2. Death is a process
rather than an event
Exceptions
3. Def – The cessation of life
3 vital system –
nervous, circulatory, respiratory
Atria mortis – death portal of entry
4 -6 minutes - serious permanent
impairment to brain
6-10 minutes – total loss of function
4. Irreversible damage to brain stem
(somatic death)
Organ transplantation
Loss of spontaneous breathing
ability, cardiac arrest (cellular death
progresses)
5. IEA 108 presumption of survivorship.
Burden of proving that person is alive who
has not been heard of for seven years. -
Provided that when the question is whether a
man is alive or dead, and it is proved that he
has not been heard of for seven years by
those who would naturally have heard of him
if he had been alive, the burden of proving
that he is alive is shifted to the person who
affirms it.
6. IEA 107 presumption of death.
Burden of proving death of person
known to have been alive within thirty
years. - When the question is whether a
man is alive or dead, and it is shown that he
was alive within thirty years, the burden of
proving that he is dead is on the person
who affirms it.
7. Historical Perspective
Prior to the advent of
mechanical respiration, death
was defined as the cessation of
circulation and breathing
8. Historical Perspective
1959 Coma de’passe’ Mollaret and Goulon
1968 Irreversible Coma/Brain Death Harvard
Medical School Ad Hoc Committee
1981 Uniform Determination of Death Act -
President’s Commission for the Study of
Ethical Problems in Medicine (US)
1994 American Academy of Neurology Guidelines
for the determination of Brain Death
1994 Transplantation of Human Organs Act (India)
9. Brain Death Current Consensus
Absent Cerebral Function
Absent Brainstem Function
Apnea
23. Mechanism of Cerebral Death
Neuronal Injury Neuronal Swelling
ICP>MAP is
incompatible with
life
Decreased Intracranial Increased Intracranial
Blood Flow Pressure
24. Conditions Distinct From Brain Death
Persistent Vegetative State
Locked-in Syndrome
Minimally Responsive State
25. Persistent Vegetative State
Normal Sleep-Wake Cycles
No Response to Environmental Stimuli
Diffuse Brain Injury with Preservation of Brain
Stem Function
27. Minimally Responsive State
Static Encephalopathy
Diffuse or Multi-Focal Brain Injury
Preserved Brain Stem Function
Variable Interaction with Environmental Stimuli
28. Brain Death Neurological Examination
Clinical Prerequisites:
Known Irreversible Cause
Exclusion of Potentially Reversible Conditions
Drug Intoxication or Poisoning
Electrolyte or Acid-Base Imbalance
Endocrine Disturbances
Core Body temperature > 32° C
Team of doctors at least twice, with a reasonable gap of
time in between ( 6 hours or so)
35. Facial Sensation and Motor Response
Corneal Reflex
Jaw Reflex
Grimace to Supraorbital or
Temporo-Mandibular Pressure
36. Apnea Testing
Prerequisites
Core Body Temperature > 32° C
Systolic Blood Pressure ≥ 90 mm Hg
Normal Electrolytes
Normal PCO2
37. Apnea Testing
1. Pre-Oxygenation
100% Oxygen via Tracheal Cannula
PO2 = 200 mm Hg
2. Monitor PCO2 and PO2 with pulse oximetry
3. Disconnect Ventilator
4. Observe for Respiratory Movement until PCO2 = 60
mm Hg
5. Discontinue Testing if BP < 90, PO2 saturation
decreases, or cardiac dysrhythmia observed
39. Observations Compatible with Brain
Death
Sweating, Blushing
Deep Tendon Reflexes
Spontaneous Spinal Reflexes- Triple Flexion
Babinski Sign
40. Confirmatory Testing
Recommended when the proximate cause of coma is not known or when
confounding clinical conditions limit the clinical examination
47. Transplantation of Human Organs Act
THOA 1994
8 July 1994
7 Chapters, 25 Sections and variable
no. of subsections
48. Transplantation of Human Organs Act
THOA 1994
Some definitions
“Deceased person” – A person in whom permanent
disappearance of all evidence of life occurs, by reason
of brain stem death or in a cardiopulmonary sense, at
any time after live birth has taken place
“Brain stem death” – Stage at which all functions of
the brain stem have permanently and irreversibly
ceased
49. Transplantation of Human Organs Act
THOA 1994
“Donor” – Any person not less than 18 years of
age, who voluntarily authorizes the removal of any
of his human organs for therapeutic purposes under
subsection(1) or (2) of section(3)
“Human Organ” – Any part of a human body
consisting of a structured arrangement of tissues
which if wholly removed, cannot be replicated by
the body.
50. Transplantation of Human Organs Act
THOA 1994
The brain stem death need to be certified by a team of
doctors consisting of the following
1) The RMP in charge of the hospital in which the brain stem death
has occurred.
2) An independent RMP, being a specialist to be nominated by
RMP in clause(1), from the panel of names approved by the
appropriate authority.
3) A neurologist or a neurosurgeon to be nominated by the RMP
specified in clause(1) from the panel of names approved by the
appropriate authority.
4) The RMP treating the person whose brain stem death has
occurred.
51. Transplantation of Human Organs
(Amendment) Act, 2009
Human organs and tissues
Expansion of the term “near relative’
Tissue
Transplant coordinator
Technician for enucleation of cornea
Non availability of neurosurgeon
Donor/recipient - near relative - foreign national
Minors
Swap donations
Fine/ imprisonment
52. Concern for man and his fate must always form the chief
interest of all technical endeavors. Never forget this in the
midst of your diagrams and equations.
Albert Einstein
