MEDICAL ASPECTS OF

DEATH.
There is no legal definition of death. The
diagnosis of death is traditionally made
using the Triad of Bichat which states that
death is "the failure of the body as an
integrated system associated with the
irreversible loss of circulation, respiration
and innervation"
The nature of death.
Definition of death:
Absence of life, ie the cessation of life
in a previously viable organism.
It is a process rather than an event.
In higher animals, different parts of the
body die at different times.
Division
Somatic death.
It is the complete and irreversible stoppage
of circulation, respiration and brain
functions.
Person no longer functions as a unit of
society.
He is irreversibly unconscious and
therefore cannot communicate with
environment.
c.f asleep, under anaesthesia or in
coma.
 Cellular death:
Cessation of respiration and
metabolism of body tissues.
Followed by autolysis and
decomposition
Different tissues and organs die at
different rates ( vulnerability to oxygen
deficiency)
Skin , bone, muscle, ct elements can
survive hypoxia for a long time.
white blood cells can remain motile for
6 hours after cardiac arrest.
Nervous system is very vulnerable to
hypoxia ( neurones die after 3-7
minutes of complete deprivation of
oxygen).
Nerve cells lower down CNS are more
resistant but eventually die.
Hence brain death is important
ethically, legally and also for organ
transplant
Brain death is not an exact term,
Should be divided into:
: brain stem death,
: cortical death OR
: whole brain death.
1. Cortical or cerebral death with an
intact brain stem.
This produces a vegetative state in
which respiration continues, but there
is total loss of power of perceptions by
senses.
This state of deep coma can be
produced by cerebral hypoxia, toxic
conditions or wide spread brain injury
 2. Brain stem death, where the
cerebrum may be intact, though cut off
functionally by the stem lesion.
The loss of vital centres that control
respiration, and of the reticular
activating system that sustains
consciousness , cause the victim to be
irreversibly comatous and incapable of
spontaneous breathing.
 This can be produced by raised
intracranial pressure, cerebral oedema,
intracranial haemorrhage etc.

3. Whole brain death ( combination of 1 &

2).
Brain death:
For the permission of the removal of
vital organs, such as heart, or liver
irreversible coma must be established.
This consists of:
1. Deep unconsciousness with no
response to external stimuli.
2. No movements, no spontaneous
breathing.
3. Cessation of spontaneous cardiac rhythm
without assistance.
4. No reflexes.
5. Bilateral dilatation and fixation of pupils.
6. Flat isoelectric EEG
Functions of brain stem
a. A precondition for full consciousness
enabling cerebral hemisphere to work in
an integrated way
b. Lesions in this part are associated with
profound coma
c. Brain stem also responsible for
respiratory drive and for the maintenance
of blood pressure
d. all motor output from the brain travel
through the brain stem
e. Except vision and smell, all sensory
traffic coming into brain arrives through the
brain stem
f. brain stem also mediates the cranial
nerve reflexes.
Brain stem death diagnosis.
i.Cause of coma should be established.
ii. It should be made sure that the
patient is not suffering from drug
intoxication, hypothermia, or profound
metabolic disturbance.
ii.Brain stem reflexes should be absent.
a. pupillary response to light.
b. Corneal reflex
c. Vestibulo-ocular reflex
d. No grimacing in response to
painful stimuli
iii. Patient should be deeply comatous,
and the effects of depressant drugs,
primary hypothermia or metabolic
disorders to be excluded.
 The diagnostic tests should be
determined by two doctors.
If it is proposed to request organ
donation the doctor who treated the
patient or diagnosed brain death
should not be part of the transplant
team.
 Whole or part of the brain can be
irreversibly damaged due to hypoxia,
cardiac arrest, intracranial haemorrhage,
poisoning or trauma
If the cortex alone is damaged, patient
passes into deep coma, but the brain stem
will function to maintain respiration
 This is called persistent
vegetative state and death may
occur months or years later due
to extension of cerebral damage
or from intercurrent infection.
 If the brain stem is damaged by trauma,
cerebral oedema , haemorrhage, hypoxia
etc respiratory motor system fails, and
damage to the ascending reticular
activating system causes permanent loss
of consciousness, and higher centres in
the cortex are also irreversibly damaged
causing whole brain death
Tissue and organ transplantation
Legal aspects vary greatly with the
tissue concerned with national laws
and ethnic/ religious practices o the
country.
1. Homologous donation- moving of
tissue from one part of the body to
another in the same person eg skin
graft.
No legal implications.
2. Live donation- blood and bone marrow
transfusion.
Poses no threat to the life or health of
the donor.
Recently also included paired organs
such as kidneys.
(Increased risk to donor).
3. Cadaveric donation- the only means of
obtaining unpaired organs such as
heart.
Most organs must be taken whilst
donor heart is still beating .
After brain death, the retention of the
patient on the ventilator facilitates a
fully oxygenated cadaver transplant, so
called beating heart donor
 The results of the transplant are much
improved.
This has no legal sanctions
Modes of death
There are three modes of death,
depending on whether death begins in
one or other of the three systems.
1. ANOXIA: stoppage of vital functions
depends on upon tissue anoxia.
Types:
I. Anoxic anoxia;
Oxygen cannot reach the blood because of
lack of oxygen in lungs.
This occurs from;
: breathing in contaminated atmosphere eg
fumes and tanks.
: from mechanical interference with passage
of air into airway.
ii. Anaemic anoxia; oxygen carrying capacity
of blood is reduced eg haemorrhage, CO
poisoning etc.
iii. Stagnant anoxia; impaired circulation
leading to reduction of O2 delivery to
tissues, eg heart failure, embolism and
shock.
iv. Histotoxic enzymic processes are
blocked eg cyanide poisoning.
2. COMA.
It is a state of unarousable unconsciousness
determined by the absence of any
psychological understandable response to
external stimuli or inner need.
It involves the central portion of brain stem
coma is a clinical symptom and not a cause
of death.
Causes:
i. Compression of the brain from any
cause.
ii. Drugs eg opium, cocaine or alcohol
iii.Metabolic disorders and infections
iv. Other causes eg embolism and
thrombosis of cerebral vessels, epilepsy
etc.
3. SYNCOPE
Sudden stoppage of action of the heart,
which may prove fatal.
It is due to vasovagal attacks resulting
from reflex parasympathetic
stimulation.
 it is caused by reflex bradycardia or
asystole, or by reflex splanchnic
vasodilatation
due to the acute reflex circulatory
changes, blood pressure falls
suddenly causing cerebral anaemia
and rapid unconsciousness.
Recovery is common.
Causes:
i.Anaemia due to sudden and excessive
haemorrhage.
ii. Asthenia with deficient power of heart
muscle as in myocardial infarction, fatty
change etc.
iii. Vagal inhibition
iv. Exhaustive diseases.
CAUSE OF DEATH
Is the disease or injury responsible for
starting the sequence of events which
produce death.
May be divided into:
1.Immediate cause ie at the time of
terminal event eg bronchopneumonia,
2.Basic cause ie pathological process
responsible for death at the time of
terminal event eg gunshot wound of
abdomen complicated by generalized
peritonitis.
3. Contributary cause i.e the
pathological process involved in or
complicating, but not necessarily
causing terminal event
MANNER OF DEATH.
If disease- death is NATURAL.
If violence, suicide, homicidal death
is UNNATURAL.
MECHANISM OF DEATH.
Is the physiological or biochemical
disturbance, produced by the cause of
death which is incompatible with life
eg shock, sepsis, toxaemia etc.