Death and its causes

Dr. Dipayan Deb Barman

Professor &HOD
SSSMC&RI

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Learning Objectives:

At the end of the session the participant should be able to:

 Define death
 Define Bishop’s tripod of life
  Discuss about natural and unnatural death
 Enumerate the types of death
 Describe somatic death, clinical death and molecular death
    Describe  Brain death
  Discuss  about cortical death and brain stem death
  

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Learning Objectives (Contd)
At the end of the session the participant should be able to:
    Define sudden natural death.

 Enumerate the factors  that can cause sudden natural death

    Discuss the medico legal issues that could arise in case of a

sudden natural death

 Discuss about organ transplantation and organ

transplantation ACT 2011

    Discuss in brief about the issues related to organ donation 

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Death is the cessation of all biological functions that sustain a
living organism

Bishop’s Tripod of life:

Life stands on respiration, circulation and brain functions

Death, & types of death:

Death is defined as permanent and irreversible cessation

of circulation, respiration and nervous system function

Types of death :

I. Natural death
II, Unnatural death

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I. Natural death

a natural death is one that occurs as a result of the aging

process or disease. 

II. Unnatural death:

An unnatural death is one where death is caused due to

interference with continuity of life as a result of some intentional
injury ( homicide, suicide) or unintentional (accident)

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Natural causes of death:

a) Heart disease
b) Lung disease
c) Respiratory diseasess
d) Kidney diseases
e) GI diseases
f) Metabolic diseases
g) Infectious diseases
h) Autoimmune diseases
i) neurologic disease

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Death can be also classified according to the manner:

1. Accidental
2. Homicidal
3. Suicidal
4. Undetermined
5. Pending

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 1. Accidental death:

 accidental death , defined  as an event that strictly occurs as a

result of an accident. Deaths from car crashes, slips, choking,
drowning

2. Homicidal death

Homicide is the act of one human killing another.

Such deaths are called homicidal deaths

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 Suicidal deaths:

Suicide is the act of intentionally causing one's own death

Suicidal deaths are defined as deaths which are caused by the

own intentional act leading to serious harm or injury to self

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 Undetermined death:

An undetermined manner of death is assigned to cases of

unnatural death when a clear preponderance of evidence
supporting a specific manner (homicide, accident, or suicide) is not
available.

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 Pending manner of death

If the cause and manner are pending further study,

a death certificate listing “pending” as the cause of death will be
issued. ...

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Death occurs in a sequence of

- Clinical death/ Somatic death

- Biological death
- Molecular death

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Clinical /somatic death

death as judged by the medical observation of cessation of vital

functions. It is typically identified with the cessation of heartbeat
and respiration

- though modern resuscitation methods and life-support systems

have required the introduction of the alternative concept of brain
death.

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no heartbeat + no breathing + no brain activity = clinical death, but
it does not necessarily spell Death

Biological Death is where the victim's brain is damaged and

cells in the victim's heart, brain and other organs die from a
lack of oxygen. The damage caused by Biological Death is
irreversible.

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Molecular death:

molecular death (also known as cell death) refers to the cessation

 

of the individual tissues and the cells.

Cessation
No blood
of
supply
circulation

Cell injury
Anoxia
and death

Ischemia

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Anoxia and cell damage and death can occur due to
either if one is effected

Brain

Heart Lungs

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Terminologies which are important in the context of death and
diagnosis of death:

Coma
• Prolonged absence of wakefulness, awareness and the capacity for
sensory perception or responsiveness to the external environment

Circulation
• Anterograde flow of blood through the aorta and arterial system
Diagnosis of death:

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Previously the diagnosis of death rested on
absence of heart beat, absence of breathing

Diagnosis and declaration of death in most countries is a legal

responsibility of a medical practitioner

3 sets of criteria to diagnose death:

- Absence of breathing /apnea

- Absence of pulse, heart beat

- Unresponsiveness, and absence of brain functions

Modern diagnosis of death:

- Diagnosis of death is depending on brain functions

Brain death and more specifically brainstem

death is now the most criterion:

Situation when declaration of death becomes important:

- A patient who is critically ill and is in coma on
life support

- Irreversible condition

- Question of organ donation

 Brain death:

Brain death (also known as brain stem death) is when a person on

an artificial life support machine no longer has any brain functions.

- This means they will not regain consciousness or be able to

breathe without support. A person who's brain dead is legally
confirmed as dead.

- The US National Library of Medicine Medical Subject

Headings (MeSH) system defines brain death as including
the brainstem

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Cortical brain death

In cortical brain death, the cortex is destroyed. Often the

brainstem is still intact, e.g. persistent vegetative state, i.e. the
patient can survive indefinitely if sufficient nutrition.

For this condition to be diagnosed there must be a demonstration

of no perfusion of the cortex via cerebral angiography.

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Cortical brain death

• Brain stem is intact

• Person continues to breathe spontaneously

• Total loss of power of perception by senses

• Deep coma is produced by cerebral hypoxia, toxic conditions or

brain injury

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Brain stem death:

- Brain stem is not functioning

- Centres of respiration in the brainstem are not functioning

- Spontaneous respiratory drive is absent

This is considered as the most important criterion for declaring

brain dead

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 Brain stem death:

• Cerebrum intact
• Loss of vital centres that control respiration
• Loss of ascending reticular activating system function
• Person is incapable of spontaneous respiration and becomes
comatose

Can be caused by:

- Raised ICP
- Cerebral edema
- Intracranial pressure

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 Combined brain death:

- Combined cortical and brainstem functions are impaired

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 Brain death:

Brain death is irreversible and determined by absent:

- motor responses
- loss of all brainstem reflexes
- and apnoea after a CO2 challenge

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Prerequisites:

- Coma ( cause known, irreversible)

- Neuro imaging explains coma

- No neuro depressant drug/substance use (e.g. narcotics,

barbiturates etc)

- No evidence of use of paralytics

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Prerequisites :

- Absence of acid base, electrolyte abnormality

- Normothermia or mild hypothermia ( core temperature > 36

degree Celsius )

- Systolic blood pressure <100 mmhg

- No spontaneous respiration

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How to determine brain death:?

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Ocular examination

- Pupillary reaction to light must be absent

- Corneal reflex is absent
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Oculocephalic reflex

- The doll's eyes reflex, or oculocephalic reflex, is produced by

moving the patient's head left to right or up and down.

- When the reflex is present, the eyes of the patient remain

stationary while the head is moved, thus moving in relation to the
head.

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Oculocephalic reflex

assesses brain stem function [it is responsible for basic vital life
functions such as breathing, heartbeat, and blood pressure.] ...

If eyes remain stationary, the reflex is absent and this is bad

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Oculovestibular reflex :

The vestibulo-ocular reflex (VOR) is a reflex acting to stabilize gaze

during head movement, with eye movement due to activation of
the vestibular system

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Oculovestibular reflex :

The vestibulo-ocular reflex is driven by signals arising from the

vestibular system of the inner ear.

The signal for the horizontal rotational component travels

via the vestibular nerve through the vestibular ganglion
and end in the vestibular nuclei in the brainstem

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Other examinations:

- No facial movement in response to painful stimuli

- Absent gag reflex

- Cough reflex absent to tracheal suctioning

- Absence of motor response to painful stimuli in all four limbs

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 Apnea testing:

- Patient is hemodynamically stable

- Ventilator is adjusted to maintain PaCO2 to 35-45 mm Hg

- Patient preoxygenated with 100% O2 for 10 minutes

(Pa O2 >200 mmHg

- Provide O2 with a suction catheter to the level of the carina ,

6 L/min

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Apnea testing:

- Ventilator disconnected

- No spontaneous respiration

- Arterial blood gases taken obtained at 8-10 minutes

- PCO2 > 0 mmHg or 20 mmHg rise from normal baseline value

- Apnea test aborted

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 Ancillary testing:

Only when clinical examination is not possible or apnea test is

aborted

- EEG
- Cerebral angiogram
- HMPAO SPECT

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Sudden natural death:

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Sudden natural death definition:

Sudden unexpected (natural) death is defined

as death occurring instantaneously or. within an estimated
24 hours of the onset of. acute symptoms or signs

- Sometimes sudden natural death can occur during sleep

- In most cases aetiology is obscure

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 Causes of sudden natural death:

- Myocardial infarction
- Hypertensive heart disease
- Intracerebral haemorrhage
- Bronchial asthma

- Cardiomyopathies and genetic channelopathies  

Bruguda syndrome

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Medico legal issues associated with sudden death

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Diagnosis of sudden cardiac death (SCD) is the most important
forensic practice because of :

1) misdiagnosis of extrinsic death as SCD,

2) under-report of unusual (unnatural) death

3) difficulty in diagnosis by autopsy, histology, and death-scene

investigation

4) difficulty to judge the contribution of accident, ...

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- Cause of death is unknown

- Relatives may call out for alleged foul play

- Always difficult to prove and diagnose alleged foul play in a

sudden natural death

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Two men are found dead in their respective apartments. Both
apartments are locked and secured, and there are no signs of
foul play.

One decedent is 20 years old and was previously healthy. The

other decedent is 80 years old and had a history of coronary
artery disease with multiple cardiac bypass grafts.

The death of the 20-year-old man is significantly more

suspicious and more likely to receive a complete
autopsy than the older man with a history of heart
disease.

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Organ transplantation:

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Organ transplantation

- It is a medical procedure in which an organ is removed from one

body and placed in the body of a recipient, to replace a damaged
or missing organ

- Organs that have been successfully transplanted include

the heart ,kidneys,  Liver, lungs,  pancreas, intestine, thymus  
and uterus. 

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 Transplantation of Human Organs Act

In India Transplantation of Human Organs Act was passed in 1994.

It provides a system to regulate removal, storage and
 transplantation of human organs

-   For therapeutic purposes and for prevention of commercial

dealings in human organs

- Consequently, this act was amended in 2011

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The Government of India enacted the Transplantation of
Human Organs (Amendment) Act, 2011 that allows swapping
of organs and widens the donor pool by including grandparents
and grandchildren in the list

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Living donors are permitted to donate the following:

- one of their kidneys

- portion of pancreas
- part of the liver

Living donors must be over 18 years of age and are limited to

donating only to their immediate blood relatives or, in some special
cases, out of affection and attachment towards the recipient

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Deceased donors:

Deceased donors may donate six life-saving organs: 

- kidneys, liver, heart, lungs, pancreas, and intestine

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Medicolegal issues:
- Illegal organ trade
- Human trafficking

- Murder to harvest organs

Ethical issues:

Two major ethical issues that are of considerable concern

are the autonomy of the donor and recipient and the utility
of the procedure

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 Legal and ethical issues:

- Consent of the donor and recipient

Who can donate:

• parents, siblings, children

• first degree relatives should provide proof of

relationship – test, and/or by legal documents

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 Legal and ethical issues:

No first degree relative available :

- Special permission from Govt appointed authorization

committee

- Interview infront of the committee

- Proof that donation is purely on basis of affection for the

recipient

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Authorization committee :

- regulate the process of authorization

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- approve or eject transplants between the donor and recipient

- ensure that donor is not exploited for money or forced by

coercion

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 Declaration of death in a cadaver donor

- Brainstem death is sole criterion of death declaration

- Doctors should be appointed by appropriate Govt authority

- two certificates are required six hours apart from doctors

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Key take home message :

• Death : permanent irreversible stoppage of circulation,

respiration and nervous system function

• Types of death: Natural and unnatural

• Manner of unnatural death: homicidal, suicidal, accidental,

indeterminate, pending

• Somatic death: stoppage of circulation, respiration and nervous

system function

• Molecular death: Death of cells and tissues

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Key take home message :

• Brain death : cortical death, brain stem death

• Brainstem death: most important criterion for declaration of

death

• Brain stem reflexes, apnea test

• Organ transplantation act of 1994 (amended in 2011)

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THANK YOU!
QUESTIONS?

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