what the state of rest of his body, giving four signs for such a diagnosis: Deep irreversible coma with fixed dilated pupil and absent cranial reflexes No spontaneous respiration Absence of electrical brain activity Cessation of circulation in the retinal vessels 

Rantoul and Smith (1973):³ Complete and persistent cessation of respiration and circulation´

Death is not a moment but a Continuous Process

CLASSIFICATION OF DEATH
Biologically Death occurs in bits & pieces Moment of start of this disintegration, cannot be ascertained Declaring------Death - has become more difficult ± Since 1967-Dec (First human heart transplant was successfully carried)

Thus Death was classified into 2 Groups. ‡ Body Separate entities ‡ Organs Body may be dead Organs may survive = in the same body = in another unit of life 

The living body depends upon the integrity of three principals, interdependent upon each other, these systems are 1) Respiration 2) Circulation Respiration Circulation 3) Enervation The failure of one of them Will cause failure of other two This lead to the death of an individual. Enervation 

1.

There are two phases of death
Extinction of the personality is the immediate sign of vital process OR Somatic Death Progressive disintegration of the body tissue OR Molecular Death / Cellular Death

2.

TRIPOD of LIFE (Atria mortis)

BRAIN LUNG HEART

TWO STAGES 1) Somatic Death (Soma-Body)
Irreversible loss of integrating and cocoordinating functions of the organs as a whole is labeled as Somatic Death.
It is the complete and persistent loss of coordinated functioning of tripod of life i.e stoppage of Functioning - and failure to return
a) b) c)

Brain Heart Lung

TRIPOD of LIFE (Atria mortis) BRAIN

Deaths protocol of entry
HEART

LUNG

Same is also called Systemic Clinical

Death
Legal

II.

Molecular Death
It is the death of individual organs and tissues (which persisted individually after somatic death)

In 1967- Single Organ, ± Shifted from a dead unit to another living unit. During interval ± it was kept alive to avoid molecular death. Till it was shifted to already prepared body ± Ready to receive ± Heart of Dead

Time ± Interval between Somatic & Molecular stages Heart Liver Kidney Cornea Blood Bone Marrow Survives For Survives for Survives for Survives for Survives for Survives for 60 minutes 15 minutes 45minutes 6-24 Hours 6 Hours 6 Hours

Types of brain death 

 

1. Cortical or Cerebral 2. Brain Stem 3. Whole brain death (cortical + brain stem) 



DEATH Means an irreversible cessation of the entire function of brain stem. BRAIN DEATH Means irreversible loss of brain and brain stem functions simultaneously, DONOR Means a person who donates any part of his body, organ. tissue or cell; 

 



Brain death
Brain stem death.(mid brain, pons & medulla)  Brain is responsible for all the coordination between the organs.  Once brain stem death has established, no matter how healthy an individual, Life will not return to the patient.  Even with continuous cardiopulmonary support Complete loss of consciousness / absence of brainstem function / reflexes 

Criteria for determining permanent non functioning of the brain. I. Unreceptivity and unresponsivety II. No movements and breathing III. No reflexes AND Flat isoelectric encephalogram EEG (confirmatory test)

Philadelphia Protocol, 1969: 
  

1. lack of responsiveness. 2. absence of spontaneous breathing 3. no muscular movements, flaccidity 4. Reflexes and Responses: 

(a) pupils, (b) corneal reflex, (c) pressure response, (d) no ocular response to ice water, (e) no superficial or deep tendon reflexes, (f) no planter response. 



5. Falling arterial pressure 6. ECG for 5mins repeated every 30 mins for 6 hrs

Harvard Criteria: 
   

Unreceptively and unresponsively No movements Apnea Absence of reflexes Absence of ECG

DIAGNOSIS OF DEATH
Brain death is declared ± when there is 1. Permanent ± fixed bilateral dilatation of pupils. 2. Absent ± all nerve reflexes 3. Cessation of respiration (without aids.) 4. Cessation of cardiac activity (COMPLETE FLAT ECG)

D/D of Death
1. 2. 3. 4. 5.

Suspended animation Barbiturate poisoning Electrocution Drowning Hypothermia

Immediate physical changes 
   

Loss of tripod of life Absence of brain function Loss of muscle tone Onset of muscular flaccidity / primary flaccidity Loss of reflexes 
  

Dropping of lower jaw Loosness of limbs No response to external stimuli Cooling of body

Cause of brain death / Manner of death 

Natural Unnatural 

Natural 
   

 

Haemorrhage into brain tissue / CVA Apoplexy (rupture of vessel in to an organ) Aneurysm / embolism of cerebral vessels Cystic tumor / abscess which may rupture into ventricles Cerebral haemorrhage Subarachnoid haemorrhage Epilepsy (cont discharge of impulses)

Natural 
      

cont.

Cerebral thrombosis and subsequent infarction Cerebral embolism Meningitis Tumor of brain producing pressure Tumor of brain with sudden haemorrhage Metabolic disorders e.g. uraemia Cardiovascular condition e.g MI Respiratory condition e.g Asthma, COPD

Unnatural 
 

  

Accidental head injuries e.g. RTA Homicidal head injuries e.g. stab, lacerated, incised, firearm Suicidal head injuries e.g. firearm injury Poisoning e.g. Opium, alcohol Asphyxia Syncope

Mode of Death
1. 2. 3. Coma :- failure of function of brain :Syncope :- failure of function of heart :Asphyxia :- failure of function of respiratory :system  

Coma:- failure of function of brain and irreversible damage to its vital centers Due to
Raised ICP, due to injuries to or diseases of brain e.g meningitis  Poisons such as opioids and alcohol  Metabolic disorders like Uremia Post mortem :oedema and congestion of brain and membranes   

Syncope :- death due to failure of function of heart due to decrease flow of blood to brain and leading to hypoxia of brain. Due to
Heart diseases  Diseases of blood  Hemorrhage  Poisoning due to digitalis, aconite, potassium. Postmortem findings:Viscera appear pale and capillaries appear congested   

Asphyxia :- is death due to failure of respiratory system. Due to
Lung diseases e.g pneumonia,  Paralysis of respiratory centers,  Opioid poisoning  Breathing of irrespirable gases  Traumatic asphyxia Postmortem findings:Cyanosis, petechial hemorrhages, visceral congestion, injury mark on neck. 

SIGNS OF DEATH
‡ ‡ ‡

Immediate Early Late

A. Immediate Signs:
(Somatic,systemic & clinical death)

a. Insensibility and loss of voluntary power to move. b. Cessation of circulation (Flat ECG for 5 minutes) c. Cessation of respiration. d. Cessation of brain activity ± absent reflexes. (Flat EEG for 5 minutes)

a.

Insensibility and loss of voluntary power to move. (Not a sure sign of death)
It is the foremost sign but also occurs in: Prolonged fainting Vagal inhibition Epilepsy Electrocution Drowning Suspended Animation

-

b. Cessation of circulation
‡

No heart beat for a continuous period of 5 minutes (with stethoscope - sure sign) Difficulty in - Feeble sounds

- Thick Chest - Emphysema

c. Cessation of Respiration
i. ii. iii. iv. v.

No abdominal movement (Ant.wall) No auscultation with stethoscope for 5 minutes Mirror Test Feather Test Glass water Test. (Winslow¶s Test)

B. Early signs (molecular death)
a. b. c. d. e.

Cooling of body Eye changes Skin changes Post-mortem lividity Muscles changes ± Rigor Mortis

B. EARLY SIGNS

cont«

a)
I.

Cooling of body: (Algor Mortis)
During life: Balance of temperature maintained i.e. Heat produced = Heat loss is

II.

After death no heat production, so only heat loss. The heat loss is gradual. This remarkable phenomenon was used to calculate time since death.

III. IV.

b)
i. ii.

Eye changes
Permanent fixed bilateral dilatation of pupils. Cornea becomes hazy & opaque

iii. Corneal & Conjunctival reflexes are lost iv. Luster of cornea is lost. v. Eyes become sunken.

C) Skin changes
i.

Skin becomes pale(more on non dependent parts Skin elasticity is lost Skin luster is lost

ii. iii.

d)

Post ± Mortem Lividity

It is the staining or discoloration of skin and organs of a dead body due to accumulation of blood because of gravitation and arrest of circulation resulting in distension of toneless capillaries and veins of dependent parts.

Also called:
P.M. Hypostasis Livor Mortis P.M staining Cadaveric Lividity Subcutaneous Hypostasis Suggilations Vibices

DEVELOPMENT OF LIVIDITY
After somatic or clinical death: Circulation stops  Blood remains fluid for some hours  O2 in blood (which is carried in loose combination with Hb) is still being supplied to the tissue(till molecular death).  No more pumping of blood by heart  O2 is gradually decreased & Hb is reduced (Blue colour)  Due to gravity blood settles, directly in dependent areas of skin or viscerae

C.

Late signs

Putrefaction (Ultimate fate of all living creatures.)
It is the final stage of dissolution of the body tissue resulting in breaking down of complex organic body constituents into simpler inorganic ones.  Arrest of putrefaction. (Extra ordinary phenomenon) - Mummification - Adipocere formation 



PUTREFACTION :Decomposition / dissolution of body tissues into 
 

Gases Liquids Salts 

The ultimate fate of body by conversion of organic to inorganic state. It is absolute / surest sign of death

MUMMIFICATION
‡ It is also a modification of putrefaction process, which becomes arrested and body tissues undergo mummification. mummification. ‡ It is characterized by dehydration of body tissues and viscerae after death

ADIPOCERE (SAPONIFICATION) It is a modification of process of

putrefaction, which may become arrested and fatty tissue of body may get converted into fatty acids. It has the properties of fat and wax, so the name (Adipo soft fat) (Cera - Wax)

‡

Suspended animation
(Apparent Death) Heart beat & respiratory movements are not heard ordinarily (as they are at a very low pitch. pitch.)

I. Involuntary Suspended animation may occur in: 
      

Drowning cases New born Anesthesia Concussion Heat Stroke Prolonged illness Electrocution Deep Shock

All may revive by resuscitation methods

II. Voluntary Suspended animation
S.A
‡

Yogis (Holding of Breath)

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